This blog chronicles my travels as a 2016-2017 Thomas J. Watson Fellow exploring cultural attitudes towards health technology around the world. Starting from and returning to New York City, USA, I am traveling to Sweden, Qatar, India, Singapore, Japan, and Botswana over the course of one year.
I leave Botswana tomorrow, and even though the date of July 18th has been in my head all year, it still doesn’t quite feel here.
My trip home will take 28 hours, including a couple hours in Doha (hello again!) on the way to NYC. Thanks to the new electronics restriction on flights coming into the US from the Middle East, I was going to have to pack my laptop away in my checked bag for the whole trip (and worry about it not breaking – a nice welcome home from the new president). But just now as I went to check in with Qatar Airways, I saw that the ban was lifted, so that’s good news! Now I’ll be able to take my Kindle on the plane with me and finally finish the book I started ages ago (The Goldfinch).
I’ve been packing for the last time today, and I’m definitely ready to stop living out of my suitcase. I’ve somehow accumulated a extra bag’s worth of stuff over the year – I packed so tightly when I left that I didn’t leave room for the few clothes, small trinkets, and many papers that I would acquire throughout the year. My packing right now is a bit sloppier than most of the times I’ve packed this year, but this time I just have to get my stuff home instead of setting up someplace new.
Most of what I brought with me is coming back, except for pants I managed to rip yesterday (oops) and the travel quick-dry granny panties I unceremoniously tossed a few days ago. A few other things got tossed and replaced throughout the year, but for the most part I’m very happy with what I packed.
Today is President’s Day in Botswana, and as presidents are apparently very revered here, everything is closed. Botswana will stay quiet until Wednesday (after I’m gone), and the one meeting I had scheduled for late last week was canceled because the doctor started his holiday a bit early. It’s been nice to slowly wrap things up and not worry about any more meetings, but now I’m getting antsy to go home (I wish, at least, my Zumba class were open today, or the cafe where I have a free coffee that I’ll never redeem). The journey home will be long enough that I want to get it started!
I’m very excited to finally come home and return to NYC after the longest continuous time I’ve spent away from the city. I’m sure the end-of-Watson feelings will kick in a bit later, maybe on the plane – I’ve said a lot of goodbyes these past few days without actually feeling them. (I think that after a certain number of goodbyes, you just go through the motions because it would be too emotionally exhausting to really feel them all. That will all sink in eventually, too). For now, I’m excited to have one last crazy long journey and go home to my friends, family, and of course, the dog.
P.S. This is my last post written from abroad on the Watson, but not my last post on this blog – I’ll keep writing for a little while longer to cover coming home, the Watson conference, and the final Watson report.
Peek Vision is a health startup aimed at improving access to vision services and eye care. Their main product is the Peek Acuity mHealth solution, a smartphone app that allows anyone to conduct a vision screening in a few minutes. They have a few other products as well, all of which contribute towards their goal to perform vision screenings (particularly for schoolchildren) as well as make a real impact by providing eye care and/or glasses for those who need them.
Peek was founded by a London-based PhD candidate, piloted in Kenya, and has had a chapter in Botswana for a couple years (here is a great TED Talk by Peek’s founder). Last year, Peek partnered with the Botswana government to perform screenings in 49 schools, rural and urban, in the country’s Good Hope district.
I interviewed Maipelo, the project manager of Peek Botswana, to learn more about the screenings. She traveled to many of the schools involved throughout the screening process and personally helped train local healthcare workers so that they could use the app.
Since the app is free, I downloaded it myself. The app acts as a replacement for the “tumbling E” boards typically used in visual acuity tests – children are supposed to tell screeners which way the “E” is pointing (for example, an “E” in the usual orientation is pointing to the right; a backwards “E” points to the left). The typical boards can get lost or damaged, and the pattern of Es can be memorized by children (a sequence of up, right, down, etc). The Peek app addresses those problems while also keeping track of anyone who fails the test for follow-up purposes.
