Why the War in Ukraine Could Make Root Canals More Difficult

Russia’s assault on Ukraine is being felt around the world, and the US healthcare system is not immune.

Both Russia and Ukraine are powerhouses in the supply of certain products – in this case, ammonium nitrate and natural gas. These raw materials, after being refined, can produce two gases that are crucial for the health system: nitrous oxide, commonly known as laughing gas, and helium. They are used in millions of procedures every day. And crimped supplies could make every root canal that much more painful and every MRI exam that much more expensive.

The disruption also represents more turbulence for the US healthcare system supply chain.

“The shortages we’re experiencing right now have been going on for years and so come as no surprise to anyone,” said Wally Hopp, a University of Michigan professor who specializes in medical supply chain. Hopp led a group convened by the National Academies of Sciences, Engineering and Medicine to present a March report on securing supplies for US industries.

These issues could have been addressed earlier by government and the private sector, Hopp said. “But now they can only scramble to deal with the crisis with the health of American citizens at stake,” he added.

The years since the start of the pandemic have been punctuated by supply chain issues. The infant formula shortage — which began after a Michigan plant closed due to contamination concerns — is just the most recent. Hospitals are facing a shortage of contrast dye used in diagnostic scans, the result of a covid lockdown at the Shanghai factory where most of it is produced. As a result, hospitals from New Jersey to Washington state have attempted to ration testing for the most serious cases. And at the start of the pandemic, the scarcity of personal protective equipment for frontline healthcare workers was a defining feature of the unprepared and haphazard response to covid.

These shortages are among the most pressing patient safety issues today, safety organization ECRI said in a January roundup of the year’s top safety issues. Shortages ranked second. “Unavailability of products could result in an inability to treat patients and protect staff, which could result in injury, illness or even death to patients and clinicians,” the summary states. He noted that many regions have few key providers, which means a problem in a distant corner of the world could send dominoes falling through the US healthcare system.

The impact is felt in the innards of body scanners and other medical machinery.

“Helium is a terrific element for diffusing heat,” said Bob Karcher, contract services manager for Premier, a company that offers group buying services to vendors. “It’s used in large MRIs and CT scans, to draw heat away from the source.”

Hopp said the helium supply had been tight for some time and the war had exacerbated the problem.

Russia now sends relatively smaller amounts of natural gas to Western countries. This has prompted other countries to transport gas to these countries via pipelines, rather than shipping it in liquid form. These decisions affect helium supply because converting natural gas to liquid involves removing traces of helium, so shipping by pipeline has the unintended consequence of reducing the amount of helium available for industrial use.

Other idiosyncratic factors are also negatively affecting supply: for example, a Texas facility that produces helium continues to be shut down for a security breach.

All of this means higher costs for suppliers. Hopp said he’s seen estimates that helium costs were around $34,000 per MRI machine in 2019. “It’s definitely higher than that now and it’s going even higher,” said he declared. “Even worse, I’ve seen speculation from health systems that the shortage may become severe enough to force them to shut down MRI machines.”

David Facchini, director of radiology at Yale New Haven Hospital in Connecticut, said the effects would likely affect community hospitals the most. In the long term, he suggested, manufacturers could build machines that don’t need helium. But that’s “in months or years,” he said.

Helium isn’t the only gas missing. Nitrous oxide is mainly used by dental practices during surgical procedures. About 40% of the ammonium nitrate, the source of laughing gas, comes from Russia.

Premier “sees pricing pressures, rising costs,” said senior manager Donna Craft. This is likely to hurt dental practices, which generally receive an allowance based on normal, habitual use. As the country emerges from pandemic shutdowns, this baseline may be too low for practices to see more patients or attempt to expand.

Additionally, Karcher warned, the medical sector may find it difficult to secure noble gases. Suppliers might prefer to buy their wares from higher bidders outside of health care.

ECRI says healthcare providers relied on a “just-in-time” inventory strategy, that is, deliberately keeping supplies low in stock to avoid inventory costs. This strategy is reasonable when everything is quiet. It’s less tenable when there’s a big earth war and a pandemic.

Because these grunts are the product of decisions made years ago and resolving them requires more than quick sewing work, short-term reactions are “usually too little, too late,” Hopp said. “Once a full-fledged supply shortage is underway, the options available to the government are narrow.”

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