Hello from Watamu.

I’m spending a few days on Kenya’s sunny Swahili coast with family and a few friends (it’s an easy one-hour flight from Nairobi). A highlight so far has been a sunset trip on an old wooden dhow, the sailing boats that merchants have plied the Indian Ocean with for over a thousand years.

This week’s newsletter, like last week’s, circles back to some of the biggest geopolitical crises shaping global health right now. We’ll look at more effects from conflict in Iran, the medical consequences of a fuel blockade on Cuba, along with a few other stories on broader global health funding and treaties.

My name is William Herkewitz, and I’m a journalist based in Nairobi, Kenya. This is the Global Health Checkup, where I highlight five of the week’s most important stories on outbreaks, medicine, science, and survival from around the world.

With that, as we say in Swahili: karibu katika habari — welcome to the news.

What happens if the water stops flowing

The ongoing Iran war is leaving a lot of industries at risk. Like oil and fertilizer production, global shipping, and even (as we discussed last week) medicine. But an interview in Think Global Health last week highlights what is arguably the most vulnerable piece of infrastructure: the plants that turn seawater into drinking water.

It’s a fact that Arabian Gulf nations depend more on desalination than anywhere else on Earth. In total, they produce between “45 to 50%” of the world’s desalinated water. It’s a necessity in a broader Middle East that has “6% of the world's population but less than 2% of renewable fresh water.”

That water, as the article notes, “underpins households, hospitals, schools, hygiene, and sanitation services.” And several early attacks and threats on desalination plants are raising alarms.

The article breaks down how Iran has accused “the United States of attacking a freshwater desalination plant on Qeshm Island,” Bahrain has said that “Iranian drone strikes damaged one of the country's 103 desalination plants,” and “after President Donald Trump threatened to obliterate Iran's power plants, [Iranian leadership] vowed to retaliate against Gulf water and energy facilities.” 

And on Monday, Trump escalated further, threatening to blow up “possibly all desalinization [sic] plants” in Iran if no peace deal is reached.

Now to be clear, the vast majority of the desalination plants in the Arabian Gulf are currently unharmed. But the story, and taking seriously the threats that the war could spiral toward these systems, has me wondering: How bad could it get if this war starts knocking desalination offline?

To discuss, I reached out to Peter Gleick of the Pacific Institute, one of the world’s leading water resource experts, and Kaveh Madani, director of the United Nations University Institute for Water, Environment and Health, and a former senior Iranian policymaker. The conversations were grim.

“If major desalination plants are attacked and damaged,” Gleick said, “there will very quickly be serious ramifications for public health,” with the worst effects in “countries with the greatest dependence on desalination for public supply, especially Qatar, Bahrain, and Kuwait.”

The issue isn’t just the fragility of these systems, Gleick says. It’s that for many nations, there is no real Plan B if they are destroyed. “Very few nations that rely on desalination have sufficient storage or backup alternatives if those plants were to be attacked,” he says. The logical alternative is groundwater, which has “long been seriously overpumped and overdrafted,” and is now "limited, typically of lower quality, and often not easily accessed in the volumes and locations that would be needed.”

Madani was largely in agreement, and said that generally speaking, “the smaller the state, the more vulnerable it is in this situation.” In countries like Bahrain, where 103 desalination plants provide more than 90% of drinking water for the population of 1.6 million, “in some cases the smaller states have only a few days or few weeks of water reserves” available if those plants are forced offline. 

And Madani said some of the most important risks are still being overlooked. For example, “to put a desalination plant out of service, you don't have to directly attack it,” he said. A power blackout can cripple these systems just as effectively as a bomb.

“And another risk we don’t hear much about is water quality disruption,” Madani said. Few environmental disasters rival a major oil spill. If the conflict leads to more “oil tankers being sunk or attacked,” the resulting spills will contaminate coastal waters and could force desalination plants offline.

Together, the experts I spoke with had a few clear takeaways: First, this conflict must change future water supply planning. Many Gulf nations’ reliance on a small number of massive desalination plants creates an enormous vulnerability. As Gleick put it, the best way to reduce that risk in the future will be to sacrifice some of the efficiency of those large systems and build “smaller, decentralized, and redundant systems,” instead. 

And of course, the rising threats to these facilities are also a reminder that drinking water systems are protected under international law. Under the Geneva Conventions, deliberately attacking civilian water systems (which is being actively threatened by both American and Iranian leaders) can constitute a war crime.

Stranded cholera aid

Last week we discussed how the Iran war is scrambling the movement of some global medicines. 

This week a Reuters report shows those consequences already bubbling up. Cholera aid for countries across Africa is now snarled in the disruption.

According to the article, “emergency cholera medical ​supplies for several African countries have become stuck in a logistical quagmire," with vital "stocks stranded in Dubai warehouses." 

• Disease breakdown: Cholera is a bacterial infection that infects up to 4 million people each year. It largely spreads through water contaminated with feces, and thrives where basic sanitation has broken down. (Think conflict or flooding.) Cholera’s horror is its speed. It causes sudden, violent diarrhea that can empty the body so quickly that stools turn a pale, milky white. Without treatment, cholera can kill in a matter of hours.

The timing here matters quite a lot. Cholera is a waterborne disease that often surges during rainy seasons. In some high-risk countries like Sudan and Chad, those rains begin around May. 

What’s stuck? The supplies in Dubai warehouses are essentially “mini field hospitals … with rehydration treatments, as well as chlorine to treat sewage and drinking water to prevent further spread.”

