The agency tested 75 types of cinnamon after hundreds of children were poisoned by the spice in applesauce. It found some lead in cinnamon brands sold at some dollar stores and other markets.The Food and Drug Administration is telling consumers to throw out certain brands of cinnamon that were found to have elevated levels of lead, and it urged companies to recall the products from store shelves.The agency conducted tests across the country after at least 460 children were sickened last year by illnesses linked to applesauce pouches. Those products had been contaminated with very high levels of lead from cinnamon processed in Ecuador.The F.D.A.’s latest tests, however, detected far lower levels, 2 to 3 parts per million, in the cinnamon. In contrast, the cinnamon from Ecuador that sickened children last year had 2,200 to 5,100 parts per million.“Although we have concern about these products in the safety alert, they do not present the same level of risk to human health as the cinnamon in the apple purée and applesauce products,” Conrad Choiniere, an F.D.A. food official, said in a release on Wednesday.Lead is a potent toxin that is particularly hazardous to young children and has been tied to learning and behavior challenges as well as developmental delays. The agency said no illnesses were reported in relation to the latest batches of cinnamon, which were singled out over elevated lead levels after tests of 75 samples from retail stores.The latest batches of cinnamon and the applesauce pouches were both sold at Dollar Tree stores. The company has said it is committed to the safety of the products it sells. Brands that the F.D.A. has urged companies to recall include Supreme Tradition cinnamon, sold exclusively at Dollar Tree and Family Dollar stores. Other cinnamon with elevated lead levels in the recent tests included the La Fiesta brand sold at La Superior SuperMercados and the Marcum brand sold at Save A Lot.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Lawmakers want shopkeepers to remove e-cigarettes that were not authorized by the F.D.A. Retailers say it is not that simple.The chairmen of five key Senate committees on Thursday warned the chief executives of major convenience stores and wholesalers to stop sales of illicit flavored vaping products that they called “widespread violations of federal law.”The senators voiced their concerns in letters to the companies, amplifying the frustration among some lawmakers in Congress over the continued availability of e-cigarettes in vivid colors and candy flavors that attract young people who could become addicted to nicotine. The unchecked sales, they wrote, “pose a tremendous public health threat.”“F.D.A. and the industry must do more to address the youth vaping epidemic and remove unauthorized vaping products from their shelves immediately,” Senator Dick Durbin of Illinois, the Democratic whip, said.The letters were addressed to retailers including 7-Eleven, Circle K, bp America, Pilot, Kwik Trip and others. The Food and Drug Administration had earlier issued warnings about sales of unauthorized brands like Elf Bar, E.B. Design and Funky Republic.The senators’ letters reminded the companies that Congress gave the F.D.A. authority over tobacco products in a landmark 2009 law. Selling unapproved items can result in fines or an order to stop selling any tobacco products, the letter notes.“Today, millions of children use unauthorized e-cigarettes, risking nicotine addiction, respiratory illness, exacerbation of depression and anxiety, and many other harms,” read the letter to Joseph DePinto, the chief executive of 7-Eleven. The company did not respond to a request for comment.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Hundreds of children sickened from high levels of lead in applesauce pouches last year put a spotlight on lapses in the food-safety system.A recent outbreak of lead poisoning from cinnamon in applesauce has drawn attention to the toxic effect the heavy metal can have on children. The cinnamon in the applesauce was believed to have been intentionally contaminated, possibly to add to its value as a commodity sold by weight. It had unusually high levels of lead.The Centers for Disease Control and Prevention estimates that more than 400 children were poisoned in the applesauce outbreak. Their median blood lead levels were six times higher than the average seen during the height of the Flint water crisis, the C.D.C. said.While such poisoning cases are rare, lead is a widespread contaminant and has been under increasing scrutiny. Here’s what you need to know.How do children get exposed to lead?Paint is one of the most common and well-known sources of lead. Children can also be exposed by drinking water that flows through old lead pipes.Lead poisoning through food is less common but does occur. Lead can get into food at low levels when plants draw it up from the soil. For instance, a study about baby foods found that sweet potatoes had some of the highest levels of lead among the products tested.A lead-based pigment is sometimes illegally added to spices to bulk them up or make their color pop. The Food and Drug Administration suspects that the additive caused the applesauce contamination last year.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

