BEIRUT, Lebanon — Black SUVs pull up to the palm tree-lined driveway and deliver patients to Clemenceau Medical Center.
The commanding, mirror-windowed complex towers over one of the capital's wealthiest and trendiest neighborhoods. In the lobby, a musician plays a baby grand piano. A mass of pink balloons and colorful flowers welcome a baby girl. A man stumbles to the ground; medical staff rush to his aid.
The founders of Lebanon's newest and most advanced hospital envisioned an institution with impeccable service, upscale amenities and the best medical care in the Middle East. Offices, laboratories and operating rooms would be equipped with the latest technology. Doctors would operate under the toughest safety standards.
To make it happen, they turned to Johns Hopkins.
"They were the secret behind much of the success of this hospital," says Dr. Mounes Kalaawi, Clemenceau's CEO and founder. "The strategic partnership we created made this happen. Otherwise, this would be very different."
Clemenceau pays Johns Hopkins a consulting fee for its services, which includes second opinions on medical cases, advice on starting new clinical programs, operational advice and symposiums. Neither side would say how much Clemenceau pays. They agreed this year to extend their original 10-year contract for another decade.
Clemenceau is one of 19 projects in the growing portfolio of Johns Hopkins Medicine International, the arm of the Baltimore-based institution that's charged with taking the Hopkins mission and brand global.
The varied ventures, which span five continents, are aimed at improving health care overseas, creating research opportunities and opening up new sources of revenue. Hopkins International has helped overseas partners modernize their medical care, introduced cutting-edge procedures in developing nations, and assisted in running an entire health system in Saudi Arabia.
But the efforts also face challenges — and potential hazards. It can be difficult, particularly in a setting as intimate as health care, for foreign institutions to adapt to local cultures and customs. Critics say the arrival of wealthy hospitals in poor countries can widen disparities in care. And failures can tarnish reputations.
"It is fraught with risk," says Dr. Randolph Gordon, a managing director of Deloitte who works with large health systems. "There have been examples where the brand has been eroded. The international presence or partnership hasn't lived up to the expectations or the standards of the academic medical institution."
Pamela Paulk, president of Johns Hopkins Medicine International, gets questions from her own family about how Hopkins could work in Saudi Arabia. The Middle Eastern nation is routinely cited by human rights watchdogs as among the most repressive on earth. Hopkins has partnered with Saudi Aramco, the government-owned oil company, in running a health system for some 360,000 beneficiaries.
Paulk says Hopkins tries to stay out of local politics, and focuses instead on what she calls the universal need for good health care.
"It is important for us when we are going some place to make sure we can be helpful," she said. "It is not important for us to be involved in politics. Our mission is to provide health care, education and research."
The international market is still a relatively small part of Hopkins' mission, Paulk says, but one the institution approaches very strategically.
"We are not just going to go into a place for a year or two and get out," she says. "We really want to help build a health care system that could sustain itself beyond any Johns Hopkins involvement."
Hopkins was looking to expand into the Middle East when Kalaawi approached a decade ago about a partnership.
Lebanon was still rebuilding from the 15-year civil war that ravaged the country from 1975 to 1990. Once home to some of the most advanced hospitals in the Middle East, it had suffered an exodus of medical professionals during the fighting. Progress had stagnated.
Kalaawi, a surgeon who had trained in the United States and Britain, saw an opportunity.
"It was clear we needed to build a state-of-the-art hospital to catch up with the best in the world," he says.
Johns Hopkins had a global reputation. Kalaawi was eager to tap its expertise.
"Rather than try to reinvent, I wanted to bring the experts here," he says. "I needed someone to tell me that what I was doing was right. That what I was doing was wrong. Or that I could do it better this way."
Lebanon, meanwhile, was attractive to Hopkins. The Johns Hopkins University already had a relationship with the American University of Beirut, collaborating on research, education and medical training.
Paulk says Kalaawi presented a plan that fit Hopkins' principles of providing a high standard of care and improving outcomes for patients.
