To the village

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There’s not much to do in Sekhutlane, but we had some fun at this bakery.

Last week, I had the opportunity to visit the remote village of Sekhutlane (pronounced something like ‘Sek-qui-kla-nay’), a 5 hour’s drive from Gaborone. I was there with some members of BUP, the University of Botswana – UPenn Partnership, to meet government healthcare workers who had participated in a mobile health program to perform vision screenings on schoolchildren using a smartphone app (called “Peek Acuity;” more on that in another post).

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On the way to Sekhutlane.
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A welcome sight after waking up at 5:00am in Gaborone!

Sekhutlane is a village of about 700 people, and most people seem to farm or work in government-sponsored volunteering positions that provide food and water. There are hardly any shops, and the closest upper high school is in the next village, 70km away. Since the main mode of transport in Sekhutlane is a donkey-drawn cart, 70km is a prohibitive distance for most.

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Sekhutlane.
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This  is the car we took to get to the village. Four-wheel drive is a must; our last hour on the way to the village was along a bumpy dirt road.
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It’s pretty common to hire drivers for these sorts of trips and pay them in cash for their driving and the gas.
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The only shop in the village is a small shack of corrugated steel where you can buy basic items over the counter.

We hadn’t brought any lunch, and the only place to get ready-made food in the village is a small bakery that makes simple rolls and loaves in an outdoor oven. The bread was warm, soft, and delicious after such a long car ride. We learned from the healthcare workers, Kenewe and Kagiso, that the villagers eat canned food most of the time, especially canned beef and fish. Kenewe and Kagiso are not from Sekhutlane originally – the government assigned them there to work for two years. They are both far from home and hope to get reassigned to a less remote location in the future.

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One of the BUP team members enjoys a freshly-baked roll in front of the bakery’s oven.
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Kenewe (left) and Kagiso (right). They were so lovely to talk to.

Though we were there to learn more about a mobile health endeavor, the challenges in Sekhutlane rarely involve technology. There are vision problems in the village, often due to the dust, but the more pressing issues are HIV/AIDS management and teenage pregnancy. Kagiso said that, since junior high is the highest level of school in the village, many of them finish school at 15 and become parents. They don’t know what else to do, he said, especially since they aren’t exposed to a range of possible professions they might aspire to. Kagiso is also frustrated with the way the government “spoon-feeds” the villagers, providing them food and even housing for minimal work – he wishes the government would instead incentivize them to become self-sustainable in some way.

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A home in Sekhutlane.

The president of Botswana is experiencing a bit of backlash right now for a recent visit to Sweden, where he discussed Botswana’s military policy and its “need” for an air force. A few people I’ve met, including the healthcare workers in Sekhutlane, are frustrated that the president is talking about war in such a peaceful country. Instead, they say, he could be focused on bringing health and education to all areas of the country.

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A man on his way out of Sekhutlane.

We arrived on Sekhutlane’s “ARV Day” – the healthcare workers devote one day each week to providing the villagers with the newest stock of antiretroviral drugs for HIV/AIDS treatment – so the clinic was quite busy. Kagiso and Kenewe told us that HIV is so common, and the village so small, that they can usually figure out which villager is responsible for a new case. They said that since HIV/AIDS is so out in the open in Sekhutlane, there’s very little stigma about it there, and people feel comfortable talking about their partners and the disease.

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The clinic of Sekhutlane. Check out the spots on that goat!

When I was in Lobatse, someone said that a main contributing factor to the high rate of HIV/AIDS in Botswana is an attitude here of “I am my own boss.” I suppose it’s the flip-side – the lack of a common collective attitude – that is the real culprit, a mindset that doesn’t encourage thinking about how your actions affect others. Kagiso and Kenewe also happened to mention this individualism with regards to other issues in the village. Kenewe talked about a time she once tried to help a young child at school by providing him with new clothes. The other parents became jealous and angry with Kenewe, and they stole the clothes off of the child to put on their own children. She gave up after that.

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Sekhutlane.

