CITY OF LIFE AND DEATHBY ROBERT POWERS

Facing a growing crisis， the private health industry is betting on dedicated cities for seniors—and banking on foreigners to help

八年前后，我們兩度走訪燕達(dá)健康城，

在那里看到了行業(yè)的發(fā)展、創(chuàng)業(yè)的艱辛，

以及那始終存在的健康養(yǎng)老之夢(mèng)

B

us tours dont stop any more at the Yanda International Health City—visitors get a slick reception from the Yanda marketing department， if representing government or media， or a classy individual tour when coming on behalf of elderly family members. But when TWOC first visited this sprawling vanguard of futuristic healthcare back in 2010， it was a different story.

Yanda can still be found on the outskirts of Beijing， in a part of Hebei province increasingly surrounded by the encroaching capital. A long， bombastic 2011 ad for the City， heavy in CGI and stock images， pinpointed its location to the sparsely developed Yanjiao， a town of some quarter million， 30 kilometers east of Tiananmen Square.

Here， dozens of prefab high-rises， medical facilities， and community buildings straddle a rectangular 125-acre tract of land， bisected by man-made lake that draws from the nearby Chaobai River. Plans for this “health city” date back more than a decade， when China was readying itself for the international opportunities afforded by the 2008 Olympics. Yandas website suggests that a consortium of developers and “high-tech building material” executives sketched out ambitious plans to become the worlds go-to destination for the burgeoning market in medical tourism， focusing on the elderly， wealthy， and retiring.

Conceptually， this self-proclaimed “hybrid treatment and care facility” is made up of six components： the Yanda Hospital， Yanda Golden Age Health Maintenance Center for housing seniors， Yanda Medical Research Center， Doctor and Nurse Training Center， International Conference Center， and the Yanda International Medical School.

Some 10 billion yuan in funding （almost 1.68 billion in todays USD） was secured， and in 2007， ground broke on hardened soil in Hebei. By March 2009， a posting on zhaobiao.gov.cn， a governmental portal soliciting construction bids， listed Yanda Citys official launch as January 1， 2010. In the summer of 2010， a blizzard of promotional materials began appearing in Chinese media， including the English-language Global Times.

A now-deleted infomercial on Blue Ocean Network featured Anglo-American siblings living in China， discussing the daily rituals and needs of their far-flung aging parents， while hovering over a laptop. Filmed in soft focus， with a soothing synth soundtrack， the pair call home to discuss moving their parents from their well-appointed US abode to Yanda. The four-way conversation is intercut with tracking shots of a putative medical director waxing on the Yanda dream， enumerating the activities and shopping destinations that will finally be available after expatriating to China.

Another quarter-page ad in China Daily on July 2， 2010 boasted that “Phase One has been completed； by Octobers National Day， Yanda would become “fully operational.” Nestled in the verbose text was a list of target markets： “1） 150 million high-income domestic Chinese with annual incomes of over 40，000 USD； 2） around 15 million foreigners working， living and staying in China on a long-term basis； 3） the international market outside China； 4） average citizens living adjacent to the Yanda International Hospital.” （According to the National Bureau of Statistics， only 217，000 foreigners held work visas in 2008， and only 7.75 million visited China as tourists during 2009）

Yandas original promotional material suggested international residents would be its second largest long-term market. With aging parents in the US beginning to think about retirement， I decided to see what Yanda offered. And I was impressed—though perhaps not entirely in the intended sense.

It was a cloudless day in 2010， 35 degrees Celsius， and I was waiting in Yandas concrete parking lot； various groups bustled between outpatient building. The high-rises appeared unblemished by the dust storms common to northern China in the spring. With me was a Chinese colleague who had agreed to help with translation—essential when we were later pitched various experimental therapies.

“Weve had so many tour groups through here，” customer service rep Chu Xiangli told us； Chu was in her 20s， and carried a parasol to protect her from the sun； she asked us to call her Monica. “Ive lost count，” she added： Most were pensioners， drawing social security from their danwei. Chu agreed to show us all Yandas operational facilities， as well as the complexs expansive grounds.”

