Health post: Challenges of scope

This past week I met with two women, Sireesha and Vyoma, of Access Health International, an organization that works to provide quality, affordable healthcare in India and other countries around the world. Both Sireesha and Vyoma are based in Bangalore but travel for their work with Access Health, so I was glad for the opportunity to ask them about what factors in India (as opposed to other countries) influence the adoption of medical technology.

First, we talked about the attitude towards health in India in general. Sireesha said that, in her experience, there is no concept of an annual physical check-up – except for those who have private health insurance. Only 17% of the population has health insurance, so that is a small number, but it’s growing as more people are provided insurance by their companies in employment packages (http://www.thehindu.com/news/national/only-17-have-health-insurance-cover/article6713952.ece; however, most people I’ve talked to seem to think the number is closer to 7%). Overall, though, preventive promotive care is not something that really happens in India. Sireesha’s example was that unless there’s a wound in your foot and it’s not healing, you won’t go to the doctor and learn about your diabetes. Since many medical devices are for preventive care and/or self-management of a condition, these devices won’t easily succeed in such a market.

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These photos are unrelated to the meeting with Access Health, but I took them walking around Bangalore. This is a Hard Rock Café in a beautiful old “Tract and Book Society” building!

The most important factor in India that determines whether or not someone accepts a medical device, though, is purchasing power. Sireesha and Vyoma are two of many people here to tell me that cost is first and foremost what influences peoples’ attitudes towards medical technology. Beyond cost, we talked about who might use medical technology and why. The main health issues in India are NCDs (non-communicable diseases) such as diabetes and hypertension, which would require devices like glucometers and blood pressure monitors.

Sireesha and Vyoma suggested that elderly people would be more likely to use medical devices, as they are the ones with chronic illnesses that have progressed further and therefore have a greater need for devices. I’ve heard the opposite from everyone else, so I thought this was an interesting view. Most people have told me that elderly people would not want to use medical devices, either to save money for their children or due to a lack of comfort with technology in general.

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Bangalore has lots of green streets like this.

Sireesha mentioned that the availability of traditional medicines (Ayurveda, homeopathy, and so on) takes some of the market share away from medical devices. Lack of awareness of medical devices is not the only reason besides cost that someone might choose against using a medical device. If people see the technology as too complicated or prone to glitching, they might prefer traditional medications, which don’t have batteries that die or readings that fluctuate.

What I found most valuable about our meeting, however, was that we also discussed the challenges with my project and my approach – mainly the need to normalize my experiences so that I can compare the countries. My project topic, which is already so broad, is complicated by the fact that it has to morph with each country I visit. How can I make sense of all my meetings at the end? How can I put them all into a framework so that these meetings don’t each disappear into one-off experiences? Obviously, I can’t see everything everywhere I go, so each meeting does have to be its own little unique example. Can I make generalizations based on these individual meetings? In addition, I have a time constraint: I only have a matter of months each in these countries with multifaceted histories, cultures, and populations, so I can only see various slivers of each country in this limited time. But maybe taking out the factor of time – seeing each country at a snapshot in time – simplifies the normalization problem.

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There’s lots of fun architecture in Bangalore, and I quite liked this example. Also, check out all the motorbikes – the best way to get around the Bangalore traffic!

The other issue is bias. Everyone I meet speaks from their own individual experience, which is biased based on where they’re from and what they’ve seen. Many of the people I talk to are quick to point out that “this is just my perspective and I don’t know for sure” (which is how I feel all the time). Then their perspective gets filtered through my own when I write about my meetings, meaning that I’m adding my own subconscious bias to each experience. Vyoma called a problem of “counter factors,” which I thought was a really cool way to put it. I’m trying to understand and collect these factors for acceptance, but as I do that, I have to be careful to consider the “counter factors” – the biases – that work against my complete and objective understanding of what influences someone to use a medical device.

On top of that, there’s bias that results from the way I travel on the Watson, mainly that I tend to stay in urban areas. First of all, it’s easiest to find housing in urban areas; if I have a family friend offering a place to stay in a country, chances are they live in one of the bigger cities of that country, and if I’m looking for an Airbnb or a guesthouse, I’m looking for one in a city. Many of the companies I research have offices in cities. For safety reasons, I stay in cities. And finally, I stay in urban areas just because that’s what I know about a country in advance – its cities – and I’m ignorant of its rural areas (and how to get there and stay there). Of course, this means that I miss out on a big part of the experience, and my meetings tend to be biased towards the urban upper class, and an even more elite minority of that group – the English speakers. In Sweden and Qatar, where I saw most of the population by traveling to Stockholm, Gothenburg, Malmö, and Doha, this wasn’t a problem. However, most of India’s population lives in rural areas. So my experience here to date has definitely been skewed.

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A lot of the flyovers have colorful murals on the supporting pillars.

One reason I wanted to spend more time in India and Japan compared to the other countries I’m visiting on the Watson is to explore the differences in urban and rural areas. So far in India, I’ve mostly been staying in Mumbai and Bangalore, two of the most urban and cosmopolitan cities in the country (so, not at all representative of India, not that any one place here would be representative of the whole country – Vyoma mentioned that I could do my entire Watson in India, and it would still be like visiting a bunch of different countries). Still, the urban vs. rural conversation has come up far more in my meetings in India than it ever did in Sweden or Qatar, either by my prompting or that of my project interviewees. That’s good, but I am also hoping to plan some sort of field visit to a rural area for the project to understand these issues first-hand. It will be tough to plan and get approval, but of course it would be a hugely valuable experience, so hopefully I can work something out.

Anyway, as I continue having meetings, it’s good to keep this in mind so that I think of each meeting as a part of the framework, a piece of the puzzle, rather than an isolated experience.

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