As public health groups pressure the Biden administration to impose a ban on menthol cigarettes, research suggests similar moves in other countries have led to lower smoking rates.Nearly a quarter of menthol cigarette smokers quit in the year or two after a ban on menthol went into effect, according to a study published on Wednesday.Researchers found that about half of the menthol smokers switched to other cigarettes and another quarter managed to keep smoking menthols. The rate of menthol smokers who quit was higher in nations that imposed bans, in contrast with cities or states, since it was harder for people to drive a few miles to keep buying menthol cigarettes, according to the study.The Food and Drug Administration has been urging the Biden administration to impose a ban on menthol cigarettes, a goal that has generated intense opposition from retailers and tobacco companies alongside concerns in a presidential election year that it could alienate Black voters.Black smokers, who heavily favor menthol cigarettes, also stand to gain the most from such a ban, public health researchers say, noting that premature deaths from cancer, heart and lung disease could be avoided after a sharp decline in smoking rates.The study analyzed the effects of bans in other countries, including Canada and some in the European Union, as well as bans in force in states, including Massachusetts. The researchers reviewed studies, smoking rates and cigarette sales as part of their analysis.“Our review found that a menthol ban will have a pro-equity impact, meaning that we expect smoking to reduce the most among Black individuals who smoke as compared to other racial or ethnic groups,” said Sarah Mills, lead author of the study and an assistant professor at the University of North Carolina school of public health.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

The F.T.C. and H.H.S. are examining the tactics of group purchasing organizations that generic industry executives say have led to scarce supplies of treatments like chemotherapy.The Federal Trade Commission and the Department of Health and Human Services said on Wednesday that they would examine the causes of generic drug shortages and the practices of “powerful middlemen” that are involved in the supply chain.The federal agencies’ inquiry is aimed at the group purchasing organizations and drug distributors that have been in the spotlight in recent months as drug shortages reached a 10-year peak. The agencies want to examine the companies’ influence on how the drugs are sold to hospitals and other health facilities, assessing whether the middlemen put pressure on pricing and manufacturing that led to breakdowns.During Congressional hearings in the last year, oncology experts have testified about the effects of the shortages, describing difficult decisions that forced them to ration key chemotherapy drugs. They detailed month-to-month, sometimes week-to-week, gaps in supplies that were posing deadly risks for some patients.“For years Americans have faced acute shortages of critical drugs, from chemotherapy to antibiotics, endangering patients,” Lina Khan, the F.T.C. chairwoman, said in a statement. “Our inquiry requests information on the factors driving these shortages and scrutinizes the practices of opaque drug middlemen.”In earlier interviews with The Times, generic drug industry executives had expressed deepening concerns about their reliance on three major group purchasing organizations for contracts to sell medicines to hospitals and health center customers. The generic executives complained that their companies sometimes offered below-market prices to get big contracts, a strategy that had eroded stability in the industry, especially among makers of sterile injectable products often used in surgical and cancer care.Lawmakers have echoed the concerns. Late last year, Senator Ron Wyden, a Democrat of Oregon and chairman of the Senate Finance Committee, criticized “very powerful health care middlemen” in the generic drug industry. Last month, he and Senator Mike Crapo, a Republican of Idaho, outlined ways to limit drug shortages, focusing in part on proposed changes to Medicare payments for sterile injectable drugs.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Under a settlement with regulators, the company must revamp some operations before resuming sales of its CPAP and ventilator devices in the United States.Philips Respironics announced on Monday that it would halt sales of all of its breathing machines in the United States after reaching a settlement with the Food and Drug Administration over continuing problems with the devices.Millions of the company’s ventilators and CPAP machines, used to ease breathing at night, were recalled after reports that they blew bits of foam and potentially toxic gases into consumers’ airways.Under the settlement, Philips said it would have to meet a list of standards in a “multiyear” plan before it could resume business in the United States. The company said further details would be disclosed when the agreement was finalized in court. But it added that it would continue to repair existing devices and provide service for people using them.The company initially began the recall of millions of devices in June 2021 and paused sales of new sleep therapy machines to the United States, according to Steve Klink, a spokesman for Philips. At the time, the company and the F.D.A. cited the potential for serious injury or permanent impairment from the potentially cancer-causing chemicals emitted from the devices.The company has since released results of additional testing, saying the devices were “not expected to result in appreciable harm to health in patients,” and it said it was continuing to conduct tests. The F.D.A. has pushed back on some of the company’s updated claims, and at one point called them “unpersuasive.” Philips has also faced continuing scrutiny and undertaken more recalls in its attempts to upgrade the devices.Dr. Jeff Shuren, director of the F.D.A.’s device division, said the agency could not comment until the agreement was finalized and filed with the court.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? 

