Most of the news about Puerto Rico focuses, predictably, on the hardships being experienced on the Island as disaster relief efforts drag on. The most recent issue of the New England Journal of Medicine points out that Puerto Rico’s continuing problems are affecting all of the United States in one very important way: a shortage of saline solution that is becoming more dire as the months pass.
Forty million bags of saline solution are needed every year in the U.S.; saline is used for almost every patient admitted to a hospital. Only three companies in the U.S. produce saline solution. One, Baxter, was shut down by Hurricane Maria six months ago. Production hasn’t yet returned to pre-hurricane levels. Baxter normally supplies half of all the saline solution used in the United States, especially the solution in small bags which is normally used intravenously to deliver medications or help patients stay hydrated. Its competitors don’t have the capacity to make up the difference.
“Drug manufacturers are not required to have redundancy in their facilities or even a business contingency plan in case of a disaster, no matter how essential or lifesaving the medication they are producing,” the NEJM points out. “Neither Congress nor the Food and Drug Administration (FDA) can force any manufacturer to produce a medication, no matter how lifesaving the product or how critical the need.”
What are hospitals doing to manage without the saline solution they need? One workaround is to use large quantity bags instead of small ones. This requires changes in the normal procedure and can easily lead to errors and contamination. Using substitutes or trying to manage with less can lead to dangerous compromises in patient care. The FDA approved two additional sources of saline solution soon after the hurricane, but there continue to be issues with access, quality, and cost for these additional sources. One option is to use saline solution past its expiration date. Some facilities are just using tap water for some applications.
Another workaround is to have nurses inject patients repeatedly with medications which would otherwise be delivered through an IV. Leaving aside the stress for patients, this also keeps nurses from doing work they otherwise would be doing during the additional time spent giving injections. Hospitals are having to make difficult decisions. And every change and stopgap measure significantly increases time spent on record keeping and administration — more resources diverted from patient care.
The NEJM article is, understandably, tinged with frustration. While most people expressing frustration over the slow pace of recovery in Puerto Rico are calling upon the federal government to provide more funds or the Puerto Rican government to prioritize resources more effectively, the NEJM article wants manufacturers to be held responsible — and is asking the government to make that happen.
“The Department of Homeland Security could mandate that saline be considered part of the essential infrastructure,” the author suggests, “which would require the relevant companies to develop business continuity plans, although implementing manufacturing redundancies would be costly and require significant time.”
Faced with a continuing lack of reliable electricity and clean water, companies in Puerto Rico might be unable to comply with a directive from Homeland Security which would require plenty of time and money. The NEJM recognizes this, but points out that simply deciding not to buy from companies with facilities in Puerto Rico is not an option. “Since drug companies are not required to disclose the identity or location of the manufacturer that produces a drug,” the article explains, “a complete list of medications affected by Hurricane Maria is available only to the FDA and not to clinicians who need to plan for patient care.”
Would boycotting Puerto Rican manufacturing facilities be a good solution? The economic consequences for Puerto Rico could be severe. The territory’s economic problems — problems largely caused by its territory status — led to the weakness of the power grid in the first place, and have limited Puerto Rico’s ability to recover from the hurricane. From the point of view of Puerto Rico, this could create a vicious circle.
Saline production in Puerto Rico is expected to get back on track in the coming weeks and months, but medical professionals in the States are naturally concerned about future shortages, as well as the consequences of the current ongoing saline shortage.
Americans in general, and U.S. leaders, should also be concerned. Viewing Puerto Rico as a distant place where they’re having problems is one of the factors that caused the saline shortage. Legislators have been pointing out for months that the exodus from Puerto Rico to the States is already causing bottlenecks in housing, education, and healthcare in the States where large numbers of people from Puerto Rico have settled. How many more consequences are waiting in the wings?
Ignoring Puerto Rico is not an option. Puerto Rico is a possession of the United States, and the connections between the Island and the States are many and varied. Congress has a responsibility to the people of Puerto Rico, and to their own constituents as Puerto Rico’s situation continues to affect the States.
