https://portside.org/2021-12-28/how-brigham-health-helped-create-chinese-hospital-elites-and-almost-nobody-came

It was worlds away from the Longwood medical hub: There were no traffic-clogged intersections, no ambulance sirens slapping the sides of buildings, no harried doctors and nurses rushing in scrubs for a quick fix of caffeine.

On that spring weekend in 2018, the president of Brigham Health and about a dozen of Boston’s top doctors and nurses flew to Hainan, a tropical island at the southernmost tip of China, rimmed by sandy beaches and studded with lush resorts.

This was no vacation, though. The delegation was there on a mission — to celebrate the opening of a gleaming new hospital stamped with the Brigham and Women’s brand. So many of the best hospitals in the United States, including Mass. General, had created lucrative collaborations abroad, designed to reach wealthy patients who would pay out of pocket for top-notch health care.

Now it was the Brigham’s turn.

Brigham’s blue crest soared atop the glass-lined building. A contract was already bringing in millions of dollars. “We are honored to share our experience and the lessons we have learned,” said Dr. Elizabeth Nabel, then Brigham Health’s president, in a statement hailing the opening.

This new Boao Evergrande International Hospital was just the beginning. Brigham had big plans to help the hospital’s owner, China Evergrande Group, build a nationwide health care network boosted by the hard-won prestige of the Brigham and its affiliation with Harvard Medical School. With state authorities back in Massachusetts blocking expansion efforts by its parent company, this initiative could not have been better timed.

Greeted with bouquets of pale peach roses that day, basking in applause for their speeches, the Boston visitors may not have imagined what could go wrong with an endeavor so bold and potentially lucrative.

That unwelcome answer, though, would come with remarkable speed: Almost everything.

A Globe correspondent, visiting the hospital this fall, found a nearly empty lobby and the Brigham sign removed from the front entrance. Multiple staffers involved in the project told the Globe that there were typically no more than 10 patients at a time in this state-of-the art facility with 647 beds. And now Brigham’s partner, the giant real-estate developer Evergrande, is in crisis, rattling markets worldwide.

“Unfortunately, the Evergrande hospital was not a business success for its owners,” said Brandon Eldredge, the chief new clinical business officer for parent company Mass General Brigham, in a striking understatement.

Few involved in this venture were willing to speak publicly to the Boston Globe Spotlight Team as it examined how Brigham Health signed onto this venture, selling its name and squandering valuable brainpower and time on what would become a near-empty shell.

Where there was once so much ambition, there are now critics asking questions: Should a prestigious Boston hospital be trying to help wealthy patients in China — and even if that answer is yes, how did this go so woefully wrong?

It all began with a brilliant professor, a determined billionaire, and a great hospital’s dream to expand its footprint in the world.

The professor was Shing-Tung Yau, chairman of the Harvard mathematics department, and a past winner of the Fields Medal, known as the Nobel Prize of math.

The billionaire was Hui Ka Yan, the chairman of Evergrande, a sprawling Chinese conglomerate looking to expand into health care.

The hospital, of course, was the Brigham.

Yau, a genial scholar with string theory as a specialty, was as comfortable in the classrooms of Cambridge as he was befriending and raising funds from China’s ultra-rich. He had a dream of elevating the study of mathematics in his native country, and he has gathered untold sums from donors including the Hong Kong-raised billionaires Ronnie and Gerald Chan for Chinese math centers and competitions. This work has made him, some say, a singular force, a rainmaker without peer on the Harvard faculty.

“Yau has become a fund raiser on a scale totally unmatched by other Harvard faculty members, not only in mathematics, but in all subjects,” one faculty colleague, Wilfried Schmid, wrote on the occasion of Yau’s 70th birthday.

In Evergrande’s chairman, Yau found another vein of gold.

Hui Ka Yan had climbed from working-class roots to become one of China’s richest men. His company’s turbo-charged rise was fueled by extravagant borrowing, and he flaunted his powerful ties to China’s Communist Party. As Hui splurged on lavish homes and a mega-yacht, his country’s press chronicled his exploits with tabloid fervor.