The agency has reviewed reports of cancer patients whose treatments resulted in the development of secondary blood cancers. Several companies will be required to carry the new warning.The Food and Drug Administration is requiring companies that make specialized cancer therapies known as CAR-T to add a boxed warning that the treatments themselves may cause cancers.The agency noted that the benefits still outweighed the risks of the therapy, which involves removing a type of white blood cells — T cells — and then genetically engineering them to create proteins called chimeric antigen receptors (CAR). Infused back into a patient’s blood, the engineered cells allow the T cells to attach to cancer cells and kill them.But the therapies, which mostly treat blood cancers, including multiple myeloma, had already carried a warning for dangerous immune responses and for neurological risks. And the new warning follows reports of about 20 cases of secondary cancers that federal health officials and others have suspected were caused by CAR-T treatments, although more investigation may be needed to establish a definite link. The therapy has been used by an estimated 25,000 to 30,000 patients since it was first approved by the F.D.A. in 2017.Cancer patients who receive CAR-T treatments tend to have few options left, and would be unlikely to alter course even with the new warning, said Dr. John DiPersio, an oncologist with Washington University in St. Louis.“The risk of not doing this therapy for most patients who get it is rapid progression of their disease or certain death,” he said.The F.D.A. raised concerns about the adverse effects of the treatments late last year.In letters dated Jan. 19, the agency outlined the warnings to be included by some of the companies making CAR-T therapies, which had also been ordered to monitor patients for secondary cancers and report any to the F.D.A. The secondary cancers can lead to hospitalizations or death, the agency noted, requiring the drug companies to provide warnings on drug labels that secondary cancers “may present as soon as weeks following infusion, and may include fatal outcomes.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? 

With Covid deaths rising to about 1,500 per week, researchers question why Paxlovid use has remained low among high-risk patients.As Covid rises again, killing about 1,500 Americans each week, medical researchers are trying to understand why so few people are taking Paxlovid, a medicine that is stunningly effective in preventing severe illness and death from the disease.A study of a million high-risk people with Covid found that only about 15 percent who were eligible for the drug took it. If half of the eligible patients had gotten Paxlovid, 48,000 deaths could have been prevented, authors of the study, conducted by the National Institutes of Health, concluded.It’s not because people don’t know about the drug — most do — but the reluctance seems to come from doctors worried about interactions with other drugs and people wary of a possible rebound case or the metallic aftertaste.Regional differences offer a clue, with uptake highest in the Democratic strongholds of the Northeast and Pacific Northwest regions of the United States and lowest in deep red areas including Florida and Indiana. Yet no careful study has clarified why so few people used the medication, which cut the risk of death by 73 percent for high-risk patients in the N.I.H. study.“I don’t know why there is such variability and why uptake isn’t higher across the board,” said Dr. Josh Fessel, a senior clinical adviser on the National Institutes of Health team that studied the drug’s use. “If you can take Paxlovid and you do take Paxlovid within the recommended time frame, the likelihood of death or hospitalization are significantly reduced. That’s a big deal.”Covid deaths have been elevated since September at about 1,200 to 1,300 deaths per week, inching up to about 1,500 per week in December. Researchers say they will most likely continue to rise unless more people get the updated Covid vaccines and antiviral treatments.Dr. Fessel said that over the course of the entire million-person N.I.H. study, about 10 percent of high-risk patients eligible for Paxlovid took it, though the rate rose to about 15 percent toward the end of the study period in early 2023. All told, the N.I.H. authors estimated that about 135,000 hospitalizations and 48,000 deaths could have been avoided if half of the patients eligible for the antiviral got it.Paxlovid, made by Pfizer, is a two-medication treatment meant to be taken within five days of the onset of Covid symptoms to quash viral spread within the body. It was approved for adults who are at high risk for severe Covid, which tends to include those 65 and older and people with diabetes, obesity, asthma and other conditions.Federal officials still have more than one million free doses out to pharmacies, but officials have handed distribution of the drug off to Pfizer, which has priced it at $1,400 per course.Pfizer, via ReutersReasons for not prescribing or taking it have varied: Doctors balk at the long list of medications not to be mixed with Paxlovid, including common drugs meant to lower blood pressure or prevent blood clots. Patients tend to complain about the drug’s metallic aftertaste. Many wave off the drug in the early days of Covid, when symptoms tend to be mildest, bypassing the chance to limit early viral growth.