Another example of this thinking came up in our discussion about the vision screening, the initial reason we went to Sekhutlane. As a result of the screening, two children were diagnosed with vision problems, and their parents needed to bring them to a specific site on a specific day to receive glasses. Only one family had the means to do this, so only one of the two children actually got their glasses. “Why couldn’t that family take the other child, too?” I asked. “You only take care of your own here,” said Kenewe. That’s the attitude: fierce independence, even to the disadvantage of other community members. I’m not sure what caused this “I am my own boss” culture, but it’s been fascinating to hear it come up in so many discussions about health here.

Overall, it was great to see Sekhutlane and understand rural Botswana as a contrast to Gaborone.

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A donkey cart in Sekhutlane.
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The most water and green I’ve seen since arriving in Botswana! Apparently this is South Africa, though, on the other side of the river.

Last month

I arrived in Sweden on July 19th, 2016, which means that yesterday – June 19th, 2017 – I began my very last month of the Watson year. At the beginning of the year, I noticed the 19th of each passing month, these milestones that seemed enormous at the time: 1 month in! Two months in! Somewhere along the way, I stopped counting like that. Then yesterday, it hit me again: the 19th. One month left.

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My favorite building in Gaborone: the Parliament.
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A statue of Sir Seretse Khama, the first president of Botswana.
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The winter sky of Botswana is so beautiful and clear.

My first month on the Watson was long and difficult. After the first week, I thought to myself that this would be the longest year of my life. I had a large, unmeasurable swath of unknown ahead of me, which was scary and exciting and overwhelming. I wondered if I would ever feel like I was on my way home. Within the first month, I stayed alone in an apartment without wifi after four years of the intensely social college experience; I felt myself undergoing various changes as I learned how to be alone and love it; I lived in two different Swedish cities; I lost two of my grandparents, and heard the news over Skype; and I began my project, meeting with strangers kind enough to give me some insight into their medical device work.

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On the campus of the University of Botswana.
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A sign on the university campus.
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Have you ever seen a wild monkey eat a homemade bagel? This monkey grabbed a bagel in a matter of seconds and scurried up the tree to enjoy his new and unusual treat.

Once I hit the one month mark, 1/12 of the way through the Watson, I felt like I had hardly made a dent in the year despite having already experienced so much. Now, at 11/12 of the way through, having one month left feels like nothing. It’s hard knowing that so much of the adventure is done, that the vast unknown has become something very known, measurable by photo albums and ticket stubs and friends left behind; but also thrilling knowing that this seemingly insurmountable year has been easier and far less lonely than I expected.

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Street-side stalls in Botswana sell hard candies, sausages, and the local “fat cakes,” dense doughy bread rolls.
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A pedestrian bridge in Gaborone, at the city’s main train station.

It’s weird how your perception of time changes so easily – how a month can go from being so long to being so short. Time flies by faster the older you get, and somehow the Watson has magnified that phenomenon.

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The white tiered building down the road is the Ministry of Health, where I sat in on a meeting to discuss funding for the national rollout of an mHealth project.

The distance between NYC and Singapore is nearly 10,000 miles. That’s the farthest away from home I’ve been this year. But Tennessee Williams said that “time is the longest distance between two places,” and that feels far more accurate to me. I just want to make sure I make the most of the time I have left, but I’m not too worried about it – I think Botswana is a lovely place to be for the next month.

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World War II memorial.
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More Gaborone street scenes.

Health post: App for Assistive Technologies

Last week, I visited the Botswana chapter of the South African Federation for the Disabled, SAFOD. SAFOD is an organization that supports disabled people in 10 countries in southern Africa, and the Botswana chapter is called BOFOD. They are currently working on the “AT-Info-Map,” a three-year project to develop a smartphone app with information about all the assistive technologies (AT) available in the country. It will be released to Batswana users in a year or two and ultimately made available in the other member countries as well (Angola, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe).

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Mr. Kayange (left) holds a smartphone with the latest version of the AT-Info-Map app. To the right is Mr. Chiwaula, Director General of SAFOD.

