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Decades of underfunding, blockade have weakened Gaza’s health system − the siege has pushed it into abject crisis

Hospitals have been destroyed, and doctors and health care staff killed. Gaza’s health services may take years to recover, warns a Palestinian health…

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A health service on its knees. Abed Zagout/Anadolu via Getty Images

For the wounded, injured and sick in Gaza, there is seemingly no escape. On Oct. 17, 2023, news broke that at least 500 patients, staff and people seeking shelter from Israeli bombs had been killed in an explosion at a hospital, according to health authorities in the Hamas-run enclave.

It amounts to a devastating loss of life during a campaign of bombing that has not spared the frail or sick. Just days earlier, the World Health Organization said in a stark assessment that an order to evacuate from hospital beds and head south amounts to a “death sentence.”

By that time, four hospitals had already ceased functioning in Gaza’s north because of damage from Israeli bombs.

Beyond the sheer immediate devastation of the current conflict – in which thousands of Israelis and Palestinians have been killed – there will be significant and undoubtedly long-lasting implications for the Gaza Strip’s health system.

As a Palestinian expert in global health who has worked with medical professionals from Gaza, I know that even before this latest escalation of violence, health services in Gaza were in a poor shape. Insufficiently and poorly resourced for decades, doctors and hospitals also had to contend with the devastating effects of a 16-year blockade imposed by Israel, in part with coordination with Egypt.

A system completely overwhelmed

The immediate concern in Gaza is for those seeking assistance due to the bombing campaign that Israel ordered after an attack on its people by Hamas fighters. An expected ground offensive will only further risk more civilian casualties.

Hospitals in Gaza are completely overwhelmed. They are seeing around 1,000 new patients per day, in a health system with only 2,500 hospital beds for a population of over 2 million people. It has forced hospitals to tend to patients in corridors and nearby streets. People maimed in the bombing are being treated for horrific injuries without basics such as gauze dressings, antiseptic, IV bags and painkillers. Those experiencing traumatic injuries are unable to receive sufficient care, increasing rates of infection and amputation.

Paramedics roll over a man on a a gurney.
A citizen receives first aid at a hospital in Khan Yunis, Gaza, on Oct. 16, 2023. Abed Zagout/Anadolu via Getty Images

And things may soon get worse. According to the United Nations’ Office for the Coordination of Humanitarian Affairs, Gaza’s hospitals have been forced to work without electricity, using fuel to run generators to ensure life-saving equipment remains functioning. The U.N. estimates this fuel will run out any day due to a complete siege placed on Gaza by Israel.

Such conditions have led to concerns that alongside the massive number of bombing victims, Gaza health services will soon have to contend with the outbreak of disease. Patients with immediate health needs, like dialysis or chemotherapy, are among those being ordered to leave and head for greater safety in Gaza’s south, although evacuation routes have also been bombed.

A century of underfunding

The current devastation to Gaza’s health system is obvious. But Gaza’s health care system was already under stress before the latest bombardment. In fact, policies that stretch back decades have left it unable to meet even the basic health needs of Gaza’s residents, let alone respond to the ongoing humanitarian catastrophe.

In just over a century, the health system in Gaza has been administered by six authorities: the Ottomans until the end of World War I, the British during the mandate period from 1917 to 1947, Egypt from 1949 to 1967, Israel under occupation starting in 1967, and then a Ministry of Health led first by the Palestinian Authority from 1995-2006 and since then by Hamas.

What each have had in common is that, from my perspective as a global health expert, they invested little in Palestinian health. For periods of the 20th century, the health priorities of successive governing bodies appeared focused more on reducing the spread of communicable disease to protect foreigners interacting with the native Palestinian population.

There was seemingly far less attention paid to building health infrastructure, adequately training health personnel, promoting preventive care and other long-term initiatives that make up a sustainable health system.

Under Israeli occupation from 1967, several Palestinian hospitals were turned into detention centers or military offices, while others were closed, and new ones were prohibited from opening. Palestinian physicians working in the occupied territories earned one-third the salary of their Israeli counterparts.

As a result of this neglect, health indicators throughout what are now called the occupied territories – the West Bank and Gaza Strip – have been poor.

Maternal and infant mortality – typical indicators of health system functioning – tends to be high. For example, in the mid-1980s, infant mortality was over 30 per 1,000 live births for Palestinians, compared with just under 10 per 1,000 among the Jewish population of Israel. And infant mortality has remained stubbornly high in Gaza.

Meanwhile, a lack of a reliable drinkable water infrastructure and overall unsanitary conditions resulted in the spread of parasitic and other infectious diseases, like rotavirus, cholera and salmonella – which remain leading causes of death in Gaza’s children.

Dying before they can leave

Most residents of Gaza fled there in 1948 after being displaced from their homes in what became the state of Israel. They were classified as refugees, many receiving limited services from the United Nations Relief and Works Agency for Palestine Refugees in the Near East that was established in 1949.