“They want to wait and see if things get worse, but if you wait and see it’s not effective,” said Dr. David Gifford, chief medical officer of the American Health Care Association, which represents nursing homes. People think, “‘It’s just a cold and I’ll tough it out,’” he said. “And that needs to change.”Price has also become a factor. The federal government provided the five-day course of the medications at no cost in the months since its initial emergency authorization in December 2021. (The Food and Drug Administration fully approved the drug in May.) Federal officials still have more than one million free doses out to pharmacies, and the medication will be free through 2024 for Medicaid and Medicare patients. But in recent weeks, officials have handed distribution of the drug off to Pfizer, which has priced it at about $1,400 per course, though private insurers are expected to cover some portion of the price and Pfizer is offering co-payment assistance.No study has looked at the effect of the handoff. The N.I.H. study period ended early last year. It found wide regional variation in Paxlovid use, with as many as 50 percent of eligible patients getting the medication in Utah and in the Northeast and Northwest regions of the United States. However, rates dipped close to zero in states in the Southeast and in parts of the lower Midwest.Dr. Fessel, of the N.I.H., said he would be curious to see if concerns about so-called Paxlovid rebound contributed. The misgiving has been that the medication dampens symptoms initially and then leads to a second stage of illness.In a recent review of studies, the Centers for Disease Control and Prevention found “no consistent association” with Paxlovid use and Covid rebound. Studies show rebound can also happen without treatment.Denis Nash, a professor of epidemiology at the City University of New York, has also been studying Paxlovid use. In a far smaller study, his team also found uptake of the medication at nearly 14 percent, though lower among some, including 7 percent among people who are Black and nearly 11 percent among those with the lowest income levels.He said his team worked on a nationally representative survey of 4,000 people to dig deeper (results have not yet been published or peer reviewed). One interesting finding, he said, was that awareness of Paxlovid was high — with about 80 percent of respondents saying they knew that it was available.Yet respondents showed a lack of recognition about their own risk: Only about one-third of people older than 65 considered themselves to be at high risk for severe Covid, even though the C.D.C. considers all in that age group high risk. The finding was similar for patients with asthma or diabetes, though half of patients who were overweight or obese recognized their risk.“People don’t necessarily perceive themselves to be at risk,” Dr. Nash said.Another recent study found that starting Paxlovid very early, or on the first day of symptoms, improved odds of survival or avoiding hospitalization, compared with starting the drug a day or two later.Studies have also looked at the use of another antiviral drug, molnupiravir, made by Merck, which was less effective and is used less frequently. Gilead, which makes the antiviral infusion remdesivir, is also studying a Covid antiviral pill called obeldesivir and plans to seek F.D.A. approval. The N.I.H. is studying yet another antiviral option, ensitrelvir, by the company Shinogi that also appears to reduce duration of the illness.Researchers have also reported low Paxlovid use in nursing homes, given the risk patients face of serious illness or death. About one in four nursing home residents got an antiviral prescription to treat Covid by the end of 2022, a study found. The data showed that the rate rose to closer to one-third of nursing home residents by May 2023, said one study author, Brian McGarry, a University of Rochester assistant professor of medicine.After that, federal officials stopped asking about Paxlovid use in their weekly nursing home Covid questionnaire.“I think things are a little bit better,” Dr. McGarry said, “but at the same time, facilities are now dealing with Covid, plus R.S.V., plus flu.”