We walked over a stone bridge， along winding paths lined by newly planted saplings awaiting turf， and learned of the Church Area that would accommodate four foreign faiths： twin Christian churches； a Buddhist temple with ornamental dragons contouring its roof； and a mosque with a crescent moon atop an onion dome. Construction workers banged away inside an unidentified fifth building. “Thats the bank，” Chu explained.

Billboards on cordoned-off areas advertised future facilities—a supermarket， library， gym， swimming pool， sauna， golf course， senior citizens college， post office， psychological consulting room. A furnished “show apartment” looked not unlike the advertising promo； the rest were unoccupied. The “fishing pavilion” in the brochure， part of a “ribbon-shaped water garden，” was still a concrete-lined pond with greenish water and teeming koi. “Everything will be finished by 2012，” Monica reassured.

I imagined my parents reaction： Would they respond to its grandiloquent flourishes， its superlative voiceovers proclaiming： “Yanda people warmly welcome friends all over the world to join Yanda International Health City of China for a brilliant tomorrow… Blessing China， benefiting Asia， and embracing the world！” Would they bless， embrace， and settle in this region with an entirely different climate， language， culture， and political system？ Or would they rather move to Florida？

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n 2016， the medical tourism market was valued at a staggering 100 billion USD in a global study by the Medical Tourism Index. Out of 41 destinations， Canada， the UK， Israel， Singapore， and Costa Rica ranked in the top five； China came 23. Patients Beyond Borders， a travel guide for would-be medical refugees， estimated some 15 million spend an annual 3，800 to 6，000 USD on cosmetic surgery， dentistry， cardiovascular care， orthopedics， reproductive health， weight loss， scans， second opinions， and cancer treatment overseas. Yandas vision also aligned with a 2009 pronouncement that China would offer universal healthcare to all citizens by 2020.

Inside a small office in the staff dormitory， Monica introduced Zhang Shugang （“Call me Glen”）， sales manager for Yandas marketing and business development center， along with “Mr. Yang，” who managed its international hospital； both wore open-collar white shirts under black jackets. “Our president [of Yanda] is a very influential person in Beijing，” Zhang warned cheerily. “He has personal relations and ties with the government.” Yanda “is a provincial-level project that enjoys preferential policies，” including support from the State Council.

Mr. Yang asked about my parents： Were they sick？ Seeking cancer treatments？ “To live longer is the whole of humanitys dream，” Mr. Yang beamed. “We have a stem cell bank. Stem cells are the building blocks of life， and are highly prized for their ability to change into the cells of other tissues.

“Ours，” he continued， “is a first-class private hospital that can accommodate 12，000 patients. Most Chinese ones are public [and] can hardly cooperate with international hospitals and organizations.” When fully complete， Mr. Yang added， Yanda would house up to 15，000 staff and have “business partners in Canada， America， Japan， and Singapore.

“Weve already brought in many foreign doctors and experts who have achieved a lot in the field，” he concluded. When I checked， medical recruitment site jkyc.com listed more than 60 employment opportunities at Yanda， with management positions for micro-chipping， pharmaceuticals， biological engineering， nuclear medicine， nursing， ER， gynecology， and administration.

T

he final stop of our tour is the model Yanda apartment， bustling with busloads of elderly Chinese， becalmed on a buffet now， taking refuge from the heat.

Yang Zhun， a bespectacled rep who ran the floor show for prospective buyers， explained the advancements in technology soon to be available—the jewel of which was a Swedish innovation known as the “Sky Rail.”

This was a blue sling that could gently lift a patient （of up to 300 kilos） from their bed to almost any other part of the floor， via a system of tramlines. I was offered a spin. Filmed by a couple dozen Chinese pensioners， I was soon scooting around their future potential premises like a hamster in a slingshot， smiling and waving.