I met with Mr. Chiwaula and Mr. Kayange at the BOFOD office in Gaborone to learn more about AT-Info-Map. The app, aimed towards disabled people and their caretakers or other stakeholders, will inform users of the location, availability, and cost of the assistive technologies they seek. Assistive tech, AT, includes hearing aids and wheelchairs, as well as tools not often thought of as technologies such as crutches, prosthetics, and glasses.

Mr. Kayange told me that all assistive technology in Botswana is imported from South Africa, Europe, and other areas – there are no local manufacturers. Thus the AT suppliers in Botswana sometimes have minimum order numbers that make it unfeasible for one person to get just one or two crutches, for example. Even though the government would supply those low quantities for free, said Mr. Kayange, the demand is still higher than the government’s supply, and some people still need to purchase their own assistive devices. He said that, as it is, the only people who know where to find reliable assistive technologies are wealthy people with expat connections – people who can order specific devices from abroad if need be. At least with the app, anyone with a smartphone could access the same information.

(Of course, I asked them what happens if people in their target user group don’t have smartphones. They agreed that this is a potential problem – it’s unrealistic to assume that everyone has a smartphone, which SAFOD discussed. They decided that it wasn’t enough of a reason not to make the app; those that do have smartphones will still benefit).

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A close-up of the app’s home page. Clicking “Start” opens another simple page that allows the user to search for assistive technologies in their region or by category.

A lot of our conversation centered around the issues of access and awareness – words that came up many times during my time in India. Especially in Botswana, where the population is so sparse, people may live very far away from a hospital or clinic (an access problem) and may have no idea what AT might be relevant to their needs, let alone where to get it (an awareness problem). Mr. Kayange and Mr. Chiwaula told me that the government’s idea of AT is essentially just wheelchairs and crutches. If nothing else, AT-Info-Map could inform people of other types of AT, ultimately increasing demand for better services. The AT-Info-Map app will store usage data such as the most-commonly-searched-for assistive technology, and if that data demonstrates an unaddressed need (for prosthetics, for example), SAFOD could take that data to the ministries and advocate for more government-funded prosthetics.

Without engaging the government, said Mr. Kayange and Mr. Chiwaula, they can’t be successful. In Botswana, probably because the country is so small and centralized, the government is involved in all health endeavors – so it’s crucial to partner with them if a project is going to be sustainable. However, like in most countries, this involves dealing with a lot of slow bureaucracy and government officials who are very cautious about new ideas.

There’s not as much “activity on the ground” as BOFOD would hope, and the status quo for disabled people largely stays the same year after year. Mr. Chiwaula pointed out that, as Botswana is a relatively stable and well-off Southern African country, it’s not a popular recipient of donations. Since international organizations tend to focus their resources on the neediest places, Botswana’s economic advantage has become a disadvantage – because, as Mr. Chiwaula was saying, such donations would still be welcome. This made a lot of sense to me, though it was sad to hear.

SAFOD was able to build the AT-Info-Map by collaborating with Washington University in the US for technology support, the international organization Dimagi for the mobile app design, and AfriNEAD, a network for disability research. Throughout the design process, SAFOD has also consulted with professionals, government officials in the Ministries of Health and Education and the President’s Office, and potential users. They went back and forth with potential users, performing user-centered design by returning to the field with multiple prototypes. Now, they are satisfied with the version they have and will begin deploying the app for use. Mr. Kayange and Mr. Chiwaula told me that their current concerns at the moment are how to get people to use the app once it’s available, as well as how to incentivize AT suppliers and service providers to register their information on the app. I was glad to hear that their final design is the result of several rounds of user feedback – hopefully that’s enough to guarantee a positive response on a more national scale. It will be interesting to see if the availability of AT in Botswana changes at all in the next few years once this app is in use.

 

Learning to dance at church

“Move your shoulders forward!” shouts the pastor, as he dances along to the church music.

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Yesterday I hiked Kgale Hill, just on the edge of Gaborone. This is at the top!