Key drugs have been in scarce supply, revealing a deep crisis in the generic drug industry.Stephanie Scanlan learned about the shortages of basic chemotherapy drugs this spring in the most frightening way. Two of the three drugs typically used to treat her rare bone cancer were too scarce. She would have to go forward without them.Ms. Scanlan, 56, the manager of a busy state office in Tallahassee, Fla., had sought the drugs for months as the cancer spread from her wrist to her rib to her spine. By summer it was clear that her left wrist and hand would need to be amputated.“I’m scared to death,” she said as she faced the surgery. “This is America. Why are we having to choose who we save?”The disruption this year in supplies of key chemotherapy drugs has realized the worst fears of patients — and of the broader health system — because some people with aggressive cancers have been unable to get the treatment they need.Those medications and hundreds of other generic drugs, including amoxicillin to treat infections and fentanyl to quell pain during surgery, remain in short supply. But the deepening crisis has not fostered solutions to improve the delivery of generic drugs, which make up 90 percent of prescriptions in the United States.Dr. Robert Califf, commissioner of the Food and Drug Administration, has outlined changes the agency could make to improve the situation. But he said the root of the problem “is due to economic factors that we don’t control.”“They’re beyond the remit of the F.D.A.,” he said.Senator Ron Wyden, a Democrat of Oregon and chairman of the Senate Finance Committee, agreed. “A substantial portion of these market failures are driven by the consolidation of generic drug purchasing among a small group of very powerful health care middlemen,” he said at a hearing this month.In interviews, more than a dozen current and former executives affiliated with the generic drug industry described many risks that discourage a company from increasing production that might ease the shortages.They said prices were pushed so low that making lifesaving medicines could result in bankruptcy. It’s a system in which more than 200 generic drugmakers compete, at times fiercely, for contracts with three middleman companies that guard the door to a vast number of customers.In some cases, generic drugmakers offer rock-bottom prices to edge out rivals for coveted deals. In other instances, the intermediaries — called group-purchasing organizations — demand lower prices days after signing a contract with a drugmaker.The downward pressure on prices — no doubt often a boon to the pocketbooks of patients and taxpayers — is intense. The group purchasers compete against one another to offer hospitals the lowest-priced products, which intermediary companies say also benefits consumers. They earn fees from drugmakers based on the amount of medications the hospitals buy.“The business model is broken,” said George Zorich, a pharmacist and retired generic drug industry executive. “It’s great for G.P.O.s. Not great for drug manufacturers, not great for patients in some cases.”Ms. Scanlan’s cancer was deemed curable for about 65 percent of patients after cisplatin was added to the cocktail. But during her treatment, Ms. Scanlan got only one dose of a sister drug, carboplatin.Emil Lippe for The New York TimesMany doctors wish they could do more to give cancer patients the medicines they need.“Every clinician I know would be thrilled to pay more money for a reliable supply of a quality drug,” said Dr. Andrew Shuman, a University of Michigan oncology surgeon and expert on drug shortages.In a speech to drug supply intermediaries last month, Dr. Califf exhorted them to “pay more,” saying it would enhance access to medical products and would be “good for business.”Prices fell in recent years for two of the three drugs that Ms. Scanlan was initially offered to treat her cancer. During those years, Intas Pharmaceuticals, a generics giant in India, steadily gained market share as other companies left, according to data from the U.S. Pharmacopeia, a nonprofit that tracks drug shortages.But the company had to halt U.S. production to deal with quality issues that the F.D.A. cited after a surprise inspection of one of its sprawling plants in India. Inspectors