The Crisis of a “Old Drug” Running Out of Stock: When a Lifesaving Medicine Meets Unviable Business Logic
Hello everyone, I’m your financial journalist and economist. Today, we’re not talking about some exorbitantly expensive new cancer drug or a groundbreaking AI-based medical breakthrough, but rather a seemingly ordinary, even somewhat “old-fashioned” injection—Benzathine Penicillin G (BPG).
Recently, both Japan and the United States have received the same news: this “old drug” used to treat syphilis is running out of stock.
This might seem counterintuitive. Penicillin was invented nearly 80 years ago—how could it still be in short supply? And although syphilis is an embarrassing disease, it’s not considered a terminal illness in modern medicine. So why is a drug that costs just a few cents or dollars causing such headaches for developed countries, even putting pregnant women at risk?
Today, we’ll break down the logic behind this situation in simple terms.
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Summary of Key Points
In one sentence:
The resurgence in syphilis cases around the world has led to a surge in demand for the classic drug Benzathine Penicillin G. However, due to its low price, high production costs, and meager profits, as well as the extreme concentration of suppliers (only three Chinese manufacturers remaining), the supply chain is extremely fragile. Japan and the US, as major markets, are facing a severe shortage of this drug, which highlights the commercial challenges faced by “old drugs” in the modern pharmaceutical system: the technology is mature, but the business logic does not support their continued production.
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A Deeper Look at the Crisis from Five Perspectives
1. The Time Difference Trap: Japan Just Started Using the Drug When a Global Shortage Occurred
Many might wonder: Syphilis cases in Japan have only been on the rise in recent years, so why did the drug suddenly run out? Here’s a容易被 overlooked time difference:
- Increase in Cases and Changes in Treatment Habits: Japan’s syphilis reports began to rise in 2011, with over 10,000 cases per year since 2022. Before 2021, Japanese doctors did not routinely use Benzathine Penicillin (Stiliz) for treatment; instead, they used other antibiotics.
- New Drug Approval and Demand Surge: It was not until 2021 that Pfizer’s Benzathine Penicillin was officially approved for use in Japan. This means the Japanese medical system began to use this “old global drug” on a large scale, suddenly shifting demand from scattered to concentrated.
- Mismatch between Supply and Demand: Just as Japanese doctors got used to using this drug, the global supply chain was already under strain. In 2024, Pfizer announced a shortage of the 600,000-unit dosage, in 2025 the 2.4 million-unit dosage was recalled and restricted, and in 2026, production was completely halted.
In plain language: It’s like a neighborhood where everyone used to buy their own water, but suddenly the management decided everyone had to use a specific brand of premium mineral water. The factory couldn’t keep up with the global demand. Japan didn’t create the demand; it just standardized it, which coincided with a global production bottleneck.
2. The Hidden Single Point of Failure in the Supply Chain: Many Manufacturers, but the Lifeline is in the Hands of a Few
When you go to a hospital pharmacy, you see a variety of drug brands, suggesting ample supply. But if you look further up the chain, you’ll discover a surprising fact: the supply of this drug is in the hands of a very few companies:
- Extreme Concentration of Manufacturers: Research in 2024 showed that only three Chinese companies produce the raw material for Benzathine Penicillin (API).
- Apparent Diversification of Manufacturers: Although dozens of companies worldwide produce the final dosage forms (such as Stiliz in Japan and Bicillin L-A in the US), they all rely on these three Chinese factories for the raw material.
- Lack of Redundancy: If any of these three factories encounter quality issues, environmental regulations, or logistical disruptions, all downstream manufacturers will be affected. Moreover, due to the special nature of the raw material, it’s difficult for manufacturers to switch suppliers and re-certify the product.
In plain language: It’s like if there were only three chip manufacturers in the world; if one shuts down, all phones would be in short supply. The Benzathine Penicillin supply chain is similarly vulnerable. The simultaneous shortages in Japan and the US are not coincidental; both rely on the same fragile supply chain.