Hui and Yau had connected before, as Evergrande emerged as a sponsor for one of the professor’s math competitions in China in 2013. In the months to come, the Evergrande chairman was focused on collaborations of hugely greater ambition and cost — and bearing the coveted Harvard imprimatur.

Yau brought Harvard an introduction to the Evergrande billionaire — and the promise of a giant sum of money, according to current and former officials at Harvard and Brigham Health who were knowledgeable about the donation.

How big the gift was, Harvard wouldn’t say. But Yau was less shy. “I helped raise $200 million from the Evergrande Group, China’s largest real estate developer, to found three new centers,” Yau states in the autobiography he co-wrote, “The Shape of a Life.”

The three new centers, which Harvard announced plans for in December 2013, were the Center of Mathematical Sciences and Applications, which professor Yau now directs; the Evergrande Center for Immunologic Diseases at Harvard Medical School and Brigham and Women’s Hospital; and the Center for Green Buildings and Cities at the Graduate School of Design.

Also forming behind the scenes was the Brigham-Evergrande hospital deal. Two days after the new centers were announced, breathless reports in Chinese media delivered exciting news: Harvard and Evergrande were working to develop a “Harvard hospital in China,” Evergrande announced. In fact, that was an overstatement — the type that irks Harvard, which guards its brand closely. Evergrande was in negotiations with Harvard-affiliated Brigham Health.

Here again, Yau was an important matchmaker.

“The Brigham, Harvard, and Evergrande relationship began with introductions through Harvard mathematics professor Yau,” said Steven Thompson, Brigham Health’s former point person for the Evergrande project.

Through a Harvard spokeswoman, Yau declined to comment.

It was a great moment for Yau, for Evergrande, and for Harvard. Also for the Brigham, or so it seemed.

It was a boost the Brigham was looking for.

The Evergrande deal came together at a pivotal time for the hospital and its parent company. By early 2015, Mass General Brigham had been foiled in efforts to expand within Massachusetts by a state judge’s ruling and the threat of antitrust action by Attorney General Maura Healey.

Expansion efforts, then, led to looking beyond traditional borders. Top US hospitals — Johns Hopkins, Mayo Clinic, Cleveland Clinic — were finding potential riches in collaborations abroad. Brigham’s sibling hospital and onetime rival, Massachusetts General Hospital, was already working with a private-equity company that would in 2017 open the Jiahui International Hospital in Shanghai, China’s most populous city.

“It was a time for looking internationally, for brand elevation and revenue generation,” said a former Brigham trustee, who asked for anonymity because the trustee was not authorized to speak freely about board business.

Leading the charge for the Brigham was Nabel, a cardiologist with an entrepreneurial streak and the hospital’s first woman president. Her corporate ties would come under scrutiny, but she was credited with raising the hospital’s profile and increasing revenues.

Selecting the right partner for an international hospital is no easy task, however.

“You can’t just listen to the PowerPoint,” said Mark Wen, a consultant in the Chinese health care market. “They promise you this and that, and then you turn around and everything is not quite true.”

Brigham spokeswoman Lori Schroth insisted that the provider vetted the project appropriately, doing “legal, financial, and other due diligence,” and took into account an assessment by an outside vendor.

Brigham did not explore whether the hospital would be able to attract patients, she acknowledged. “Our work with Evergrande was not related to the commercial operations or business opportunity of the hospital and therefore did not include market research,” she said.

She emphasized that Brigham Health — the umbrella entity that includes Brigham and Women’s Hospital — had an “advisory” contract with Evergrande, not an equal partnership.

As negotiations played out between 2013 and 2015, the Evergrande deal was presented to the Brigham board as a relationship with a prominent, successful Chinese real estate company, the former Brigham trustee recalled.

Evergrande also brought to the table an expansive vision, stretching across China, and Brigham Health agreed to help the company “build a network of hospitals,” explained Mark Davis, a Brigham executive leading international collaborations, in a 2016 Brigham company publication. Davis, who left Brigham this summer, did not respond to requests for comment.

There was little reason to doubt Evergrande as a partner, considering it had previously given money to Harvard, Thompson, Brigham’s former chief business development officer, told the Globe.

In fact, there was ample reason to doubt.