Since then, chronic underfunding of public hospitals has meant that Palestinians in Gaza have remained reliant on outside money and nongovernmental organizations for essential health services. This started a trend of humanitarian dependence that continues to this day, with many of Gaza’s health facilities funded by the United Nations, humanitarian agencies like Doctors Without Borders and religious organizations.

During the passage of the Oslo Accords in the mid-1990s, the Palestinian Authority was established to administer services in the occupied territories. The accords called for health responsibilities to be transferred to the newly formed Palestinian Ministry of Health as preparation for a sovereign Palestinian state, which the accords called for within a five-year period.

The Palestinian Authority received a significant influx of humanitarian aid as it took on civil responsibilities, including health. As a result, health indicators for Palestinians, including life expectancy and immunization rates, started to improve in the late 1990s.

But as it became increasingly clear that the overarching goal of the Oslo Accords for Palestinians – statehood – would not materialize, disillusion with the Palestinian Authority led to victory for Hamas in 2006 elections held in Gaza. Since then, Hamas has been considered the de facto governing body in Gaza, while the Palestinian Authority operates in the West Bank.

The rise of Hamas, which the U.S., Israel and others designate as a terrorist group, saw Gaza become isolated from the international community. It also coincided with Israel imposing a full land, sea and air blockade of Gaza.

There is no doubt that the blockade has rapidly accelerated the deterioration of the health system in Gaza and directly impacted the mortality rate.

Gazans who need advanced care, whether for cancer or other chronic illnesses, traumatic injuries and other life-threatening ailments, often can only access needed services in Israeli hospitals and require a permit to cross the border from Gaza. Some die before the permit process is complete.

Gaza health services after the siege

This vulnerable health system is now facing unprecedented challenges, staffed by health professionals who have committed to stay with their patients even under hospital evacuation orders and at risk of death.

It is uncertain what the health system of Gaza will look like in the future.

In years past, international aid would help repair and rebuild some, but not all, of the infrastructure damaged in airstrikes, especially schools and hospitals.

But Israeli Prime Minister Benjamin Netanyahu has promised a “long and difficult war.” And with the level of destruction seen in just a few days, it remains unclear just what will be left in the aftermath.

Already at least 28 doctors and other health workers have been killed in Gaza, with ambulances and a number of hospitals rendered useless by the bombs.

Replacing this human capital and vital infrastructure could take years, if not generations – and that is without the limits of a punishing blockade and continued bombardment.

This article was updated on Oct. 17, 2023 to add news of an airstrike on a Gazan hospital.

Yara M. Asi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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Four burning questions about the future of the $16.5B Novo-Catalent deal

To build or to buy? That’s a classic question for pharma boardrooms, and Novo Nordisk is going with both.
Beyond spending billions of dollars to expand…

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To build or to buy? That’s a classic question for pharma boardrooms, and Novo Nordisk is going with both.

Beyond spending billions of dollars to expand its own production capacity for its weight loss drugs, the Danish drugmaker said Monday it will pay $11 billion to acquire three manufacturing plants from Catalent. It’s part of a broader $16.5 billion deal with Novo Holdings, the investment arm of the pharma’s parent group, which agreed to acquire the contract manufacturer and take it private.

It’s a big deal for all parties, with potential ripple effects across the biotech ecosystem. Here’s a look at some of the most pressing questions to watch after Monday’s announcement.

Why did Novo do this?

Novo Holdings isn’t the most obvious buyer for Catalent, particularly after last year’s on-and-off M&A interest from the serial acquirer Danaher. But the deal could benefit both Novo Holdings and Novo Nordisk.

Novo Nordisk’s biggest challenge has been simply making enough of the weight loss drug Wegovy and diabetes therapy Ozempic. On last week’s earnings call, Novo Nordisk CEO Lars Fruergaard Jørgensen said the company isn’t constrained by capital in its efforts to boost manufacturing. Rather, the main challenge is the limited amount of capabilities out there, he said.

“Most pharmaceutical companies in the world would be shopping among the same manufacturers,” he said. “There’s not an unlimited amount of machinery and people to build it.”

While Novo was already one of Catalent’s major customers, the manufacturer has been hamstrung by its own balance sheet. With roughly $5 billion in debt on its books, it’s had to juggle paying down debt with sufficiently investing in its facilities. That’s been particularly challenging in keeping pace with soaring demand for GLP-1 drugs.

Novo, on the other hand, has the balance sheet to funnel as much money as needed into the plants in Italy, Belgium, and Indiana. It’s also struggled to make enough of its popular GLP-1 drugs to meet their soaring demand, with documented shortages of both Ozempic and Wegovy.