At the end of this unlikely jaunt， I again imagined my parents spending their final years in Yanda， nearly 7，000 miles from home， and felt compelled to ask about end-of-life services. “The Health City doesnt have a cemetery，” Yang responded frankly. “But there is one nearby. Im not sure who runs it.” What happens when a resident dies， I asked Monica？ “The immediate family would be contacted before its too late，” she quickly explained. The international hospital has a morgue and the Church Area can accommodate “small funerals.”

Death—a tricky topic in most cultures—sometimes seems doubly difficult to discuss in China， even in communities like Yanda （which， in common with most Chinese buildings， doesnt permit any fourth， 13th or 14th floors）. But everyone has to die sometime—would they choose to do so at a place like Yanda？

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ight years on， TWOC visited the complex again to see if Yanda vision had been realized. In March， the sunbaked soil had once again been broken by fresh excavators and concrete foundations. Phase Two of Yanda， according to new marketing director Li Donghui， offers an added 7，800 beds， and a membership scheme that gives seniors the rights to an apartment for 10 to 30 years， during which they can sublease the unit， or bequeath it. Other family members can also live on-site and—with the completion of a new kindergarten and supermarket—“seniors can bring grandchildren to live here，” Li says： Three generations under one Yanda roof.

Membership schemes already exists in Chinese real estate. In 2016， Dong Pan， director of the Real Estate Research Center at Beijing Normal University， lambasted this practice to China Business Journal as legally gray； “Selling property by another name， trying to get a faster return on the investment.” Li， though， calls it a step toward offering a “full cycle” of services. Though many areas remain swaddled in scaffolding， and the wind kicks up dust from numerous unpaved paths， the complex is filling up； the Golden Age Center already had a waiting list of nearly 1，000 families.

Like many enterprises before them， Yanda has found success by trading off international ambitions to milk windfalls from Chinas own middle class. None of the senior centers current 1，600 residents are foreign nationals （“I remember an old American gentleman， years ago， and a Russian patient at the hospital，” Li offers when asked）. The hospital directors emphasize that the “international” aspect of the health city now refers to their technology， management standards， and the overseas training of many of their doctors—and while health tourism is not off the table， its no longer a priority.

The reason for this change of heart appears to be a regulatory snafu： China offers no appropriate visa for foreign retirees to live in the country long-term； even seasonal medical tourists （“snowbirds”） may find it hard to get temporary visas as they get older and their liability grows in the eyes of Chinese officials. Foreign insurance coverage is also limited， or even non-existent for medical services in China. Then there are the bureaucratic gauntlets to bringing foreign expertise into China. “We had a French doctor in the obstetrics department， and getting the approvals was extremely challenging； they control it very strictly，” says Li Haiyan， vice-president of the Yanda Group. She makes no mention of ever trying again.

Closer to home， Yanda now advertises partnerships with Beijings Chaoyang Hospital， Tiantan Hospital， and two other big names in the municipal healthcare system. On different days， doctors from these public institutions offer consultation at the private Yanda Hospital， a stones throw from the Senior Center. Its a Ms. Zhang， sunning herself in a garden that broadcasts classical music at soothing volume， who informs us how crucial this collaboration is： “The conditions are pretty good； I prefer the natural environment here， and I can still see Beijing doctors.”

She used to work at Chaoyang Hospital herself. “They were the ones who recommended this place，” she whispers. “If I couldnt see ‘our doctors， I wouldnt have come.” Its a common perception： Chinas private and public hospitals， as well as those in first-tier versus provincial cities， offer vastly different quality of care.

This helps explain the formidable economic clout of Yandas residents. Billed as a mid-to-high-end retirement service， basic “l(fā)iving packages” at the complex—a rental apartment and basic medical services， but no food—starts at 5，000 to 7，000 RMB per month depending on unit type. Seniors requiring round-the-clock care can expect to spend at least 15，000 RMB each month. Beijing， according to its municipal civil affairs bureau， is Chinas second “most aged” city， with close to 3.3 million hukou-holders over the age of 60 in 2016. That year， the city spent around 14 billion RMB in social security payments， giving more than an estimated 90 percent of seniors in retirement homes access to medical services， including 305 such facilities in Beijings surroundings.