Evergrande had built its vast empire on the strength of massive, borderline reckless borrowing, and this was no secret. Allegations that it was using aggressive accounting to hide its true financial health had been raised long before the Brigham deal. Then in 2017, investment analyst Anne Stevenson-Yang described Evergrande as “the biggest pyramid scheme the world has yet seen.”

Evergrande had jumped into a wide variety of noncore businesses as a way of raising funds, said Stevenson-Yang: “None of these companies were viable in themselves.”

Among those new business lines to come — health care.

With the deal coming together, the question of the hour was where to build the first hospital in the proposed network. The answer they settled on was, essentially, the middle of nowhere.

In 2015, Thompson and other Brigham officials teamed with Evergrande executives on a whirlwind, three-city scouting trip.

That journey would lead them to Hainan, the island province known as the “Hawaii of China,” at the height of the summer season. The humidity was thick, and the south China sun beat down on the sandy soil. For relief, they all ditched their suits and ties for simple shirtsleeves as Evergrande leader Hui Ka Yan led them through a prospective site.

Professor Yau, who had established a math center nearby, donned a wide-brimmed straw hat and joined the tour, as chronicled by Chinese media.

And this island would be the hospital’s unlikely home — more specifically, Boao, a fleck of a town on Hainan’s eastern coast.

Only 27,000 people live in Boao, but the Chinese government was creating a medical tourism hub there. To lure health care companies and developers, officials set aside hundreds of acres of rice fields and fishing villages and announced preferential policies, including access to Western drugs and equipment not yet approved for use on China’s mainland.

Evergrande’s new hospital would focus on cancer treatment. In 2016, Brigham brought in the Dana-Farber Cancer Institute, initially as a subcontractor, for its oncology expertise.

Soon, the hospital would begin to rise out of the raw landscape of dirt roads and piles of rubble. It had a distinctive butterfly shape, with two huge rounded wings joined at the middle, and soon, too, a sign on top emblazoned with the Brigham name. It marked the first time Brigham had shared its brand with another hospital.

Also, its reputation.

If the new venture would, in time, prove a failure, it was not for lack of effort by Brigham.

Interviews with a dozen current and former administrators, doctors, and other sources in the United States and China indicate that Brigham Health was involved at just about every step, helping to pick the site, design the facility, create its management structure, set its standards, hire administrators and doctors, and train clinicians.

Larry Han, a physicist in the Evergrande hospital’s radiation oncology department, said medical equipment had to be tested to hit Brigham’s standards. Dr. Jack Liu, the hospital’s chief quality officer, said he had worked for years in the United States and underwent several interviews with Brigham and Women’s before being hired.

“We had a very close collaboration with Brigham,” Liu said.

Nearly 400 Brigham and Dana-Farber faculty and staff participated in the project, with about 200 trips to the region, according to Schroth, the Brigham spokeswoman. They made 20-plus hour journeys from Boston to Boao, through Hong Kong.

But as Brigham leaders devoted energy and resources to the Chinese venture, their Boston headquarters was in turmoil. In 2016, Brigham narrowly averted a potentially calamitous strike by 3,300 nurses who assailed Brigham’s “corporate greed.” In 2017, Brigham Health shaved more than $40 million from its budget through buyouts, layoffs, and other cost-cutting.

Some in Boston worried that Brigham’s efforts in China were a distraction. As one Brigham nursing supervisor, Lisa Morrissey, worked on the Evergrande project, not enough attention was paid to staffing concerns in her Boston units, said Trish Powers, a Brigham operating room nurse who chairs the Massachusetts Nurses Association bargaining unit for the hospital.

“You could see she was not focused on us,” said Powers. “We were staffed to the bare bones prior to COVID. We never really had had that issue before.”

Morrissey, Brigham’s former interim chief nursing officer and associate chief nursing officer, was tasked with developing nursing plans and implementing training programs for the Boao hospital in 2017-2021, Schroth said. In 2018, Morrissey made four separate trips to China.

“Lisa’s role in the Evergrande project had no influence on staffing levels of the units that she oversaw,” said Schroth, who added that “nurse staffing is a challenge that is being experienced by hospitals across our state.” Morrissey declined to speak with the Globe.

