CITY OF LIFE AND DEATH

一座“国际健康城”的艰难探索,一个家庭与临终亲人的最后时光,汇聚成医疗养老产业的今天和明天

The World of Chinese - - Editor’s Letter - BY ROBERT POW­ERS 八年前后,我们两度走访燕达健康城,在那里看到了行业的发展、创业的艰辛,以及那始终存在的健康养老之梦

Hawaii, Hainan…he­bei? A real es­tate devel­oper's hopes of turn­ing a gray Bei­jing sub­urb into an in­ter­na­tional re­tire­ment par­adise may seem like a pipe dream, but lo­cals are pro­vid­ing un­ex­pect­edly high (and lu­cra­tive) de­mand. TWOC ex­am­ines China's strug­gle to re­form its ail­ing hospi­tal sys­tem and ag­ing so­ci­ety, and fol­lows a fam­ily con­tin­u­ing to care for a sick loved one against the odds

Bus tours don’t 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 125acre tract of land, bi­sected by man­made 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. Yanda’s web­site sug­gests that a con­sor­tium of de­vel­op­ers and “high-tech build­ing ma­te­rial” ex­ec­u­tives sketched out am­bi­tious plans to be­come the world’s 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 to­day’s 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 City’s 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 An­gloAmer­i­can 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 Oc­to­ber’s 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)

Yanda’s 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.

It­was a cloud­less day in 2010, 35 de­grees Cel­sius, and I was wait­ing in Yanda’s 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.

“We’ve 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. “I’ve lost count,” she added: Most were pen­sion­ers, draw­ing so­cial se­cu­rity from their dan­wei. Chu agreed to show us all Yanda’s op­er­a­tional fa­cil­i­ties, as well as the com­plex’s 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. “That’s 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.

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

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?

In 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. Yanda’s 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 Yanda’s 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 provin­cial­level 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 hu­man­ity’s 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 first­class 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.

“We’ve 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.

The 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

IN 2016, THE MED­I­CAL TOURISM MAR­KET WAS VAL­UED AT A STAG­GER­ING 100 BIL­LION USD IN A GLOBAL STUDY

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 doesn’t have a ceme­tery,” Yang re­sponded frankly. “But there is one nearby. I’m not sure who runs it.” What hap­pens when a res­i­dent dies, I asked Mon­ica? “The im­me­di­ate fam­ily would be con­tacted be­fore it’s 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, doesn’t per­mit any fourth, 13th or 14th floors). But ev­ery­one has to die some­time—would they choose to do so at a place like Yanda?

Eight 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 China’s own mid­dle class. None of the se­nior cen­ter’s 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, it’s 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 Bei­jing’s 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 stone’s throw from the Se­nior Cen­ter. It’s 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 couldn’t see ‘our’

doc­tors, I wouldn’t have come.” It’s a com­mon per­cep­tion: China’s 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 Yanda’s res­i­dents. Billed as a mid-to-high-end re­tire­ment ser­vice, ba­sic “liv­ing 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 China’s 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 Bei­jing’s sur­round­ings.

Li Donghui es­ti­mates that Bei­jingers make up 98 per­cent of Yanda’s 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 isn’t with­out its fair share of ob­sta­cles in this adopted home. Even as Mrs. Zhang and her com­pan­ion, Ms. Wang, tally Yanda’s sell­ing points, they see an op­por­tu­nity to take a few com­plaints to the top when they spy Li Donghui with us. “I think it’s too hard to get med­i­cal treat­ments,” Zhang be­gins. “There’s on-site clinic [at the se­nior cen­ter], but if there’s any ma­jor prob­lem we have to go across the lake to the hospi­tal.”

“It’s 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; I’m 80!” Ms. Wang coun­ters. “It’s a trek!” Mrs. Zhang cack­les, then con­tin­ues an un­der­tone. “It’s 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 doesn’t; I got medicine from over there”—she points at the hospi­tal—“and they wouldn’t in­ject it for me here,” at the clinic. “It’s not co­or­di­nated: I don’t think I’ve been able col­lect my govern­ment meal sub­sidy, ei­ther. Or is it the traf­fic sub­sidy..?”

“You’re right,” Li in­ter­rupts with a smile. “They haven’t re­laxed the reg­u­la­tions in Bei­jing—but we’re work­ing on the prob­lem. As peo­ple live longer and the econ­omy grows, things will get bet­ter.”

“That’s right,” Ms. Wang nods.

Progress on Yanda’s 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 coun­try’s 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 doesn’t dwell on this—nor does he bring up the fact that in 2015, the min­istry’s ban ex­pired, and the govern­ment pub­lished new guide­lines and strate­gies for stem cell re­search and treat­ment, sug­gest­ing that both are back on the na­tion’s 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 hospi­tal’s 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 Bei­jing’s 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 Yanda’s 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 China’s 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 city’s best years are still ahead: “It’s pre­dicted that 2021 will be the re­tire­ment boom. We’ve come at the right time.”

Sit­ting in her taste­fully wood­pan­eled of­fice, sur­rounded by the still-un­fin­ished cor­ri­dors of a new wing of the hospi­tal, Li is al­most a metaphor of the tale she’s spin­ning— the vi­sion­ary project that set­tled for suc­cess in an im­per­fect sys­tem, and find­ing it a pretty good bet, for now. “Look how we’ve 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.

Yanda’s se­nior cit­i­zens’ col­lege stands op­po­site the on-site clinic— health and re­cre­ation all in one

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