Hello from Nairobi.

We had a lovely, long Easter weekend. (Both Good Friday and the Monday after Easter are national holidays here.) And later this week, I’m planning on driving some visiting family upcountry to the foothills of Mount Kenya, where we'll see the last two northern white rhinos in the world.

This week’s stories cover some (déjà vu triggering) disruptions to U.S. medical aid, the rollout of a promising HIV prevention drug, the growing damage war is inflicting on Iran’s health system, among a few other stories. 

My name is William Herkewitz, and I’m a journalist based in Nairobi, Kenya. This is the Global Health Checkup, where I highlight some 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.

A proposal for more U.S. medical aid disruption

The United States is preparing a major, disruptive overhaul in how it delivers HIV and malaria aid, Reuters reports. The proposed changes represent an “upheaval likely to cause more medicine shortages” and risk “a second dislocation of life-saving services in just over a year,” across Africa and Asia.

Some background: For the last 10 years, the United States has routed a fairly astonishing volume of medical supplies through one large program called the Global Health Supply Chain Program — Procurement and Supply Management, which is run by the for-profit company Chemonix. Just how much? Between 2016 and 2024, that program “delivered a total of more than $5 billion of HIV and malaria products to 90 countries,” making the United States by far the largest funder of these tests and medicines worldwide.

But, according to the Reuters investigation, State Department leadership has asked “staff in 17 African countries and Haiti in an ​email [on March 31] to cease implementing the supply program by May 30.” 

The program will theoretically be replaced by new systems set up under “bilateral agreements with other countries” and private distributors, which would have to be negotiated extremely quickly.

All told, the month-and-a-half timeline is raising concerns about “immediate risks to service continuity if the transition is rushed or incomplete,” with potential shortages of HIV drugs, malaria treatments, and other basic health supplies millions of people rely on. As the article outlines, ordering and shipping medical supplies to remote clinics can take many months.

The directive “did not lay out a clear transition plan, instead asking each U.S. country office to set ​out how it would implement the handover, and to inform Washington of any risks or need for more time.”

I reached out to a senior, overseas State Department official with direct knowledge of the program, who agreed to speak on background to provide context. 

My source confirmed the broader uncertainty around the transition. To their knowledge, even basic guidance on the proposed upheaval (including the email referenced in the Reuters report) has not yet circulated across all countries served by the program.

They echoed the strong concerns in the Reuters report that such a severe and rapid disruption could lead patients without lifesaving medicines. But what I found most interesting is that they noted that even if the United States ultimately shifts medical procurement to the international organization the Global Fund (an option that we reported on last week) simply purchasing medical supplies is only part of the coming challenge. 

What remains dramatically unclear is the rest of the supply chain: warehousing, logistics, and actually getting drugs into clinics. 

At the risk of getting too in-the-weeds: These risks may be especially acute in countries where the State Department did not inherit parallel supply systems from the now-defunct U.S. Agency for International Development that could temporarily absorb the shock. (In other words, some countries have backup systems to keep medicines flowing. Others do not.)

My takeaway: It’s still unclear how much of this proposal will actually move forward, or whether the State Department may walk back the plan or timeline. I’ll be following this story closely.

Is there enough of this game-changing HIV prevention drug?

Late last year, a new injectable drug to prevent HIV infection called lenacapavir began rolling out in several African countries. The drug has generated enormous excitement because a single injection protects people for about six months, and it provided close to perfect protection in clinical trials.

But that early rollout is already raising questions. In Eswatini, which received the drug first and has the world’s highest rate of HIV, clinics are already running through their tiny initial shipments, The Guardian reports. 

One clinic only “received 130 doses.” Nationally, only a few thousand people have started the drug so far. (Keep in mind, a quarter-million people in Eswatini are HIV+). As one source in the story put it, “The coverage so far has been very, very, very low. But my impression is that interest is extremely high.”

The story raises an obvious question, and also had me wondering if this goes beyond one country: Is lenacapavir’s wider rollout already being hampered by supply limits? To ask, I reached out to Mitchel Warren, executive director of the AIDS Vaccine Advocacy Coalition, who we last spoke to about lenacapavir in October. 

To start, Warren told me to pump the brakes. It is still early days. While “the initial deliveries are quite small to each country … it is actually too early to tell about the actual supply constraints (if any),” he said.

Warren noted that countries like Kenya, Nigeria, and Zimbabwe only just received their first shipments last month. “So we don’t yet know that demand is truly outstripping supply — yet.”

Still, Warren said the bigger picture for HIV prevention is far from reassuring amid the broader pullback in global health aid. 

