Clermont, Florida Correspondent — The saline shortage after Maria showed how thin some of these chains had become. One storm, and hospitals in this state were rationing IV bags and mixing drugs by hand, because most of the supply came off an island that had no power. It took most of a year to work through.

Trying to reshore every generic would raise costs more than most people are prepared to accept, and it would create its own shortages during the transition.

The practical route is selective resilience. Identify the truly critical drugs and active ingredients, keep domestic or closely allied surge capacity for those, use multi-year procurement to keep that capacity alive between crises, and get real visibility into the full chain rather than into the label. Stockpiles help for the short list. Broad attempts to bring everything home will produce higher prices somewhere you weren’t looking.

Owatonna, Minnesota Correspondent — Market forces alone won’t solve this, because the lowest-cost location wins every purchasing cycle until the crisis arrives, and then the crisis is somebody else’s budget.

Targeted incentives, advance purchase commitments, and streamlined regulation for essential medicines can preserve capacity without permanent high tariffs. The distinction I’d draw is between resilience for a critical list and autarky, which are different projects with different price tags and which get conflated constantly.

Sydney, Australia Correspondent — Most countries face this tension and most of us have concluded the same thing. Pure national production is expensive. Pure global just-in-time is fragile. The workable middle is diversified sourcing among trusted partners plus domestic surge capacity for essentials.

We hold a national medical stockpile and we’ve discovered the hard part isn’t building it. It’s maintaining it through years when nothing happens and the storage line looks like waste to whoever is drafting the budget.

I’d also note that the same handful of Indian and Chinese plants supply Australia, Britain, Canada, and the United States. A national solution to a shared exposure isn’t really a solution. Coordinated stockpiling and shared visibility among allies would do more for less, and it has the advantage of being achievable.

Sheffield, Jamaica Correspondent — Selective redundancy for the most critical drugs and active ingredients is the practical goal, not an attempt to manufacture every medicine at home.

Full reshoring would raise costs more than most health systems are prepared to bear, and I would ask the Americans in the room to consider what their reshoring does to the price we pay. When a large purchaser leaves a global market, the smaller purchasers do not get a better deal.

Better visibility into actual sources, modest surge capacity, and reliable long-term contracts for the highest-priority items deliver most of the resilience benefit without the full price penalty.

Tyler, Texas Correspondent — You don’t have to cook every pill in Smith County. You do have to stop pretending a single foreign plant is the market working.

Dual-source the critical list. Pay a premium that’s real and limited in time. Use multi-year contracts so a domestic or allied line can exist without losing every bid to the cheapest vial that vanishes in a bad month.

Costs will rise some. The cost of a shortage isn’t a model. I write coverage for clinics, and last winter I had two calling about whether a canceled procedure schedule was a business interruption. It wasn’t, under their form. That’s a real conversation I had.

Treat this as a security file rather than a purchasing file. Purchasing will always take the low bid and then act surprised. Map the chokepoints and fix those first.

Long Island, New York Correspondent — Hospital purchasers here already know which injectables vanish without warning, and they keep informal lists that never appear in any policy document.

What you want is visibility into the real source. Not the label — the source, meaning the plant that makes the active ingredient, which is frequently not the company on the box and sometimes not in the country on the box.

Add stockpiles for a short list and allied production, and you’ve beaten the fantasy of making everything domestically at yesterday’s price. Don’t substitute a trade fight for a formulary. Redundancy is boring and it works, and boring is what you want in a vial.

Las Vegas, Nevada Correspondent — A tourism town notices when a common drug simply isn’t on the shelf, because we have a lot of visitors having a bad day a long way from their pharmacy.

Diversify the source. Pay for surge capacity the way you pay for rooms you hope not to need, which is a cost you carry on purpose and don’t apologize for in the good years.

Targeted capacity, multi-year buys, a list that’s actually short. Don’t nationalize the industry and then act shocked when the talent leaves.

Jacksonville, Florida Correspondent — The port can move a box. It can’t invent an ingredient plant by Friday.

Targeted redundancy, not a parade about making it all here. Find the molecules, the gloves, and the sterile packaging that have exactly one address, and give those addresses a cousin.

Costs go up at the margin. Empty shelves cost more, and they cost it all at once.