The sides agreed to pursue a partnership. Staff from Hopkins helped Clemenceau's founders set up hiring and human resources standards. They advised them in the design of a state-of-the-art campus. They guided them through an intense international accreditation process, conducting surveys and mock assessments, to set up safety standards as tough as those in the United States.
Paulk, who at the time headed up human resources for Johns Hopkins Medicine, helped write compensation rules for the new hospital, interviewed some of the first job prospects and trained new hires in customer and patient services.
The hospital opened in February 2006 in Clemenceau, a neighborhood of extravagant villas between downtown Beirut and the Hamra shopping district.
Steve Thompson, then the CEO of Hopkins International, joined medical leaders, government ministers and members of parliament for the opening. Kalaawi spoke effusively of the partnership.
"'Thanks to our affiliation with Johns Hopkins Medicine International and to this renowned institution's resources of knowledge and services, CMC will deliver the best clinical service to patients from Lebanon and the region," Kalaawi told the crowd. "I am sure the affiliation with Johns Hopkins Medicine International will be fruitful to our physicians, nurses, staff and especially our patients. …
"Johns Hopkins is considered the best hospital in America, and we definitely benefit from the knowledge exchange."
The hospital quickly attracted patients from throughout the Middle East. It routinely treats Lebanon's top leaders; Nabih Berri, the speaker of the Lebanese parliament, had his gall bladder removed there in February, according to news reports.
In 2012, the hospital became the first in Lebanon to offer the da Vinci robotic system, which allows doctors to perform minimally invasive surgeries. In 2015, a cardiovascular team performed a heart surgery on a 92-year-old woman, using catheters to replace a clogged aortic valve, eliminating the need for open heart surgery. At the time, she was the oldest patient to undergo such a procedure in Lebanon.
Clemenceau Medical Center became a symbol of a resurgent city. But in recent years, the resurgence has slowed. Wages have stagnated, and the war in neighboring Syria has unleased a flood of refugees, putting pressure on many segments of the economy, including health care.
The threat of violence is never far. A would-be suicide bomber wearing an explosive belt was detained inside a busy coffee shop near Clemenceau in January. Security checkpoints protect high-end hotels. The State Department warns U.S. citizens against travel to Lebanon "because of the threats of terrorism, armed clashes, kidnapping, and outbreaks of violence," especially near the borders with Syria and Israel.
Political conditions can make doing business overseas more challenging. Hospitals must also consider the regulatory environment and cultural differences.
"It is a matter of having sophisticated management that can be sensitive to what those laws and regulations are," said Ken Rodgers, director and healthcare ratings analyst at S&P global ratings.
Hopkins faced local criticism over a venture in Singapore. Hopkins first opened a cancer research facility in the Asian nation in 1998, with plans to open a for-profit hospital in partnership with three other investors. But doctors there complained it was advertising its services with brochures, in violation of the local medical ethics code. They also said Hopkins was charging more than was typical in the area.
Hopkins announced it would refocus its plans, operating within a 10,000-square-foot ward at a local hospital instead of its own facility. Executives at the time said they wanted to advance patient care, and that was coming into conflict with the pursuit of a for-profit venture.
The criticism can also come from home.
One of Hopkins' largest overseas operations is the partnership with Saudi Aramco. Human Rights Watch says the Saudi government "systematically discriminates against women."
Paulk says Hopkins has established programs aimed at empowering women: A doctorate of nursing program that graduated 13 Saudi women this year, and a half-day conference called A Women's Journey, in which Saudi women were able to ask three female doctors who traveled from Baltimore any health questions they wanted.
One goal of the overseas ventures is to generate revenue. Like many of the American hospitals operating in other countries, Hopkins is moving to middle-class areas, where patients can afford to pay the bills.
J. Stephen Morrison is director of the Global Health Policy Center at the Center for Strategic and International Studies.
"What I find most intriguing is whether it is feasible to build new durable high-quality capacity in these settings that can reach more than a small elite population," he said.
In Lebanon, the health system is largely centralized. The most advanced hospitals are located in Beirut and a few other cities. Health care elsewhere is provided mostly through free clinics and nonprofits. Private hospitals such as Clemenceau take only a limited number of poor patients.