Li Donghui estimates that Beijingers make up 98 percent of Yandas older residents， boasting that they “all own apartments in the center of the city.” The Health City even provides shuttles for those who wish to check up on those homes or spend a day in the city. “But they always come back here—they think of this as their home now.”

Life isnt without its fair share of obstacles in this adopted home. Even as Mrs. Zhang and her companion， Ms. Wang， tally Yandas selling points， they see an opportunity to take a few complaints to the top when they spy Li Donghui with us. “I think its too hard to get medical treatments，” Zhang begins. “Theres on-site clinic [at the senior center]， but if theres any major problem we have to go across the lake to the hospital.”

“Its just a few minutes walk； in a real emergency， the rooms have a call button for an ambulance，” Li reassures us.

“A few minutes for young people； Im 80！” Ms. Wang counters. “Its a trek！” Mrs. Zhang cackles， then continues an undertone. “Its a pity the [consulting] doctors leave at the end of the day. The doctors here are no good.”

Ms. Wang takes up the baton： “The hospital accepts my social security， but the clinic doesnt； I got medicine from over there”—she points at the hospital—“and they wouldnt inject it for me here，” at the clinic. “Its not coordinated： I dont think Ive been able collect my government meal subsidy， either. Or is it the traffic subsidy..？”

“Youre right，” Li interrupts with a smile. “They havent relaxed the regulations in Beijing—but were working on the problem. As people live longer and the economy grows， things will get better.”

“Thats right，” Ms. Wang nods.

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rogress on Yandas stem-cell work since 2011 has happened， if at all， mostly in private. News updates on the Yanda Medical Research Center website stop after 2014. According to Li Donghui， this was another dream sacrificed to regulatory restrictions. A report by Guolian Securities says， between 2007 and 2012， 62 percent of the countrys Class A hospitals operated stem cell therapies， bringing in foreign experts for research， and advertising “stem cell tourism，” all helped by favorable policies. In 2012， however， the Ministry of Health ordered a halt to all stem cell treatment on the mainland in response to domestic and international pressure over lack of regulation.

Li doesnt dwell on this—nor does he bring up the fact that in 2015， the ministrys ban expired， and the government published new guidelines and strategies for stem cell research and treatment， suggesting that both are back on the nations agenda.

Yanda already has other fish to fry. This January， its hospital was honored with a “Best Annual Advancement in Medical Systems” award by the Renmin Health News and the 10th Healthy China Forum. The hospitals English-language website currently implores “Come to Yanda and embrace the health！” Foreign patients could “embrace the health” in other mainland locations， but they also come with caveats： Bloomberg reported on one 3 billion USD medical tourism hub， under construction in Hainan in May 2017， as another Yanda-esque situation： Rushed development， half-finished complexes， and occasionally vague planning.

Perhaps its real-estate connections did help Yanda grasp two key advantages compared to the newcomers—location and timing. In 2016， Yanjiao was incorporated into Beijings Jing-Jin-Ji Urban Agglomeration， a long-term plan to relocate key industries and develop transportation links that will allow Hebei to absorb service industries that political support the cultural center of Beijing and commercial hub of Tianjin.

The Health City was one of the earliest designated pilot institutions for Jing-Jin-Ji， and one enticement was that Yandas residents would receive equal retirement benefits as Beijingers. In January 2017， Yanda Hospital was finally authorized to accept Beijing social security—something promised since 2013， the same year Chinas policymakers also proposed to nationalize social security （still a work-in-progress）.

The Health City began to make a profit in 2015， and now expects a return on its investment in 12 to 15 years， a few years more than the 10 to 12 years initially predicted. Li Haiyan seems to believe the citys best years are still ahead： “Its predicted that 2021 will be the retirement boom. Weve come at the right time.”

Sitting in her tastefully wood-paneled office， surrounded by the still-unfinished corridors of a new wing of the hospital， Li is almost a metaphor of the tale shes spinning—the visionary project that settled for success in an imperfect system， and finding it a pretty good bet， for now. “Look how weve grown， from just a few dozen seniors at the start. This is because the country has made retirement planning a priority， coming out with a lot of policies like tax cuts， long-term care insurance. So if they make reforming visa regulations a priority too， then…” she trails off meaningfully. The dream， evidently， is not dead.