Last Sunday, I was invited to church by a local Motswana, a woman my age that I met at the University of Botswana’s cafeteria. I’ve gathered that religion is important here, where asking someone to church is as simple as an invite to a social gathering. So, following my when-in-Rome Watson attitude, I accepted the invitation despite being nonreligious myself. When my new friend asked me what church I go to back home, I mentioned the name of a Presbyterian church in NYC where I attended an hour-long Easter service a few years ago. Throughout the day, I avoided mentioning that I’ve never been a regular churchgoer so as not to insult anyone.

Sunday morning began at the university, where my friend was having a small gathering with the campus chapter of her church, which I learned is called First Love. After an hour, we all got in a combi – a 12-seater van that serves as the main mode of public transportation in Gaborone – and traveled to a big church just outside the city. We were joined by many other First Love chapters from around Gaborone for a congregation of maybe 100 people.

The service started at 11am, and to my surprise it continued until 3pm. The first two hours of the service provided the most lively and interactive church experience I’ve ever had. There was more singing and dancing than I thought possible, and it was fun – the choir sang Christian lyrics to popular beats and melodies, and a whole dance crew of young churchgoers performed a hip-hop set to the crowd. Everyone was standing up and dancing as much as they could between the narrow rows of plastic chairs. The pastor encouraged the dancing as well, and I found myself moving and clapping to the beat with a smile on my face.

After the singing and dancing, though, the more traditional sermon started, and I felt increasingly less comfortable (and increasingly hungry as no one stopped for lunch!). People were treating the sermon as a lecture, even taking notes. My new friend passed me a notebook and a pen, and it was clear that I was expected to take notes, too. Even when the service ended at 3pm, I couldn’t leave right away; I was ushered into a meeting for newcomers where I was asked to provide contact information and given a quick Bible lesson. Apparently I joined the church without exactly intending to.

By the time I got home, I had been out for 8 hours, most of them spent in a religious space, and I was exhausted. I had expected it to be shorter; on the Watson, it’s hard to lose control of your time. Something I’ve noticed this year, with the Watson’s emphasis on complete independence and intrepidity, is that you get used to being your own boss, making your own decisions about where you go and when and how much time you spend there. A few times this year, I’ve been in situations where I’ve lost that control and been at the mercy of other’s people’s schedules. Sitting in church, as the hours ticked on by and I wondered how I would get home, I tried to avoid feeling as though my time had been hijacked, my independence compromised. If all these people did this every Sunday, I thought, it must be okay. And it was.

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Satellites and art atop Kgale Hill.

A couple days later, I was in a car with a Motswana woman as we traveled to a clinic together as part of an ongoing mobile health project. She had a Bible with her all day, and we had to keep moving it around the car. At one point she asked me if I was religious. I said no. I’m worried I offended her, but I can’t lie either. She seemed disappointed, and we didn’t talk about it after that.

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Sunset in Botswana.

I read an article yesterday by a Motswana author, Lauri Kubuitsile, who realized that something she loves about Botswana is the fatalism. In contrast to the US, she says, where we value answers and having control and making your life the way you want it to be – with reasons to point to when things go wrong – her people, the Batswana, have a more fatalist attitude. What will be will be. Kubuitsile says that while it might be frustrating to hear that “it will all turn out okay” when things really aren’t okay, it’s also liberating to be less responsible when things go wrong. Things tend to move slowly here in Botswana, and ascribing that to fatalism made a lot of sense to me. Fatalism also fits well with religion, I think; 80% of the country is Christian (source).

Of course, I wondered how this might apply to medical devices – how fatalism and religion intersect with attitudes towards health and technology. I would guess that preventative health measures and monitoring devices would seem fairly pointless in a more fatalist society. Kubuitsile discusses the effect of fatalism on end-of-life care; in the US, we use technology and hospital services right up until the end, and we expect reasons for cause of death. “The oxygen failed to work,” writes Kubuitsile. “As if death is not a natural part of life.”