The impact won’t be immediate. The parties expect the deal to close near the end of 2024. Novo Nordisk said it expects the three new sites to “gradually increase Novo Nordisk’s filling capacity from 2026 and onwards.”

As for the rest of Catalent — nearly 50 other sites employing thousands of workers — Novo Holdings will take control. The group previously acquired Altasciences in 2021 and Ritedose in 2022, so the Catalent deal builds on a core investing interest in biopharma services, Novo Holdings CEO Kasim Kutay told Endpoints News.

Kasim Kutay

When asked about possible site closures or layoffs, Kutay said the team hasn’t thought about that.

“That’s not our track record. Our track record is to invest in quality businesses and help them grow,” he said. “There’s always stuff to do with any asset you own, but we haven’t bought this company to do some of the stuff you’re talking about.”

What does it mean for Catalent’s customers? 

Until the deal closes, Catalent will operate as a standalone business. After it closes, Novo Nordisk said it will honor its customer obligations at the three sites, a spokesperson said. But they didn’t answer a question about what happens when those contracts expire.

The wrinkle is the long-term future of the three plants that Novo Nordisk is paying for. Those sites don’t exclusively pump out Wegovy, but that could be the logical long-term aim for the Danish drugmaker.

The ideal scenario is that pricing and timelines remain the same for customers, said Nicole Paulk, CEO of the gene therapy startup Siren Biotechnology.

Nicole Paulk

“The name of the group that you’re going to send your check to is now going to be Novo Holdings instead of Catalent, but otherwise everything remains the same,” Paulk told Endpoints. “That’s the best-case scenario.”

In a worst case, Paulk said she feared the new owners could wind up closing sites or laying off Catalent groups. That could create some uncertainty for customers looking for a long-term manufacturing partner.

Are shareholders and regulators happy? 

The pandemic was a wild ride for Catalent’s stock, with shares surging from about $40 to $140 and then crashing back to earth. The $63.50 share price for the takeover is a happy ending depending on the investor.

On that point, the investing giant Elliott Investment Management is satisfied. Marc Steinberg, a partner at Elliott, called the agreement “an outstanding outcome” that “clearly maximizes value for Catalent stockholders” in a statement.

Elliott helped kick off a strategic review last August that culminated in the sale agreement. Compared to Catalent’s stock price before that review started, the deal pays a nearly 40% premium.

Alessandro Maselli

But this is hardly a victory lap for CEO Alessandro Maselli, who took over in July 2022 when Catalent’s stock price was north of $100. Novo’s takeover is a tacit acknowledgment that Maselli could never fully right the ship, as operational problems plagued the company throughout 2023 while it was limited by its debt.

Additional regulatory filings in the next few weeks could give insight into just how competitive the sale process was. William Blair analysts said they don’t expect a competing bidder “given the organic investments already being pursued at other leading CDMOs and the breadth and scale of Catalent’s operations.”

The Blair analysts also noted the companies likely “expect to spend some time educating relevant government agencies” about the deal, given the lengthy closing timeline. Given Novo Nordisk’s ascent — it’s now one of Europe’s most valuable companies — paired with the limited number of large contract manufacturers, antitrust regulators could be interested in taking a close look.

Are Catalent’s problems finally a thing of the past?

Catalent ran into a mix of financial and operational problems over the past year that played no small part in attracting the interest of an activist like Elliott.

Now with a deal in place, how quickly can Novo rectify those problems? Some of the challenges were driven by the demands of being a publicly traded company, like failing to meet investors’ revenue expectations or even filing earnings reports on time.

But Catalent also struggled with its business at times, with a range of manufacturing delays, inspection reports and occasionally writing down acquisitions that didn’t pan out. Novo’s deep pockets will go a long way to a turnaround, but only the future will tell if all these issues are fixed.

Kutay said his team is excited by the opportunity and was satisfied with the due diligence it did on the company.

“We believe we’re buying a strong company with a good management team and good prospects,” Kutay said. “If that wasn’t the case, I don’t think we’d be here.”

Amber Tong and Reynald Castañeda contributed reporting.

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Petrina Kamya, Ph.D., Head of AI Platforms at Insilico Medicine, presents at BIO CEO & Investor Conference

Petrina Kamya, PhD, Head of AI Platforms and President of Insilico Medicine Canada, will present at the BIO CEO & Investor Conference happening Feb….

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Petrina Kamya, PhD, Head of AI Platforms and President of Insilico Medicine Canada, will present at the BIO CEO & Investor Conference happening Feb. 26-27 at the New York Marriott Marquis in New York City. Dr. Kamya will speak as part of the panel “AI within Biopharma: Separating Value from Hype,” on Feb. 27, 1pm ET along with Michael Nally, CEO of Generate: Biomedicines and Liz Schwarzbach, PhD, CBO of BigHat Biosciences.

