The closure of the Strait of Hormuz by Iran is usually discussed in the language of geopolitics and energy markets. It is a chokepoint for oil, a pressure valve for global trade, and a lever of military strategy. But beneath those familiar headlines lies a less visible system of dependency — one that connects a naval blockade in the Middle East to pharmacy shelves.
Commercial shipping through the strait remains roughly 90 percent below pre-war levels, while air-cargo capacity across the Gulf collapsed sharply in early March, driving a sudden contraction in global freight availability.
The immediate effects have been familiar: rerouted ships, higher insurance premiums, and volatile freight costs. Less visible is what those disruptions mean for the movement of pharmaceuticals — a sector that depends not only on production capacity, but on precise timing, stable temperatures, and a small number of highly concentrated transit hubs.
The result is not an imminent collapse of drug supply in the US or Europe as inventory buffers remain intact. But supply-chain experts warn that the war is exposing deeper vulnerabilities that stockpiles alone cannot solve — particularly for generics, biologics, emergency medicines, and clinical trial therapies.
How drugs move through the Gulf
The US remains almost entirely dependent on foreign countries for the active ingredients in our essential medicines.
—Christina Smolke, Antheia
“The Middle East only accounts for roughly 0.3 percent of global active pharmaceutical ingredient (API) production,” David Ghozland, a gynecologist and former President of the Los Angeles County Medical Association, told DDN. “But it occupies a critical logistics position. India supplies nearly half of all US generic prescriptions, and those medicines rely heavily on Red Sea shipping.”
Christina Smolke, cofounder and CEO of Antheia, echoed this point. “The US remains almost entirely dependent on foreign countries for the active ingredients in our essential medicines. Years of offshoring production, combined with a reliance on outdated manufacturing technologies, mean that regional bottlenecks can quickly translate into years-long shortages.”
The Gulf Cooperation Council (GCC) region has become one of the most important pharmaceutical transit zones in the world. The GCC connects Africa, Asia, Europe, India, and the US through a dense network of air-cargo hubs, seaports, and free-trade zones. Its pharmaceutical market is already valued at more than $23 billion, and is projected to more than double by 2033.
At the center of that network sits Dubai, whose primary air-cargo airport ranks among the world’s busiest. Pharmaceutical shipments arriving there are often warehoused, repackaged, and re-exported globally — a model that depends on uninterrupted airspace and cold-chain reliability.
Since the conflict intensified, that system has begun to fray. Cargo rerouting has forced pharmaceutical companies to move shipments via unconventional paths — trucking medicines between Gulf airports, diverting air freight to hubs in East Asia, or shifting some products to sea routes that lengthen journeys by weeks.
Generics and biologics under pressure
Disruptions are already showing up in APIs, excipients, and packaging, driving delays, increased freight costs, and planning volatility.
—Stella Vnook, Kaida Biopharma
Not all medicines are equally exposed. “Generics are impacted first due to thin margins, minimal inventory, and heavy dependence on Indian and Chinese manufacturing,” said Stella Vnook, cofounder and Acting CEO of Kaida Biopharma. “Disruptions are already showing up in APIs, excipients, and packaging, driving delays, increased freight costs, and planning volatility. For small biotech companies relying on contract manufacturing or repurposed molecules, these delays directly impact clinical timelines and capital efficiency.”
Cem Zorlular, CEO of Er-Kim, further emphasized the impact on generics. "When shipping costs and war risk surcharges spike, the cost to transport generics can exceed the product’s margins. This can result in the medicine existing, however, the global supply chain cannot afford to move it."
Ultra-cold chain therapies, monoclonal antibodies, immunotherapies, and other biologics are also particularly sensitive to transport disruption. These medicines require tightly controlled temperatures throughout their journey. If shipments are rerouted overland through extreme heat or diverted onto longer sea routes, the risk is not just delay but degradation.
“For a cancer patient on an immunotherapy regimen, it can be life-threatening,” Ghozland noted. “And it’s not just commercial medicines. Distribution for investigational therapies is tightly timed and geographically specific, and delays there will be felt by patients before any national shortage report reflects them.”
Cargo carriers estimate that for every week of air-freight disruption, it can take more than a week to recover capacity. That lag compounds quickly, particularly when multiple routes are affected simultaneously.
“Air freight capacity is highly sensitive to airspace restrictions, rerouting, and surcharges,” said Josh Medow, CEO of Mercury Shipping. “These pressures are already evident in parts of the Middle East, where reduced passenger flights have constrained cargo space. With fewer flights available, overall capacity tightens, and lower-priority shipments are increasingly at risk of being reassigned or delayed.”
Rerouting comes at a cost. Marine insurance premiums for vessels transiting conflict zones have surged, in some cases by more than a thousand-fold. Air-cargo rates out of India have risen sharply, prompting warnings that consumers could see drug prices increase within four to six weeks — particularly for generics, where freight costs make up a significant share of total expense.
However, it’s not all doom and gloom. “The immediate risk is not that patients will suddenly lose access to medicines tomorrow,” said Kathleen Jaeger, the US Spokesperson for the Indian Pharmaceutical Alliance. “Pharmaceutical manufacturers, distributors, and health systems generally plan extensively for geopolitical disruptions and often maintain three to six months of inventory buffers. Companies have been deliberately growing these stockpiles since the COVID pandemic disruption.”
Though Ghozland argues that this isn’t the case for every part of the framework. “Large distributors like McKesson and Cardinal carry only 25 to 30 days of stock.” Hospitals themselves are advised to maintain similar buffers, but in practice, only a minority consistently do so, constrained by cost and storage capacity. The result is a system that appears robust at the top but is considerably thinner closer to the point of care.
Learning from the COVID pandemic
The COVID-19 pandemic exposed many of these vulnerabilities, but while governments and industry responded with increased stockpiling and efforts to diversify supply, the underlying structural dependencies remained largely unchanged.
“The system has to be fixed so that disruption in one country doesn’t cascade globally,” Ghozland said. “We rely on India for generics, which in turn relies on China for its own APIs. The system has to be fixed such that disruption in one country can’t cause a major shortage.”
Smolke argued that addressing those dependencies will require a more fundamental shift in how medicines are produced. “We must leverage next-generation, agile manufacturing approaches like advanced biosynthesis and biomanufacturing,” she said. “Advanced biomanufacturing will enable the US to leapfrog conventional manufacturing processes and produce pharmaceutical ingredients domestically at a fraction of the cost and time.”
But even where manufacturing capacity exists, flexibility is not evenly distributed across the industry. “In practice, small biotech companies cannot quickly pivot suppliers, reroute materials, or substitute components without triggering regulatory review,” noted Vnook. “FDA requirements around API sourcing and manufacturing changes are necessary, but they also introduce rigidity that becomes a constraint during periods of disruption. Large companies can navigate this. Small companies cannot.”
The deeper problem, experts argue, is that the industry is still treating disruption as an exception rather than a baseline condition. Despite experiencing major shocks every two to three years — from pandemics to wars to climate-driven events — the system continues to react as though each crisis is an outlier, instead of designing for constant instability.
As Zorlular put it, “Resilience should not be just about stockpiling, but about being agile enough to maintain drug access when traditional models fail.” On the policy side, he added, that means payers must account for inevitable cost spikes during disruption to prevent access gaps for essential medicines. “Ultimately, we need a permanent blueprint for operating in an era of constant disruption — one where the supply chain is as sophisticated as the medicines it carries.”