As he put it: “This continues to be a moment of cruelest irony — our best opportunity in HIV prevention coming at the worst time politically and economically.” While there is enormous potential for this new drug, “the foundational programs [which would deliver it] have been severely curtailed, and in some cases entirely decimated.”

Warren also left me with one note that’s often missing from lenacapavir coverage. HIV prevention, he says, “has always been more than a product — it is a program.” And without outreach, testing, and health systems that bring people back every six months, even a “miracle drug” (as the Guardian piece put it) won’t stop the epidemic.

Iran’s civilian health system under fire

For the third week in a row, we’re returning to the Iran war. Granted, it’s been evolving on a fairly volatile timeline, so much of what we know will likely change in the coming days. 

As I write this on Tuesday, the United States is maintaining threats to attack Iranian power plants, bridges, and other civilian infrastructure if Iran does not reopen the Strait of Hormuz. Iran is threatening similar retaliation to neighboring countries. Under international law, these are war crimes, and the potential consequences for civilian health and survival could be enormous.

To some extent, that damage is already underway. Al Jazeera reports that U.S. and Israeli strikes have already hit major parts of Iran’s health system. This includes a psychiatric hospital, a pharmaceutical company, and the Pasteur Institute of Iran, “the oldest and most prestigious research and public health center in Iran,” which has “played a central role in fighting endemic diseases such as smallpox and cholera.”

The World Health Organization says it has verified “over 20 attacks on health care in Iran,” resulting in “at least nine deaths,” including an infectious diseases health worker and a member of the Iranian Red Crescent.

More broadly, WHO Director-General Tedros Adhanom Ghebreyesus warned that “the conflict in Iran, and the region, is impacting the delivery of health services and the safety of health workers, patients, and civilians present at health facilities.”

Argentina: easier monopolies for medicines?

After pulling out of the WHO last month, Argentina has made another significant policy shift. The government has scrapped guidelines that limited which medicines could qualify for pharmaceutical patents, according to an essay in Health Policy Watch by leaders in the affordable-medicines advocacy arm of Doctors Without Borders.

Put simply, the essay argues that Argentina has essentially made it easier for pharmaceutical companies to stretch out monopolies by re-patenting small tweaks to existing drugs. (Imagine a company simply rejiggering a new dose of an existing drug, and then re-patenting it just as the original patent was about to expire.)

Ultimately, these patent extensions push generic competitors out of the market for longer, and keep prices much higher. As an example, the authors reference a hepatitis C treatment that dropped from “$147,000 to $120 per person” once generics were allowed to compete.

You may be asking: Why is this (admittedly niche) policy shift for a single country worth covering?

Well, the authors argue that Argentina's previous “more disciplined system” of patent rules showed how governments could apply strict standards, while still rewarding real innovation. By rolling those rules back, they warn, Argentina risks weakening a model other countries have looked to when trying to limit pharmaceutical monopolies. 

As for my takeaway? This story touches on a tension I run into constantly covering global health. Alongside government-funded R&D, private companies are our greatest engine of drug innovation. The big question is how and where we should draw the line between incentivizing companies to invent lifesaving medicines … and demanding those medicines remain affordable once they exist.

Honestly, I’m reluctant to even, say, cast drug patents as a “necessary evil.” As uncomfortable as they are, monopolies ultimately allow companies to recoup the enormous cost of developing new medicines. And there’s nothing shameful in that. When there’s no profit to be made (as we see constantly with the entire field of “neglected tropical diseases”), the results often fall between grim and hopeless. 

Human greed is a powerful force! Companies should see value in investing in the medicines we all rely on. But keeping that greed in check is just as important, and I think Argentina is failing in the latter to serve the former.

A ‘mysterious skin disease’ in Pakistan

We’ll finish on a small but worrying report out of Pakistan that's worth flagging. At least nine children have died in the country’s southeast Sindh province from what officials have described as a “mysterious skin disease,” though the cause has not yet been identified, Pakistan Today reports. 

On Monday, “samples from eight affected children had been sent to Karachi [the capital of the province] for testing,” but results have not yet been released.

It’s too early to know what this actually is, although the big worry is a novel outbreak. Local officials have suggested possibilities including chickenpox or mpox. (Although additional reporting suggests that while mpox has been detected in some of the cases, health officials say it was not the direct cause of the deaths.)

With no diagnosis yet and only local reporting so far, this may ultimately turn out to be a familiar disease rather than something new. Still, unexplained childhood deaths are always worth watching closely, and I’ll keep an eye out for further reporting.

I’ll see you next week!

William

Thumbnail image by Getty Images