This morning, it is Sunday again, and most of the people I’ve walked by today have been dressed for church, clustered together for services. I’ve heard singing and chanting wafting out into the streets. I’m not going to church today, but I still think the music is beautiful.

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There are still so many places I haven’t been.

Health post: Botswana Overview

Things have been going on faster than I can write about them – my handwritten notes are starting to pile up! – so I wanted to do a quick catch-up. I really feel like time is flying by now, mostly because of end-of-Watson pressure, but also because there’s more going on in Botswana than I thought.

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At the University of Botswana, which has a beautiful campus.

I’ve already had a few project meetings, and there are some very cool mHealth (mobile health) endeavors here. Many of these projects come from the University of Botswana, which has a campus in Gaborone and a partnership with UPenn back in the US. From the Botswana-UPenn Partnership (BUP), I learned about TB-PEPFAR, their project to improve TB screening and testing in Botswana. One aim of the project is to provide community health workers (CHWs) with phones to collect data on TB patients. The phones use a mobile application called RedCap, which provides secure data capture for researchers and also allows CHWs to fill out digital forms rather than paper ones.

PEPFAR, or the US President’s Emergency Plan for Aids Relief, focuses on the diagnosis and treatment of TB because the infectious disease is so common in HIV patients – it was the cause of one-third of AIDS-related deaths in 2015 (source). This is particularly relevant here in Botswana, where the biggest public health crisis is HIV/AIDS (it is the leading cause of death, accounting for 32% of all deaths according to the CDC).

A week ago I traveled with a doctor of the TB-PEPFAR team to Lobatse, a small town an hour south of Gaborone. He was there to oversee a small conference for nurses and doctors from clinics in Lobatse and surrounding areas. As it turned out, the attending health workers were not users of the RedCap app – the conference was really a training session to update the health workers on the best methods for TB screening. Even though the training day wasn’t about entering data with RedCap, I was still curious to see if technology would come up in another way.

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At the beginning of the training day, all the participants had to take a “pre-test.” Their scores get compared to the results of the “post-test” they take at the end of the training.

Also, I learned a lot about TB. I became interested in medtech via the technology, not the medicine, so I still have a lot to learn about basic medical topics. During my stay in Lobatse, I learned about the importance of ‘sputum’ for TB diagnosis (I had never heard that word before, but sputum is the name for the mucus-y fluid that you might cough up when you’re sick, and testing this sputum is essential to TB testing). I learned that alcohol, overcrowding, and HIV/AIDS all contribute to TB. I also learned that while sputum induction (SI) is one way to diagnose TB patients, there is another method, gastric aspiration (GA).

The day’s training included “how to”s for both methods, SI and GA. GA was the more complicated and time-consuming method presented, requiring more equipment than SI – including a nebulizer. The presenter of this section had a nebulizer on the table and began demonstrating how to use it. One of the conference organizers, sitting in the back, called out: “Is this the nebulizer you all have in your facilities?” Everyone shook their heads or said “no.” The presenter went on with the nebulizer demonstration, though it seemed obvious to me that everyone would prefer the SI method. He later told me that since there were so many stakeholders in this TB-PEPFAR project (including both the US and Botswana governments), it was difficult for them to change or skip slides from a pre-approved presentation.

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The nebulizer demonstration.

One of the topics of conversation throughout the day was, of course, how to diagnose patients who have both HIV/AIDS and TB. The same organizer who asked about the nebulizer above told me that TB in HIV/AIDS patients manifests quite differently than TB alone. She said that it frustrates her when medical students from American universities come into Botswana and try to diagnose TB just based on the theory they’ve learned (without recognizing that in some cases, she said, HIV/AIDS patients with TB will test negative for TB). She said that it’s a feeling you have to develop about HIV/AIDS patients – whether they have TB or not – and treat for it even if there’s no conclusive evidence. I thought that was a fair frustration and a good example of why it’s important to know the medical particularities of a place before you treat, diagnose, or develop medical devices for various conditions.

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Part of “How to Diagnose TB in Children.”

