ROCHESTER, Minn. — On the day last month when they announced the deal that connected the Mayo Clinic name with a hospital outside of the U.S. for the first time in its 130-year history, as they so often do, clinic officials recounted the example set by their founders.

"From the very beginning, Mayo Clinic's humanitarian mission as well as our values have driven our international strategy," Mayo president and CEO Gianrico Farrugia said in a statement. In the same announcement, Mayo Clinic International president G. Anton Decker cited "our roots when Drs. Will and Charlie Mayo traveled the globe," promising the four-tower, 741-bed, Sheikh Shakhbout Medical City will "provide hope and healing for those who need it most."

Critics counter that these claims for this closely-watched partnership, one making Mayo a joint shareholder with the UAE government-owned health care corporation SEHA, may have pushed a familiar Mayo narrative to its breaking point. A city of incomprehensible wealth that sits in the top half of countries globally for burden of disease, Abu Dhabi is anything but a locale drawing images of unmet need.

"The Gulf states have a tremendous amount of wealth and financial power that is quite attractive for large institutions," says Michael Page, deputy director for the Middle East and North Africa division at Human Rights Watch. "It's not just the Mayo Clinic. There are academic institutions like New York University over there, and they likely have quite generous agreements with the government, and there's a tremendous opportunity cost of not taking them in the name of expanding partnerships and relationships in a humanitarian venture. I'm not an expert in the health of the UAE, but I think there's some skepticism to be had here."

Others were less diplomatic.

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"This is offensive, but not surprising," stated Dr. Marcia Angell, Harvard Medical School faculty member, former editor of the New England Journal of Medicine, and longtime critic of the race for profits within healthcare in an email to Forum News Service. "The Mayo Clinic is joining the rest of our health industry in its race to the bottom to maximize income. Instead of distributing health care according to medical need, we increasingly distribute it on the basis of the ability to pay."

"A hospital in Abu Dhabi does not exactly speak to the Mayo Clinic’s commitment to humanitarian values," emailed Shannon Brownlee, Senior Vice President at the healthcare advocacy nonprofit the Lown Institute. "This is really about capitalizing on Mayo’s excellent, and well-deserved reputation in order to expand its business opportunities. If the Mayo Clinic really wanted to help humanity, it would build primary care clinics in rural Appalachia, sub-Saharan Africa, or any number of places in the world where people are in real need of medical services, and can’t get them because they are too poor."

To the charge of making their first step in the waters of global healthcare at lip of a gilded infinity pool, Roshanak Didehban, chair of practice administration for Mayo Clinic replied in an email that "this patient-centered joint venture is designed to be an international destination for people from all walks of life who have serious or complex medical conditions… SEHA has committed to investing into their healthcare infrastructure so that we can meet the healthcare needs of the region. Abu Dhabi is centrally located for significant populations around the world, so the combination of shared values with SEHA, necessary commitment to infrastructure, and location made this a good fit for such a collaboration."

Monetary optics aside, a more pressing question remains: how might the clinic navigate the sometimes striking social- and gender inequities embedded within the cultural and legal traditions of the UAE. These include Sharia adjudication of family law matters for citizen patients, and legally-codified restrictions on speech, expression, gender relations, divorce, sexual practices outside of marriage and public assembly.

"I think it could be described as a police state," says Page. "There really is no criticism or peaceful dissent that is allowed in the country that is not met with jailing, deportation and harassment of critics. That's been extensively documented by us and by others."

His views are reflected within publications of the United States government.

Country Reports on Human Rights Practices for 2018, a publication of the U.S. State Department, has cited "allegations of torture in detention; arbitrary arrest and detention… substantial interference with the rights of peaceful assembly and freedom of association… and criminalization of same sexual activity, although no cases were publicly reported during the year."

The UAE also lacks a free press.

"Editors and journalists commonly practiced self-censorship due to fear of government retribution," the report stated, adding that "the government used libel and slander laws to suppress criticism of its leaders and institutions," the latter of which would presumably include hospitals.

"I think what's concerning to the Mayo Clinic is they are going to run into challenges that any autocratic government poses on the health side," says Page. He pointed to a post from Dec. 11 on the UAE news website Gulf News, a report quoting attendees from a recent Mayo Clinic co-organized conference on social media and medicine.

Among a host of valid concerns about erroneous medical information on social media, it described government officials' stated intention to suppress the airing of side effects and treatment-related harms in the UAE, quoting an official that if "a patient comes online when there is an adverse event and says this happened… authorities would investigate such matters in a way similar to how they deal with posts affecting national security."

Asked if it is possible to identify practice problems in an environment of restricted speech, Mayo Clinic's Didehban replied that "part of Mayo Clinic's evaluation of the collaboration included a commitment to our core values of respect, integrity, compassion, healing, teamwork, innovation, excellence and stewardship — values we’ve seen firsthand as our team members work side-by-side with colleagues at Sheikh Shakhbout Medical City."

Asked if the clinic is concerned about the ability of Mayo clinicians to treat female and LGBTQ patients within a context placing women under separate legal status, one seemingly banning transgender, non-marital and homosexual activity, Didehban stated that "The UAE government has established a Ministry of Tolerance, and is making strides to make UAE a welcoming country. We will support that effort — as we have in the United States — with strong support of diversity and inclusion initiatives."

"You've probably seen the branding around this, that it is the year of tolerance in the UAE, a place that allows no dissent," counters Page. "It's a sophisticated kind of understanding of how western institutions work." Mayo's presence, he says, "kind of endorses the UAE and links their brand with the UAE… which the UAE of course will reference in its materials… as part of their campaign and their narrative."

When asked about civil rights in the UAE, Didehban replied that "unfortunately, there are deep social inequities throughout the world, including in the United States. We are committed to diversity and inclusion initiatives to support all people, regardless of race, color, creed, ethnicity, thought, sexual orientation, age or ability, and we would like to be part of the solution to create a more inclusive society in all of our locations."