Credit: Insilico Medicine

Petrina Kamya, PhD, Head of AI Platforms and President of Insilico Medicine Canada, will present at the BIO CEO & Investor Conference happening Feb. 26-27 at the New York Marriott Marquis in New York City. Dr. Kamya will speak as part of the panel “AI within Biopharma: Separating Value from Hype,” on Feb. 27, 1pm ET along with Michael Nally, CEO of Generate: Biomedicines and Liz Schwarzbach, PhD, CBO of BigHat Biosciences.

The session will look at how the latest artificial intelligence (AI) tools – including generative AI and large language models – are currently being used to advance the discovery and design of new drugs, and which technologies are still in development. 

The BIO CEO & Investor Conference brings together over 1,000 attendees and more than 700 companies across industry and institutional investment to discuss the future investment landscape of biotechnology. Sessions focus on topics such as therapeutic advancements, market outlook, and policy priorities.

Insilico Medicine is a leading, clinical stage AI-driven drug discovery company that has raised over $400m in investments since it was founded in 2014. Dr. Kamya leads the development of the Company’s end-to-end generative AI platform, Pharma.AI from Insilico’s AI R&D Center in Montreal. Using modern machine learning techniques in the context of chemistry and biology, the platform has driven the discovery and design of 30+ new therapies, with five in clinical stages – for cancer, fibrosis, inflammatory bowel disease (IBD), and COVID-19. The Company’s lead drug, for the chronic, rare lung condition idiopathic pulmonary fibrosis, is the first AI-designed drug for an AI-discovered target to reach Phase II clinical trials with patients. Nine of the top 20 pharmaceutical companies have used Insilico’s AI platform to advance their programs, and the Company has a number of major strategic licensing deals around its AI-designed therapeutic assets, including with Sanofi, Exelixis and Menarini. 

 

About Insilico Medicine

Insilico Medicine, a global clinical stage biotechnology company powered by generative AI, is connecting biology, chemistry, and clinical trials analysis using next-generation AI systems. The company has developed AI platforms that utilize deep generative models, reinforcement learning, transformers, and other modern machine learning techniques for novel target discovery and the generation of novel molecular structures with desired properties. Insilico Medicine is developing breakthrough solutions to discover and develop innovative drugs for cancer, fibrosis, immunity, central nervous system diseases, infectious diseases, autoimmune diseases, and aging-related diseases. www.insilico.com 


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Another country is getting ready to launch a visa for digital nomads

Early reports are saying Japan will soon have a digital nomad visa for high-earning foreigners.

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Over the last decade, the explosion of remote work that came as a result of improved technology and the pandemic has allowed an increasing number of people to become digital nomads. 

When looked at more broadly as anyone not required to come into a fixed office but instead moves between different locations such as the home and the coffee shop, the latest estimate shows that there were more than 35 million such workers in the world by the end of 2023 while over half of those come from the United States.

Related: There is a new list of cities that are best for digital nomads

While remote work has also allowed many to move to cheaper places and travel around the world while still bringing in income, working outside of one's home country requires either dual citizenship or work authorization — the global shift toward remote work has pushed many countries to launch specific digital nomad visas to boost their economies and bring in new residents.

Japan is a very popular destination for U.S. tourists. 

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This popular vacation destination will soon have a nomad visa

Spain, Portugal, Indonesia, Malaysia, Costa Rica, Brazil, Latvia and Malta are some of the countries currently offering specific visas for foreigners who want to live there while bringing in income from abroad.

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With the exception of a few, Asian countries generally have stricter immigration laws and were much slower to launch these types of visas that some of the countries with weaker economies had as far back as 2015. As first reported by the Japan Times, the country's Immigration Services Agency ended up making the leap toward a visa for those who can earn more than ¥10 million ($68,300 USD) with income from another country.

The Japanese government has not yet worked out the specifics of how long the visa will be valid for or how much it will cost — public comment on the proposal is being accepted throughout next week. 

That said, early reports say the visa will be shorter than the typical digital nomad option that allows foreigners to live in a country for several years. The visa will reportedly be valid for six months or slightly longer but still no more than a year — along with the ability to work, this allows some to stay beyond the 90-day tourist period typically afforded to those from countries with visa-free agreements.

'Not be given a residence card of residence certificate'

While one will be able to reapply for the visa after the time runs out, this can only be done by exiting the country and being away for six months before coming back again — becoming a permanent resident on the pathway to citizenship is an entirely different process with much more strict requirements.

"Those living in Japan with the digital nomad visa will not be given a residence card or a residence certificate, which provide access to certain government benefits," reports the news outlet. "The visa cannot be renewed and must be reapplied for, with this only possible six months after leaving the countr

The visa will reportedly start in March and also allow holders to bring their spouses and families with them. To start using the visa, holders will also need to purchase private health insurance from their home country while taxes on any money one earns will also need to be paid through one's home country.

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