3. The Paradox of Business Logic: The Older the Drug, the Less Motivation to Produce It
Why don’t pharmaceutical companies produce this drug? Because it’s not profitable:
- Low Price: In low-income markets, a 2.4 million-unit dose of Benzathine Penicillin might cost only $0.20 (about 1.4 yuan).
- High Costs: It’s a sterile injection, requiring expensive facilities, strict quality control, and complex management.
- Meager Profits: Developing a new drug (like a cancer or weight-loss drug) can generate billions in sales, while producing this old drug yields very little profit, sometimes resulting in losses.
- Industry Withdrawal: Since the early 2000s, six raw material suppliers and more than 40 manufacturers have left the market. The remaining companies either continue production out of necessity or struggle to stay in business.
In plain language: It’s like asking a Michelin-starred restaurant to sell 1-yuan steamed buns. They can’t refuse, but the costs of maintaining their facilities, labor, and rent are higher than the profit from selling buns. The rational decision would be to focus on more profitable products. However, society needs steamed buns, not just luxury dishes.
4. Clinical Irreplaceability: For Pregnant Women with Syphilis, This Drug is the Only Solution
For ordinary cases of syphilis, doctors might use other antibiotics. But Benzathine Penicillin has a crucial role: it’s the only proven effective treatment for syphilis during pregnancy, preventing transmission to the baby.
- Uniqueness: The US CDC states that injectable Penicillin G is the only proven treatment for syphilis in pregnant women.
- Difficulty in Replacement: Other antibiotics either can’t cross the placenta or are less effective. If a pregnant woman is allergic to penicillin, a complex desensitization process is required before using it.
- Severe Consequences: A shortage could lead to untreated syphilis in the fetus, causing lifelong disabilities or death.
In plain language: It’s like the only emergency parachute on an airplane. You might think it’s rarely needed, but in an emergency, it’s the only hope for survival. In obstetrics, Benzathine Penicillin is that “emergency parachute.” Its value cannot be measured by market prices; it’s measured by lives.
5. Systemic Failure: It’s Not That Manufacturers Don’t Want to Produce, but the Disconnection Between Different Systems
Drug shortages are often not the fault of a single link; it’s a failure of the entire system:
- Manufacturers’ Perspective: “How much do I need to produce to be profitable?” If orders are sporadic, prices are low, and risks are high, manufacturers will reduce production or stop altogether.
- Hospitals’ Perspective: “How much do I need this year?” Hospitals usually purchase in quarterly or annual increments. If forecasts are inaccurate or funding is limited, they order less.
- The Gap Between the Two: When manufacturers reduce production and hospital stocks run out, a shortage is discovered. Finding new suppliers requires re-certification, which takes too long.
- Global Impact: The simultaneous shortages in Japan and the US indicate a global imbalance. The WHO points out that reasons include inaccurate demand forecasting, rigid procurement cycles, and insufficient funding.
In plain language: It’s like a game between supermarkets and factories. Supermarkets (hospitals) think “there won’t be a shortage,” so they order less; factories (pharmaceutical companies) think “profits are too low, risks are too high,” so they produce less. The result is empty shelves and no supplies. To solve this, we can’t blame the factories alone; we also need to consider whether purchasers are willing to pay for safety stocks and whether regulatory agencies have established flexible import and substitution mechanisms.
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Conclusion: Don’t Let “Old Drugs” Disappear from the Medical Landscape
This story serves as a reminder:
1. The capability of a pharmaceutical system lies not only in developing new drugs but also in ensuring the steady supply of essential, time-tested medications that have saved generations.
2. Business logic needs to be complemented by public policy. For drugs that are clinically necessary but have limited commercial viability, market mechanisms alone can lead to shortages. Governments may need to provide subsidies, long-term procurement agreements, and strategic reserves to support their production.
3. Supply chain security is part of national security. The high concentration of raw materials for critical drugs poses significant geopolitical and supply chain risks. Establishing diversified supply channels is not only a corporate responsibility but also a strategic consideration for nations.
Next time you see a drug that costs just a few dollars, think about the fragile global supply chain, the complex business dynamics, and the critical role it plays in saving lives. Don’t let it disappear from the medical supply list when patients need it most.