All the engagement by Brigham Health personnel did yield some revenue for the hospital company. Eldredge, the Mass General Brigham executive, refused to say how much Evergrande paid Brigham Health, citing a contractual obligation of confidentiality. Instead he said the yearly payments were “significantly less than 1 percent” of the annual revenues of Brigham and Women’s Hospital. One percent would be about $27 million to $33 million each year in 2016-2019, based on the most recently available Brigham financial statements.

They had surely hoped for more, in overall revenues and the vision of a thriving new hospital. But it was something.

When the time came to unveil the Boao hospital, Evergrande didn’t skimp on the festivities: A February 2018 red carpet event drew national media. Red and blue balloons festooned the campus, and matching banners draped down the building’s facade.

“We’ve done everything together, from think about each floor in the design of the hospital,” said Davis, the Brigham executive, during the celebration. Afterward, a small group of Evergrande and Brigham leaders dined at a riverfront restaurant and toasted with red wine and baijiu, a Chinese liquor, said Han.

Nabel’s April visit brought speeches and celebratory tours of the facility. As she strode through the halls, Nabel stopped to savor a wall chronicling a visual history of Brigham dating back to 1832. Another wall of photos captured milestones in the Boao hospital project: In image after image, Brigham and Chinese staff stood shoulder to shoulder, smiling.

The atmosphere was one of high hopes, but there would be troubling signs.

One thing that worried Boston physicians was that the people they dealt with in conference calls kept changing.

The doctors from Boston didn’t treat Chinese patients directly, so they often worked around a 12-hour time difference, doing nighttime conference calls with Chinese clinicians and their translators. The Boao staff turnover couldn’t be ignored; it made it harder to provide cancer-care training.

Then there was the travel: Flying to a tropical paradise is better in theory than in practice, and the heat and long, multi-mode journey took a toll.

“Travel to China … can be long and arduous, and it is not surprising that some participants felt that it was difficult,” said Ellen Berlin, a Dana-Farber spokeswoman, via e-mail.

But the biggest problem was that there simply weren’t many patients. The Boao hospital went nearly a year before treating its first cancer patient, according to a Brigham company publication.

It was tough “getting the patients there, because of the location and the fact that people mostly wanted to be near home for treatment,” said one Boston physician who asked for anonymity.

Most people near the hospital simply couldn’t afford its prices. Genetic cancer tests could run into the hundreds of dollars, according to the hospital’s fee list, and an international telepathology consultation cost more than $1,400 — out of reach for an island population whose average annual income was 84,656 yuan, or around $13,000.

Patient volume isn’t just crucial for revenues, but also to maintain quality standards. Doctors need to keep up their training and apply their skills consistently.

Over time, concerns grew in Boston about the quality of care in Boao, and whether the effort was truly worth local doctors’ time. Low patient volume made it harder to train the Chinese staff, Dana-Farber officials acknowledged.

Dana-Farber doctors tried to train the Boao clinicians, but “it became clear that they weren’t able to implement these practices,” said a Dana-Farber executive who asked for anonymity because of the project’s sensitivity. They “weren’t prepared for the kind of specialization that would be part of the next phase of our educational collaboration, so we mutually agreed not to renew the contract.”

Ultimately, the Boao hospital appears to have been doomed by geography. To get there, most mainland Chinese patients would typically have had to take a plane or train, then travel more miles by car or bus.

“If you’re in Shanghai and Beijing and you need to see a doctor, do you want to fly all the way to Hainan or do you want to just stay in Beijing or Shanghai?” said Wen, the health care consultant. “They have a mentality that if you build it, they’ll come. The fact is that if you build it, nobody comes.”

Indeed, wealthy Chinese patients had other strong options closer to home, including the sleek new Jiahui International Hospital in Shanghai, a city of more than 26 million people, established in collaboration with Brigham’s larger sibling, Massachusetts General Hospital.

The 500-bed Jiahui hospital, aimed at patients who can afford to pay primarily out of pocket, is in a busy area of the city and boasts an international roster of doctors, as seen in lobby photos during a visit by a correspondent this fall.

