When Hurricane Maria devastated Puerto Rico in late September, hospitals across the mainland United States already faced intermittent shortages of intravenous fluids. But the Category 4 hurricane severely damaged several manufacturing plants owned by Baxter International, one of the major manufacturers of the small IV bags that deliver those fluids, setting in motion a major national shortage.
Nearly six months later, the scarcity of IV bags has reached crisis levels, illustrating what damage to a supply chain concentrated in Puerto Rico can do to one of the world’s most advanced health-care systems. This development underscores an inescapable reality: A strong sector may have great doctors, nurses, and hospitals, but if one link in the supply chain breaks, people suffer.
IV bags, simple plastic bags that are used to mix and deliver a liquid medication or salt water to patients through an intravenous line, are involved in nearly every facet of patient care in a hospital. Health-care professionals use IV bags to administer drugs and to hydrate people who have difficulty swallowing liquids. They are one of the most basic medical items in a hospital: Many people stay in hospitals because they are unable to self-administer medicine, and IV bags are often the easiest and safest way for those patients to ingest their drugs.
There have been intermittent IV bag and fluid shortages across the country since 2014, but the hurricane amplified the problem. Dr. O’Neil Britton, chief medical officer at Massachusetts General Hospital (MGH) in Boston, one of the country’s top hospitals, tells The American Prospect that while he’d seen other medical device or drug shortages, “they’ve never been this persistent or widespread, and it’s never affected the entire industry on this scale.”
About 30 percent of Puerto Rico’s GDP depends on exporting pharmaceuticals and medical devices. Two factories owned by Baxter International, a health-care product manufacturer, suffered minimal structural damage; in November, at least two of the plants were running—on backup generators. The recovery has been very slow across the island: 25 percent of Puerto Ricans still have no power. The Trump administration has been roundly criticized for its lackluster response to the disaster. The official hurricane death toll stands at 64, but outside groups have estimated that as many as 1,000 people died.
Meanwhile, the Food and Drug Administration has approved plans to allow Baxter and other companies to import IV bags from their other facilities in Brazil and Mexico. But until those new supplies start to flow into hospitals, doctors have been forced to improvise. According to Dr. Paul Biddinger, MGH’s disaster medicine director, the facility uses various strategies to deal with the shortages, including substituting drugs usually delivered by an IV with medications that can be injected with a syringe.
In November, MGH activated their emergency hospital plan—with protocols similar to the ones they would use during a natural disaster or other emergency. The hospital also set up a new group to circulate daily best-practice guidelines to clinicians. (The shortage affects different types of medicine at irregular intervals, and so clinicians must adapt day to day.)
The IV bag shortage has coincided with one of the worst flu seasons in years. Flu-related admissions at MGH are up 280 percent over last year. Flu patients often become dehydrated—and that condition means they need IV fluids. But Biddinger is most worried about cardiology patients, who use blood thinners and anti-arrhythmic drugs, which are often injected via an IV bag.
“Imagine your doctor is using a drug they’re less familiar with; it creates problems,” says Dr. Ashish Jha, a professor of global health at the Harvard School of Public Health. Forcing doctors and nurses to use drugs that they may not be as familiar with adds new stresses to an already tense environment. “If those drugs were just as easy to use, we’d use them,” says Jha of the drugs that doctors have been forced to use. “Doctors may not know the dosing effects, the therapeutic effects, because they’re not as [commonly used].”
When that supply chain gets interrupted, the whole system falters. “Our safety margin, our margin for adaptation within our supply lines, within medicine is incredibly thin and not robust,” says Biddinger. Establishing a stronger supply chain would be a good public health policy move: creating additional redundancy in the existing system would produce a more competitive marketplace, drive down health-care costs, and help stabilize the American health-care system during emergencies. Until then, many health-care professionals and patients have new perspectives on the precariousness of the medical supply chain that stretches from Puerto Rico to the outer reaches of the mainland.