Rita Rhayem is general director of Caritas Lebanon, a nonprofit that runs clinics and mobile health units to serve refugees and other low-income people. She says the entire health system has been squeezed as it works to serve refugees. Her group once served 100 a day; it now serves 200 to 300 a day.
Hopkins has long headed nonprofit projects in developing and disadvantaged nations. Clemenceau Medical Center treats the poor, though it is not its primary business. The hospital takes both private insurance and social security. Refugees generally are covered in Lebanon by the United Nations or nongovernmental organizations and nonprofits.
One businessman said perceptions of Clemenceau have affected its ability to attract some patients.
"Many of my friends think it is exclusive, expensive, ultra private," says the economist Mohammad Fheili, an assistant general manager of Jammal Trust Bank in Beirut and a lecturer at the Lebanese American University. "It is not as expensive as one would think. The services and insurance exist as it would at any other hospital."
Rasha Atwi ended up at Clemenceau after she fainted at work. She had heard about the big new hospital when it opened, but continued to go to the older hospital she had always used.
The 44-year-old had suffered from seizures for years but was told it was related to stress or sinus problems. After her latest spell, an ambulance brought her to Clemenceau.
She was given her first MRI. Results showed two benign tumors. Atwi was diagnosed with tumor-induced epilepsy.
"Because of the war, and I work and have kids, I just think it's the stress of life," Atwi says. "I figured it wasn't a real problem. Especially since no doctor ever mentioned the possibility of me having epilepsy."
Doctors removed the tumors. While Atwi suffers from side effects, such as headaches and concentration problems, she is glad she ended up at Clemenceau that day.
"I am not energetic, but I am living," Atwi says. "If those two tumors had remained in my head, I would have a lot more problems and it would be more difficult than it is now."
Fheili, the banker, says Clemenceau has had an impact beyond its campus: Other hospitals now are upgrading their facilities, expanding services and working to improve customer relations.
A decade after helping launch the hospital, Hopkins doctors visit regularly to lead seminars on women's health, orthopedics, neurosurgery and other areas. Clemenceau doctors turned to Hopkins when they needed help coming up with an antibiotic protocol to combat germs native to Lebanon. They sought Hopkins' advice when opening a $50 million cancer center.
Last year, for the first time, Hopkins residents completed part of their training at the hospital. Clemenceau physicians routinely seek second opinions from their Hopkins colleagues. A neurosurgeon traveled to the hospital in June to help another surgeon operate on a patient.
"It felt just like I was in a Hopkins operating room," says Dr. Ali Bydon, a Johns Hopkins neurosurgeon of Lebanese descent.
Every three months, staff in charge of quality control at Clemenceau hold a video conference with Hopkins. The hospital regularly reports its infection rates back to Baltimore.
"Whenever we want to, we can pick up the phone or send an email," says Dr. Rola Hammoud, Clemenceau's chief of quality. "They are very helpful."
Lebanese nurses and doctors who tried to encourage moms to breastfeed faced resistance. Moms worried about what their breasts would look like after breastfeeding and if they would still be attractive to their husbands. They wanted to rest in the hospital before they went home, not spend the time feeding the baby.
"They want to relax. They don't want to hear the baby," Hammoud says. "They want to have life easy before they go home and face reality. It is very difficult to convince them."
The Lebanese medical team worked with Hopkins to come up with educational materials and videos to explain the benefits of breastfeeding and hopefully boost the numbers of moms who do it.
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Hopkins and Clemenceau agreed this year to extend their partnership 10 more years.
Kalaawi is using what he has learned from Hopkins to open up facilities in other countries. Clemenceau recently started its own international division, which plans to launch hospitals in the United Arab Emirates and Saudi Arabia.
Paulk says Hopkins will continue to look carefully for new international opportunities — the institution doesn't want to stretch itself too thin. She says emerging markets, or areas that are expanding and maturing, such as Latin America or Southeast Asia, are most promising.
"We will become as big as we need to be, but not so big that we outstrip our ability to do a good job," Paulk says.
Reporting for this article was funded in part by a Bringing Home the World fellowship from the International Center for Journalists.