The good news is that the cholera situation on the continent is no longer as dire as last year, so this delay is less catastrophic than it might have been even just a few months ago. Last year I reported on how Africa was facing “the worst cholera outbreak in a quarter-century, with cases surging in countries as disparate as Sudan, Burundi, and Angola.” But Reuters reports that “so far in 2026, the number of cases is down by about 50% versus 2025.”

Still, progress on cholera can reverse quickly without a sustained medical response. As one World Health Organization official told Reuters, "We're talking [about] an ​explosive disease … If you don't have the time or the resources to control it in a matter of days or even ​hours, you would have an extreme contamination."

The Global Fund: doing more with less

(Fair warning. We’re about to dive back into some well-trodden Checkup territory: the wonderfully boring budgeting mechanics of global health finance.)

According to an early report of several background sources in Devex, the Global Fund (the international organization that bankrolls over $11 billion in programs fighting AIDS, tuberculosis, and malaria in more than 100 countries) is being tapped to play an increasingly important role in stabilizing global health programs after last year’s funding shortfall.

As one advocate told the outlet, “Everyone now looks to the Global Fund to ensure the continuity of critical health services.”

At least rhetorically, even U.S. officials are boosting the Global Fund. Jeremy Lewin, the senior State Department official tasked with foreign assistance, has called the Global Fund a “critical partner” in advancing the “America First Global Health Strategy.” (For reference, Lewin has been notably critical of international aid organizations; casting the United States as “suckers of the global system for so long.”)

The report describes a few early examples of this dynamic. In several U.S.–Africa bilateral health negotiations, the Global Fund has been asked to join the negotiations to provide technical guidance on programs it supports. Some of those bilateral agreements also purportedly reference its procurement platform, wambo.org, suggesting the United States may increasingly look to the fund to purchase medicines and keep programs running.

What’s my takeaway?

It’s a bit of a surreal moment. As we covered in December, the Global Fund’s latest fundraising round came up nearly $7 billion short of its target (!) and “a quarter less money than the fund received in the previous cycle.” The largest missing chunk of that shortfall was American dollars. If the Devex report is accurate, donor countries like the United States could be increasingly leaning on the fund … even as they cut the money that powers it.

Cuba: no electricity, no health care

Cuba’s fuel crisis is grinding the country’s health system to a halt, according to reporting in The New York Times.

Some background: A tightening U.S. oil blockade (and the sudden loss of Venezuelan oil shipment) has nearly eliminated fuel shipments to the island, triggering rolling, multi-day “nationwide outages.”

The story opens with a vignette that’s really stuck with me over the last few days. Jorge Pérez Álvarez, a 21-year-old Cuban man with a genetic lung disease survives only because a ventilator keeps him breathing. But power outages keep putting that machine onto a backup battery that’s repeatedly pushed to the brink. And when it dies … he does too. 

“His life depends on electricity,” his mother says.

And what does Jorge’s story look like… expanded across an entire health system? (Excuse the length of the following quote, but it really shows how widely the blockade is unraveling basic medical care.)

“Hospitals are canceling surgeries and sending patients home because doctors and nurses can’t commute to work. Clinics are struggling to administer treatments like chemotherapy and dialysis because of power outages. Many ambulances are parked because drivers can’t find gas. Pharmacies are largely empty because the virtually bankrupt state is struggling to buy medicine. Production of medicine has been mostly halted because factories run on diesel. Vaccine makers are searching for ingredients because flights that once carried them are canceled because of a lack of jet fuel. And refrigerated vaccine stocks could soon spoil if the blackouts continue.”

It’s a brutal reality for the people living in Cuba. 

What’s the takeaway? Over the weekend my mind kept wandering back to Jorge (and how his family could possibly cope.) So, for me, the story is a reminder that cold geopolitical decisions always land on real people. Surprisingly, late Monday the New York Times also reported that the United States just allowed a Russian oil tanker to break the blockade, which hopefully keeps Jorge alive.

Stalled pandemic negotiations

We’ll end this week at the WHO headquarters in Geneva where Health Policy Watch reports the negotiations over the final piece of a global pandemic treaty have stalled. 

“A snail would have a faster passage,” the article quips.

The sticking point is one final, unresolved section known as Pathogen Access and Benefit Sharing. Basically an agreement on how countries will share bacteria/virus samples of the next pandemic, and how medicines and tests developed from those samples will be distributed.

At the risk of oversimplifying it, the concern from many poorer countries is a repeat of Covid-19. Where these countries found themselves last in line for newly developed tests, vaccines, and treatments. As the article notes, they “want the assurance that if they share [information on the next pandemic], they will be able to benefit from any vaccines, therapeutics or diagnostics that are developed as a result.”

Meanwhile, several wealthier countries, including “those with powerful pharmaceutical industries … argue that compulsory benefit-sharing will stifle research and development.” And, to put a bit more bluntly, they are also reluctant to lock themselves into binding rules that might limit supply of lifesaving medicines in the future.

So what now?

It’s not clear. Some civil society observers are floating an uncomfortable option: forcing a vote to break the impasse. (Rather than wrapping up the treaty with unanimous consensus among member states.) That could push the agreement forward ahead of the World Health Assembly deadline in May… but it would also risk splitting the fragile consensus behind the pandemic treaty.

I’ll see you next week!

William

Thumbnail image by Getty Images