- ADDITIONAL REPORTING BY HATTY LIU

HEALTH IS COMING：

A brief history

Long rumored and much needed， a complete overhaul of Chinas beleaguered healthcare system is now in the works. “Reforms are taking place across the supply chain， making healthcare more accessible and affordable， especially in rural communities，” claims a recent report by CCTV.

Under the planned economy， healthcare was provided by the socialist state—though for many rural residents， this usually entailed waiting for one of the countrys 40，000 “barefoot doctors” （赤腳醫(yī)生 ch#ji2o y～sh8ng）. These were itinerant peasants， given basic medical training and instructed by production brigades in 1965 to provide essential healthcare and “physical work” for Chinas 540 million farmers. Along with vaccination drives and “Four Pests” campaigns against rats and mosquitoes， they helped reduce infant mortality， and increase average life expectancy to 65 years old.

After economic reforms， the state retreated from healthcare in the 1990s and public hospitals became for-profit institutions. Underpaid and often undertrained staff regularly took bribes to treat patients， or prescribe certain medications. Country dwellers now had to travel to cities for proper treatment， pushing a strained system to a state of near-permanent breaking point. By the time the SARS epidemic broke out in 2003， hospitals had become crowded， hostile environments， rife with mistrust and often outright violence.

With only 30 percent of China covered by insurance， new reforms began to roll out in 2003 for rural residents； this was followed by a coverage plan for city dwellers in 2007. The aim is to ensure complete coverage by 2020， reduce pharmaceutical costs， and invest heavily in rural healthcare to reduce the burden elsewhere （an average urban hospital typically sees 20，000 outpatients a day）. But the task of reducing this burden on public hospitals in favor of specialist and emergency care faces resistance—from the hospitals themselves.

Many depend on a high turnover of paying customers to remain profitable， while specialists are costly to secure and insure. A preference for city hospitals means migrants still flood urban wards—and when their expectations are not met， tempers can flare.

Meanwhile， although 95 percent of Chinese now have basic coverage， the cost of drugs and treatments has kept rising—even patients who are now insured are paying just as much as before.

China has a “l(fā)imited medical referral system，” meaning patients are often referred to different hospitals and specialists， then back again. Often， according to irate patients， this is simply to shirk responsibility for a particular complaint. CCTV says a push towards integrating these services， using big data， AI， and social credit schemes， will offer “a major contribution towards the goal of a healthy China.” - HAN RUBO （韓儒博）

TRADITION， TRADITION

Many Chinese hospitals offer Traditional Chinese Medicine （TCM） —some exclusively， some reputably. TCM facilities account for 12 percent of national healthcare， and the industry is worth 60 billion USD across China （including a billion-dollar state subsidy）.

Backed by officials who see it as promoting traditional Chinese wisdom and values to its citizens and the outside world， TCM， in ordinary conversation， can refer to both the practice found at accredited hospitals and universities， and the under-regulated industry of health supplements， miracle doctors， and dodgy private “wellness” centers. Certainly its theories echo historical Western thinking—such as the Galenic theory of humors， or Robert Burtons Anatomy of Melancholy—that is now contrary to much of modern medicine. According to basic TCM theory， the body is composed of “elements” in constant flux， such as fire， qi， yin， and yang. When these are in harmony， the body is healthy； an imbalance or incongruence between fluids or forces causes illness.

In practice， TCM doctors usually treat illnesses such as fevers， colds， inflammations， and upsets with an pharmacopeia of herbs （many of which have equivalent Western synthetics； indeed， the latter are often included in the “traditional” cure）. Treatments such as moxibustion （“cupping”） and acupuncture are more controversial， and relatively few patients would choose TCM to cure cancer. But as long as TCM occupies a place in Chinas narrative of national rejuvenation， it will continue to find investment from official institutions. - H. R.