Finally, there was a moment where the nurses and doctors discussed what might contribute to Botswana’s high TB rates – the possible social, cultural, biological, and policy factors – and I wonder if these factors also affect medical device acceptance here. The interesting answers included: high HIV prevalence (of course); migration; non-adherence to policy; not enough people in healthcare management due to the small population; and the use of traditional medications and going to church instead of seeking immediate treatment at a hospital (I have noticed that religion is quite important here – more on that later).

At the beginning of this year, I would start with examples of individual devices and only focus on cultural factors once I could generalize trends across those conversations. Now I find myself approaching both at once, looking for those cultural trends right away so that I can keep them in mind as I encounter various medical technologies. I suppose it’s a good thing because it means that I’ve gotten faster at identifying the important factors for medical technology adoption – the “big picture” stuff – without needing so many small steps to get there. That said, I’m still looking forward to learning more about specific medical device and eHealth projects here!

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My street in Gaborone.

Botswana: First impressions

The Batswana – the people of Botswana – refer to the country as “Bots,” and I love that. Gaborone is pronounced Ha-borone-y, but this city has a nickname too: Gabs. I’ve already been here for ten days, and I can’t believe it. Time flies by faster as the Watson goes on, I’m sure.

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I flew from Tokyo to Doha (back to Qatar!), then from Doha to Johannesburg, and finally from Johannesburg to Gaborone on this little plane.

Botswana is a huge change from Japan. The population here is about 2 million people; 10% of them, 200,000, live in Gabs. Japan has 127 million people with 13 million living in Tokyo alone. I knew that Gabs wouldn’t be nearly as urban or pedestrian-friendly as Tokyo, nor as safe. I even read a mildly alarming email from the US Government suggesting that visitors avoid walking around solo at all.

Luckily that email was over-cautionary (though I still won’t be walking around in the nighttime), and after a couple days in Botswana, I started to feel at home. The transition from Japan was quicker and easier than I expected. I don’t know if that’s because I’m used to transitions now, and better at adapting quickly to new and foreign places, or because the people here are so friendly and easy to talk to in English – probably both!

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Botswana is quite sparsely populated.

The surrealism of the Watson is often lost on me these days, though I frequently marveled at the lovely strangeness of it all in my first few months. It’s become an odd routine – of traveling, landing someplace new, figuring out how to get a local number, taking a couple days to figure things out and feel safe – that I’ve learned to repeat in each new country or even city. Each new destination gets easier to manage, and each unexpected interaction or step along the way seems less like a snag. That in itself is exciting and surreal, though, knowing that I now feel comfortable walking into pretty much any situation and making it feel like home.

Of course, this is the end of the proverbial road, and I won’t be traveling to another new country after Botswana. But that’s not to say the U.S. will feel exactly like the place I left, and maybe this new-country-routine is something I can apply, on a much smaller scale, to my return back home and whatever “reverse culture shock” awaits me there.

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Cracking up in this teacup at an empty amusement park here called “Lion Park.”

Speaking of home, I just extended my stay at an Airbnb here by an additional 7 weeks – the remainder of my time in Botswana. Though I might travel out of Gaborone over the next couple months (in fact, I just did yesterday), it’s always nice to have a home base. I can leave for a night or a few and come back while leaving some of my stuff in a place that I know is safe.

Anyway, this is a big milestone for me because it means that I’ve figured out a place to stay for every single night of the Watson year. Just before I left for Sweden, I only had a few weeks of housing figured out, and it scared me. I had to set up all my own accommodation for 365 distinct nights, and I didn’t know where I was going to be – and at the same time, my friends were moving into apartments with yearlong leases. I knew that I would be okay figuring things out day-to-day on the Watson year once I got over the hurdle of where to stay night-to-night. Now that I’ve booked these last 7 weeks, that’s it. I’ve done it – I found a safe place to stay every night of the Watson and stayed in budget while doing so. I’m tempted to say that it was easier than I expected, but maybe that’s just in hindsight.

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The Central Business District of Gaborone. It’s really mostly buildings under construction.

