With over 270 active drug shortages and growing global instability, the United States must protect itself from a worsening crisis in cancer care. The fragile supply of generic chemotherapy drugs like cisplatin, which is important for treating bladder, lung, and testicular cancer, could collapse if geopolitical tensions between India and Pakistan escalate further. To preserve this diminishing supply, the U.S. must reduce its overreliance on Indian pharmaceutical manufacturing and diversify its sourcing to avoid the inevitable patient suffering.

The U.S. reliance on Indian drug manufacturers

The U.S. pays only about twenty percent of total prescription spending on generics mostly manufactured in places like India. Yet these drugs account for over ninety percent of prescriptions. Our reliance on these low-price generics, however, makes our pharmaceutical supply chain acutely vulnerable to disruptions such as geopolitical tensions between India and Pakistan.

Drug shortages in the U.S. are not new, but they are increasingly dangerous. These shortages can delay care, increase costs, contribute to medication errors, and force patients to rely on unfamiliar substitutes. Generic chemotherapy agents are most vulnerable. So why do we not just make generics in the U.S.? In 2019, the CEO of Teva Pharmaceuticals stated, “Nobody is making money on generics in the U.S.” Manufacturers face razor-thin margins, high labor costs, and regulatory overhead. Competing with India’s low prices is nearly impossible without significant government support. As a result, U.S. firms have little incentive to produce drugs like cisplatin domestically, even if they are essential for patient care.

Instead to maintain profitability, many pharmaceutical firms outsource production to countries with lower labor and operational costs. Indian manufacturers benefit from economies of scale. Hubs in cities like Hyderabad allow for high-volume production and streamlined processes, reducing per-unit costs. This specialization has made India indispensable to the global drug supply, but dangerously central to U.S. pharmaceutical stability.

Current political instability of India and its potential effects

Tensions between India and Pakistan date back to 1947, when the partition of British India created two separate states: India, with a Hindu majority, and Pakistan, with a Muslim majority. Disputes over the culturally and strategically significant region of Jammu and Kashmir have led to multiple conflicts, most notably in 1965 and 1971, and were further destabilized by the introduction of nuclear weapons into both countries’ arsenals. The most recent flashpoint occurred on April 22, 2025, when militants killed twenty-five Indian nationals and one Nepalese tourist in Kashmir. Since the attack, trade routes have narrowed, border tensions have flared, and diplomatic relations have turned.

While we can only predict the effects political instability on supply trade, history has shown the influence of supply trade disruptions. In 2023, Intas Pharmaceuticals suspended production of cisplatin at its Western India facility. With only four major global manufacturers of the drug, U.S. oncologists scrambled to find alternatives. The shortage revealed how brittle the system really is and how quickly it can collapse.

When political instability disrupts trade, pharmaceutical supply chains suffer affecting U.S. consumers. Manufacturing priorities can shift inward, with countries focusing on domestic needs during times of conflict. This nationalism results in export restrictions or tariffs on critical drugs. Although designed to stabilize a local economy or assert political strength, these policies can inadvertently cripple the global supply chain for vital medications like cisplatin. The U.S., heavily dependent on imports of generic cancer drugs especially from India, becomes a collateral victim of conflict thousands of miles away.

Consequences and solutions to supply trade disruptions

The consequences of this inaction are clear. Drug shortages remain stubbornly high, and tensions between India and Pakistan show no signs of dissolving. A 2023 study in European Journal of Operational Research modeled how export bans could lead to global shortages. The findings were clear: Pharmaceutical firms that planned ahead were better able to mitigate supply chain risks. Governments that supported domestic capacity could buffer the fallout. The most effective strategy was one that used multiple variables such as regulation, trade policy, supply and demand, manufacturing capacity, and geopolitical risk within a comprehensive preparedness framework.

The U.S. cannot afford to treat global drug supply chains as stable or resilient. With new political and military risks rising in South Asia, particularly between India and Pakistan, America must treat access to cisplatin, and other generic cancer drugs, as a national security issue. We must plan now to protect patients later.

Adwait Chafale is a medical student.