I’ve been writing about drug shortages at this blog for almost 15 years. My most recent entry was in April 2020, when a major global health crisis was disrupting access to medicines and putting essential drugs into short supply. But over the past week I’ve been reading new columns about current events and their anticipated effects on the worldwide distribution of medicines. Some are predictable but some are less obvious. But the impact has been similar: Systems optimized for efficiency are vulnerable to disruption. The effective closure of the Strait of Hormuz and of several Mideast airports are exposing a reality of pharmaceuticals today: Efficiencies have built fragility into supply chains.
What’s happening now?
The Iran conflict has obviously created fuel supply issues, which are getting most of the headlines. But countless other essential products pass through this region, and it’s affecting the global distribution of medicines. Commercial activity through the Strait of Hormuz is running at a fraction of pre‑conflict levels, and air cargo rates are surging as Gulf airport capacity has plummeted. To be clear, I have not yet seen any widespread drug shortages on account of this disruption, but it could be because of existing inventory buffers: many manufacturers hold months of stock, and national/regional/local purchasers may also keep some inventory on hand.
The current state is not yet a crisis, but it is revealing strains. It echoes pandemic-era supply issues and illustrates that efficiencies in the system do not cope well with disruptive change. In the pandemic, the primary issue was lockdowns affecting manufacturing of active pharmaceutical ingredients (APIs) and their distribution. Today, it’s distribution bottlenecks and cost shocks. Both reveal system fragility. It is already being seen in how care is being delivered in conflict‑affected regions. In The Lancet, Mark Lawler of Queen’s University Belfast, notes that global cancer care is still recovering from disruptions caused by the pandemic, and this conflict could threaten quality care:
In many countries, cancer systems were already under pressure from financial constraints and the lingering impact of COVID-19. “Conflict layers an additional shock onto systems that are already fragile, and that can tip them over the edge”, Lawler said. Among the most immediate threats is disruption of medicine supply. “Even a short interruption in supply routes can quickly mean patients are not getting treatment at the time they should, or only receiving part of their treatment.” Because several cancer therapies must be administered on strict schedules, delays can have direct consequences for outcomes. “Quite quickly you can move from a system that is coping to one under severe strain, and that is when the cracks begin to appear”, Lawler added.
The importance of the Gulf
A less obvious vulnerability is not where drugs are made, but how they move. The Gulf—particularly Dubai—functions as a global pharmaceutical transit hub and has a disproportionate effect on the worldwide distribution of pharmaceuticals. As Think Global Health notes:
Dubai is central in this network. Its primary air-cargo airport—the world’s eleventh largest as of 2024—functions as a major pharmaceutical re-export hub, where medicines arrive, are warehoused, and then are shipped globally. CEVA Logistics, DHL, and DP World—Dubai’s pharmaceutical supply-chain logistics giants—have significantly grown the emirate’s pharmaceutical and health-care distribution footprint by expanding re-export and cold-chain capacities. They also capitalize on proximity to the Jebel Ali Free Zone, whose container port is the ninth largest in the world.
Dubai’s air-cargo capacity is almost 4 million tons annually. Considering the conflict-driven drop in the region’s cargo capacity, and that pharmaceuticals account for 4% of global air freight, the emirate could lose out on processing more than 10,000 tons of pharmaceutical air freight this March. These airspace disruptions are also spilling over into global-health emergency supply-chain response, and the World Health Organization’s (WHO) Dubai hub operations are currently on hold.
Which drugs are vulnerable?
Three categories of drugs seem to be at highest risk of supply shortages, based on their characteristics.
- Temperature‑sensitive medicines: Vaccines, insulin, and drugs like biologics must be stored within a narrow temperature range throughout transit to avoid accelerated spoilage. Delays, and even worse, potential temperature variations increases the risk that drug quality may be compromised – an unacceptable situation for medicines that can be lifesaving.
- Short‑shelf‑life and high‑value products: Some drugs already have short shelf lives. Disruptions to their distribution may mean that medicines, when they arrive at their destination, must be used quickly or will expire before they can be used. The longer supply interruptions exist, the greater likelihood of impact.
- Generic drugs: Generic medicines make up a huge volume of current pharmaceutical markets, and are the backbone of hospitals and public insurance programs. Their low prices and cutthroat price competition have pushed margins low, and as I noted in past posts, consolidated production to fewer places worldwide. Because generics are already produced with thin margins, with manufacturing consolidated to a small number of facilities worldwide, spikes in energy and shipping costs may push some manufacturers to cut or exit low‑profit lines, or raise prices significantly. Either will cause supply issues and price spikes, which means purchasers need to find substitutions, implement rationing or even look at compounding.
The consequence of efficient systems
The current disruption is a reminder that drug shortages are not random failures. They are predictable outcomes in a system optimized for cost and efficiency, with little margin for error when shocks, geopolitical or otherwise, appear. Recognizing that is the first step toward building more resilient supply chains and more honest conversations about the trade‑offs between low prices and reliable access for patients. A more resilient system will not be as efficient, and that likely means higher costs.
When shortages make the headlines, they’re often treated as isolated, one‑off issues. Current events highlight that shortages are the consequences of supply chains with few redundancies that wrap around the world. No nation is immune, and the solution requires rethinking incentives, infrastructure, and visibility, not just rhetoric about “resilience” and “sovereignty”. Like I wrote almost fifteen years ago, no one “owns” the supply issue, and there is no single cause of medicines shortages. The challenge is building accountability for drug supply throughout this complex pathway. If we are unwilling to change this system, we are implicitly accepting drug shortages as a permanent feature of it.