Finally, the stars here are just beautiful – Gaborone must have the least light pollution of any city or town I’ve been in this year. (If I could capture them on my camera, I would certainly post a photo). I keep getting distracted by them at night. I don’t think most of the Batswana notice.

The 10 Shrines of Tokyo (A goodbye to Japan)

A friend of mine in Japan told me about the Tokyo Jissha, the ten shrines of Tokyo, a couple weeks before I left. In 1868, at the time of the Meiji Restoration when Tokyo became Japan’s capital, Emperor Meiji chose ten Shinto shrines scattered throughout the city to be the sanctuaries for the new capital. Every shrine and temple has a unique stamp (goshuin) that can be written in a special stamp book (a goshuin-cho), and my friend had decided collect the stamps of the Tokyo Jissha in her goshuin-cho. I decided to get a book of my own, and traveling to these 10 shrines during my last days in Japan to collect goshuin felt like a pilgrimage to say goodbye.

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goshuin stamp I got at this golden temple in Nikko, a town close to Tokyo.

Just because I keep leaving doesn’t mean that it gets easier to let go. I left Japan a few days ago and I’m still wrapping it up, cleaning it away. I feel like I have to do this spring cleaning every time I leave – change my number, close the tabs of “medtech companies in Japan,” tell my friends I arrived safely, and then drift out of regular contact with them. Is it easier to leave, or to stay? I’ve become someone who leaves and I don’t know how I feel about that.

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“The 10 Jinga of Tokyo.” This was at Hikawa Jinga, the first shrine I visited out of the 10 and where I got my goshuin-cho book).
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Hie Shrine.
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Up the stairs of Hie Shrine.

The thing is, as much as I live in these places and learn to love them and get to know their people, I don’t really belong. I’ve become increasingly aware of the fact that no matter how long I spend abroad, I won’t become Indian or Japanese or Singaporean. I need to take all that I’ve done this year and bring it back with me to places I do belong. I want to know what my project would be like in the US – what impact I could have on medical technology there, where I can invest the time.

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This is my goshuin-cho. Each stamp in the book is unique – it has the name of the shrine and the current date. It takes a few minutes to get a stamp because you have to wait for the shrine attendant to paint it in.
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A bridge in Nikko.
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Kanda Shrine, probably the most popular shrine of the ten.

But I’ve gotten used to leaving everything behind every few months, and I wonder how that will manifest when I’m back home and trying to build something more permanent. Perhaps I’ll find that it’s easier to keep seeing new things, rather than to try finding new aspects of old things.

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The Kameido Jinja is very serene, and the Tokyo Skytree building is visible in the back.
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My favorite of the ten was the Nezu Shrine, with all these torii gates.

I was worried that my fleeting presence in various places this year would make people feel distant, but it hasn’t. Especially in Japan, where I was worried about the formality of the polite language, I learned that so much warmth can be imbued between the words of formal speech. It’s still hard to know, without speaking the language, if you’re doing things right or just the recipient of excessive politeness, but I’ve gotten closer to people than I expected to.

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I also traveled to Kamakura, a town very close to Tokyo, right before leaving. This is the country’s second-largest Buddha.
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The Buddha is hollow, and it’s cool to go inside and see how the different pieces were fused together.

Still, I’m getting tired of saying goodbye. I’ve arrived in Botswana now – my last project country – and that feels right. I’m used to leaving places, but I don’t want to be; it’s actually comforting to know that this cycle of coming and going, goodbyes every few months, is ending soon. I’m excited to spend two months here and explore one more new place. Also, on a lighter note, it’s lovely to be in a country with fluent English speakers!

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At the entrance to the big Buddha temple: “Stranger whosoever thou art and whatsoever be thy creed, when thou enterest this sanctuary remember thou treadest upon ground hallowed by the worship of ages.”

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A few days before I left, I finally found the prototypical Japanese garden scene in Kamakura. I really had a wonderful time in Japan and learned a lot about the culture there, and I’m also happy to keep moving forward.