“A lot of people in Shanghai want to enjoy a more premium type of health care service,” said David Xie, a partner with Deloitte Consulting China. Xie said the Jiahui hospital, with its individualized service and pleasant atmosphere, is a refreshing change from China’s crowded, rushed public hospitals.

Meanwhile, the entire Boao medical tourism zone has struggled, Xie said. “They really have to think more deeply or carefully about the positioning of the medical zone offerings to differentiate them from the rest of the hospitals in China,” he said.

Desperate for patients, Evergrande even paid a company to convince doctors to refer patients there. A handful of patients, who got a small discount in price, “came in, had the physical, chilled on the beach, played golf,” said a marketing contractor who asked for anonymity for business reasons.

The COVID-19 pandemic, which grounded most travel, only exacerbated the problem.

The grand plan that began with toasts and celebrations, pomp and publicity, ended about as quietly as a misadventure can end.

In June, Brigham’s contract with Evergrande expired, and it scrubbed the Boao hospital from its web page touting international projects. A related contract with Dana-Farber ended as well.

Few from Brigham Health are eager to talk about it.

Nabel, who left Brigham Health this year, declined a Globe request for comment. Attempts to speak with many Brigham clinicians involved in the venture — all of whom needed officials’ approval — were unsuccessful. Evergrande representatives did not respond to phone calls and e-mails.

Eldredge, the Mass General Brigham executive, conceded that the low patient volume was “disappointing,” but defended the project as an effort “to elevate global health care.”

Eldredge also distanced Mass General Brigham from responsibility. “We do not own, we do not operate, we do not take a business risk or participate in the business portion of hospitals,” he said. “Our involvement was limited to providing consulting services around quality, safety, and clinical care.”

Schroth, the Brigham spokeswoman, defended such international collaborations, saying they help pay for “mission-centric activities” in Brigham’s local community. But some critics question the institution’s sense of priorities, aiming its expertise at the ailing rich of far-off lands.

Brigham is among the worst of more than 3,000 US hospitals in providing community benefits like health education and clinics, according to the Lown Institute, a Needham-based health care think tank.

Nonprofit hospitals like the Brigham, with tax-exempt status, should not be trying to “suck up wealth in other countries to subsidize unaffordable health care here,” said Dr. Vikas Saini, Lown’s president.

Brigham’s Evergrande project, he said, “would probably be the most egregious example of what we have been talking about.”

“This is catering to elites, and the elites didn’t show up,” he said.

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Now the hospital faces an uncertain future as Evergrande, with more than $300 billion in liabilities, is officially in default. Many Chinese people fear losing their life savings after paying for unfinished Evergrande apartments and other investments. In September, protesters at Evergrande headquarters shouted, “Return our money!”

Like the shells of buildings Evergrande has left across China, the Boao hospital is a symbol of the company’s grandiose, unfulfilled promises — this one built with Brigham’s help.

Brigham and Dana-Farber officials said Evergrande had fulfilled the terms of their contract, and its end was unrelated to the Chinese company’s financial woes. Eldredge said the contract expired, “and the parties mutually agreed not to enter into a new contract.”

This fall, remnants of the collaboration remained in Boao: A weather-worn sign on the campus touted the Brigham affiliation, and brochures featured an array of Boston doctors.

What was supposed to be a premier cancer hospital eagerly welcomed patients for a variety of medical visits, no appointment necessary. A receptionist at the Boao front desk told a visitor that they had few patients when service was private-pay, so they now also took regular government insurance, available to most Chinese people.

Amid the rubble of the venture’s original plans, one global health care specialist familiar with the project summed it up:

“It was driven by the money,” the expert said. “Nothing was there. No patients. No care.”

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Researcher Xiaoxi Ma contributed to this report. Send tips and comments to the reporters at their contact information below, or reach out to the Spotlight Team at spotlight@globe.com, 617-929-7483.

Deirdre Fernandes can be reached at deirdre.fernandes@globe.com. Follow her on Twitter @fernandesglobe. Rebecca Ostriker can be reached at rebecca.ostriker@globe.com. Follow her on Twitter @GlobeOstriker. Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com.

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