had discovered quality-control staff workers shredding and throwing acid on key records. The manufacturing shutdown set off a supply shock in February that would be felt nationwide.Nearly every major U.S. cancer center reported in surveys that they faced chemotherapy shortfalls last spring and summer. One survey released in August found that nearly 60 percent of more than 1,000 pharmacy respondents deemed chemotherapy drug shortages “critically impactful.”Intas recently resumed production, but the F.D.A. still lists the drugs as being in short supply. Major cancer centers report that the shortages are easing, though concerns persist about stock in rural areas.The scarce drugs are cheap and essential and revolutionized their field decades ago, for the first time curing some patients with testicular, lung, ovarian, pancreatic and breast cancers, oncologists say.Ms. Scanlan’s cancer, called osteosarcoma, was deemed curable for about 65 percent of patients after cisplatin was added to the cocktail regimen in the 1970s.Ms. Scanlan’s medical records outline her care. For treatment in the spring and summer, she received only one infusion in March of a sister drug, carboplatin, at University of Florida Shands Hospital in Gainesville.As months passed, Ms. Scanlan’s cancer spread deeper into her bones. She was referred to Tallahassee Memorial Hospital, which, because of the shortages, treated her with one chemotherapy drug. The center then referred Ms. Scanlan to the Mayo Clinic site in Jacksonville in April, according to her medical records.Ms. Scanlan, with her dog, Rosie. “This is America,” Ms. Scanlan said. “Why are we having to choose who we save?”Mark Wallheiser for The New York TimesYet even at the gleaming Florida outpost of the elite medical system, Ms. Scanlan could not get her chemo treatments.By May, she was facing surgery, but might have been eligible to have her wrist repaired rather than amputated. Notes in her records by her Mayo oncology surgeon, Dr. Courtney Sherman, said it would depend on how Ms. Scanlan responded to treatment, though “she is not receiving standard chemotherapy given shortages.”In May and June, both Ms. Scanlan and Dr. Sherman pressed Dr. Steven Attia, a Mayo oncologist, to order the infusions. Ms. Scanlan emailed Dr. Attia: “One question, does Mayo not have the chemo that I actually need?”Dr. Attia declined requests for comment. Samiha Khanna, a Mayo spokeswoman, denied that its site in Jacksonville experienced a cancer drug shortage and confirmed that Mayo did not administer chemotherapy to Ms. Scanlan. Ms. Khanna also referred questions back to Tallahassee Memorial.A market transformedOver the course of his career in the generic drug field, Jeff Herzfeld, a pharmacist and former generics executive who works as a consultant, watched it morph from a field with modest profits to one that is cutthroat.At first it seemed no one was going to make high profits in the generic industry. As drug patents expired, companies entered the market and won customers by offering low prices.But the field of customers began to shrink about 15 years ago. Intermediary companies realized that they could organize hospitals to wield their mass-buying power to get even lower prices.Those intermediaries, or G.P.O.s, charged fees to drugmakers that could access a vast swath of customers. The G.P.O.s competed with one another for hospital clients — enticing them with the lowest prices.The competition stiffened as generic drugmakers vied for each huge deal, emerging victorious if they came in with the lowest price. “They had a winner-take-all approach,” Dr. Herzfeld said.Big deals also came with tough contract terms. One allowed the G.P.O.s to return to the generic drugmaker days after a deal with an ultimatum: Lower the price more or lose the contract. It could happen repeatedly. “You don’t have a lot of room for error,” Dr. Herzfeld said.Generic drug executives said common contract terms deterred them from helping out in a shortage. If they fail to supply promised medications, they can face hefty fines. Yet if they produce more drugs than hospitals buy, they are left with a hole in their balance sheet.Intas Pharmaceuticals, a generics giant in India, steadily gained market share as other companies left the market.Sam Panthaky/Agence France-Presse — Getty ImagesThese routine contract clauses “really penalize or punish” generic drugmakers, said David Gaugh of the Association for Accessible Medicines, which represents the generics industry.Todd Ebert, president of the Healthcare Supply Chain Association, which represents G.P.O.s, disputed those views, arguing that some generic drugmakers offered very low “predatory” prices to force competitors out of the business.Without knowing the cost of producing the drugs, companies cannot be certain if a price is a bargain — or a tactic to hobble the competition, he said. Vizient, a major group purchaser, referred comment to Mr. Ebert.Jessica Daley, a supply chain vice president with Premier, a leading drug-purchasing company, said the company strove to foster healthy markets and wanted “reasonable prices that support supply resiliency and protect patient care.”Aside from the group purchasers’ terms, generic drugmakers also point to other costs they face, including long lists of fees they pay companies that ship drugs from drug factories to hospitals.The current drug shortages have exposed the pressures on the generic market, and the scarcity of cancer treatments has put the spotlight on the troubled growth of Intas Pharmaceuticals in India. It produced two chemo therapies that Ms. Scanlan was to receive early on.Its market share for one of the drugs, methotrexate, which is also used in pediatric cancers and rheumatoid arthritis, grew to 35 percent last year from about 7 percent in 2018, according to the U.S. Pharmacopeia. The data shows the price per dose also fell, to $20 in 2022 from about $25 in 2018.Prices also fell during those years for carboplatin and cisplatin, which tumbled to $15 a dose. Intas’ market share grew, particularly for cisplatin, to 62 percent of the U.S. supply in 2022 from 24 percent in 2018.Ms. Scanlan’s husband, Joe Carr, left, helped wrap her amputated arm in the bathroom.Mark Wallheiser for The New York TimesNot ‘a first-world nation’Dr. Julie Gralow, chief medical officer of the American Society of Clinical Oncology, discovered signs of stockpiling in some health systems as early as February when the F.D.A. first announced the shortage, while shelves were empty at other health centers.“We’re calling it a maldistribution based on who has access — who can afford to create a little stockpile at their site,” Dr. Gralow said.By May her group and others relied on established tenets of bioethics to help cancer centers decide which patients should get scarce treatments, favoring patients with a shot at a cure over those staving off death. Dr. Gralow said researchers were beginning to study whether the chemo shortages are affecting patient survival. Results could take years.The emotional impact has varied widely. Some people with cancer were too focused on paying rent or feeding a family to fight for the medications they desperately needed, said Danielle Saff, a social worker with CancerCare, a nonprofit that supports patients.Others, like Lucia Buttaro, 60, a professor at Fordham University, were furious. She did not get her prescribed carboplatin for a reoccurrence of ovarian cancer in May or June, even though cancer was spreading in her lungs.“In my opinion, we don’t qualify as a first-world nation if you can’t get what you need,” she said.In the case of Ms. Scanlan in Florida, because her cancer was rare, invasive and advanced rapidly, it remains unclear whether the shortages played a role.Still, cancer experts expressed concerns that she had not received standard chemotherapy cocktail regimens before her amputation in September.Failure to use the three “modern miracle” generic chemotherapies for osteosarcoma patients “is a real problem,” said Dr. Lee Cranmer, a sarcoma expert at Fred Hutch Cancer Center in Seattle, who was not involved in Ms. Scanlan’s treatment.She has since received radiation. Last month, she learned the cancer already in her rib and spine had not spread further. Although her new care team at Moffitt Cancer Center in Tampa recently recommended palliative care, she said she felt defeated and terrified.The shortages took a toll, she said, adding: “I can’t help but think about what if something different happened from the beginning.” Ellen Gabler contributed reporting.

Lawmakers, U.S. officials and industry experts have offered measures to try to shore up the generic drug market.At several congressional hearings this year, ideas to fix drug shortages were as numerous as the number of scarce drugs.The rationing of key chemotherapies added urgency to the crisis.Two of these drugs, carboplatin and cisplatin, are inexpensive and are used to treat up to 20 percent of cancer patients, according to the National Institutes of Health.Momentum to shore up supplies of such crucial generic drugs grew this year after lawmakers returned from town hall meetings in their districts and reported on somber visits to their local hospitals. “People are dying because of this,” Representative Debbie Dingell, a Democrat of Michigan, said at one hearing.President Biden announced a plan in November to use his executive authority to expand federal authorities’ ability to invest in domestic manufacturing to ease some drug shortages, including those of morphine, insulin and flu vaccines. He also created a cabinet-level council focused on shortages and set aside $35 million to help prevent shortages of sterile injectable drugs like propofol or fentanyl, which are used in surgery.Here are some solutions that have been percolating:Set a price floor for lifesaving drugsA dozen executives in the generic industry said in interviews that their market was beset by unsustainably low prices, pushed down in part by intermediary companies. These middlemen compete for hospital clients, sometimes based on who can offer the lowest drug prices.Generic industry executives suggested setting a minimum price — sometimes referred to as a price floor — for generic drugs, particularly for the injectable ones that are most delicate to produce and are routinely in short supply.Marta Wosińska, a former economist for the Food and Drug Administration and deputy director for policy at the Duke-Margolis Center for Health Policy, has proposed a plan addressing prices that would reward drugmakers with the best record for quality and stability. “We’re paying too little for some of these drugs,” Dr. Wosińska said. “We need to be paying more for reliability, manufacturing quality. It’s not just about paying more.”Consider government manufacturingThe American Medical Association recently updated its policy on drug shortages, recommending that nonprofits or governments play a role in shoring up supplies, especially in the case of low-cost generic drugs that are challenging to make.The group, which represents thousands of doctors, urged the U.S. government to consider manufacturing some drugs, citing the examples of Sweden, Poland and India. In a related move, Senator Elizabeth Warren, a Democrat of Massachusetts, reintroduced a bill to create a federal drug manufacturing office that would oversee and encourage government production of certain medicines that are officially in shortage.Add transparency to the supply chainAbout a dozen people at the F.D.A. monitor and try to avert shortages. They also deal with ones they could not prevent. The agency has asked Congress to require drugmakers to report surges in demand. It also sought authority to require more information — like disclosure of the origins of basic ingredients — on the drug’s label.Encourage stockpilingSeveral groups have said the government could create incentives for hospitals or others in the supply chain to create a strategic reserve of key medications. The American Cancer Society said this month in a letter to congressional leadership that buffer stock would protect against catastrophes like a hurricane, a war or an unexpected event.But the group warned in the letter that the solution would be limited, “if the cause of a shortage is due to chronic unsustainable market conditions” that prompt companies to stop making drugs.Make more medicines in the U.S.The idea of reshoring — or bringing back drug manufacturing — and investing in existing domestic generic drugmaking facilities comes up routinely. Proponents note that relying heavily on other nations creates a national security vulnerability. An estimated 83 percent of the active ingredients in generic medicines are made overseas.Critics of the idea say domestic production is no panacea. They point to recent bankruptcies among generic drugmakers in the United States as well as the tornado that ripped through a Pfizer generic drug plant earlier this year.Propose more small-batch manufacturingLast winter, the Children’s Hospital Association, which represents 220 hospitals, anticipated a major supply disruption in albuterol treatments, which are given to children struggling to breathe. They turned to STAQ Pharma, an Ohio compounding pharmacy that makes custom batches of medications. The company ramped up production and helped ease the shortage. Such efforts are allowed only if a drug is on the official F.D.A. shortage list.The Association for Health System Pharmacists, a trade group, has proposed that the F.D.A. provide more information on the quality of such compounding pharmacies. Hospitals might otherwise hesitate to rely on them, given the history of problems at the New England Compounding Center, which was linked to 64 deaths after patients received tainted injections. The disaster led to criminal charges and civil settlements; the F.D.A. has since tightened requirements on such facilities.