When you first open the app, it brings you through a tutorial to show how the screening should go. The screener needs to stand exactly two meters from the student (or whoever will be screened), holding the phone so that the screen faces the student at eye level.
My favorite part about the Peek Acuity app is how the actual screening goes – the screener never needs to look at the app while the student is watching the screen. When an E is displayed on the screen, the student points in the direction of the E. The screener then swipes the phone screen in the direction that the student is pointing and never needs to look at the E. The screener doesn’t need to know if the student gave the correct answer; it is automatically recorded by the app. The Es displayed on the screen continue to change direction and size, adjusting to the student’s performance. If the student can’t see the E well enough to guess, the screener is supposed to shake the phone so that a new, slightly larger E appears.
Screenshots from the app tutorial.
After about two minutes, the phone plays a sound to indicate the end of the screening. The screener then looks at the phone and sees the result (for example, “0.8” for a student with quite poor vision). There’s also a built-in simulator that displays how blurry a chalkboard would look to someone with 0.8 vision, for example, so that the screener truly understands the numerical result. The simulator feature also ideally builds empathy for students who have had undetected vision impairments – students who struggle in school and often get written off as being lazy or naughty by teachers who assume that they can see perfectly fine. (This is true for hearing as well. The HearScreen people in Pretoria described hearing problems as a “silent epidemic” because kids with such impairments often go undetected and are treated like bad students when they don’t do well in school).
Maipelo told me that, for the most part, the screeners and the students responded well to the Peek screening. Everyone is excited when they see the app, she said; less so when they are told to use it and realize they have work to do. Regardless of how fast and easy the screening process is, it’s still work, especially when screeners work all day long checking hundreds of schoolchildren. Also, Maipelo said, those who were less comfortable with the phones would take longer to input data. Even if the difference is a minute and a half instead of, say, 45 seconds, that adds up with so many screenings per day – and it can get frustrating for the less tech-savvy screeners.
I also asked Maipelo about the follow-up process. When Peek Acuity indicates that a child has impaired vision, the app prompts the screener to enter their contact information. The app then automatically texts the child’s parents with the follow-up details – where they should go to meet with an eye doctor and when. That’s when the children would get glasses if they needed them.
That is where it could get complicated, Maipelo told me. Even though all the parents had a positive reaction to the idea of medical technology, she said, they never liked to hear that their kids had an impairment and needed a follow-up. People only question the technology after it illustrates a problem, she said. Even if the app just says that their child needs glasses, parents immediately respond negatively to anything they interpret as a “medical issue.” Maipelo said that some people believe such problems are curses or bewitchments. “Bewitchments?” I echoed. Yes, she said, people grow up hearing about witches.
This isn’t the first time I’ve heard about witches in Botswana. It seems to be a traditional idea that witches are afoot, causing problems or punishing people for various reasons in various ways. I think when there is a lack of awareness about these things – not knowing how common and remediable vision impairments are, for example – all medical problems could seem as serious as a witches’ curse.
Another local later told me that some people in Botswana have the misconception that glasses will actually worsen vision. If a well-sighted person looks through someone else’s prescription glasses, of course the view is distorted; this apparently leads some well-sighted people to believe that glasses are harmful. Also, people with glasses never stop needing glasses, needing stronger prescriptions as time goes on. Both glasses and crutches are medical devices, but crutches help you get to a point where you don’t need crutches any more; glasses stay forever. Apparently this, too, contributes to the misconception that glasses degrade vision. Of course, most people in Botswana do know that glasses help, but of course it would be best if everyone (especially the more skeptical parents) were on board.
Another interviewee phrased it like this: “In our culture, everything should be normal.” Everything should fit the status quo. People don’t accept the abnormal; they say it’s the work of witches, he said. (And there they are again). Unfortunately many impairments, including poor vision, aren’t normalized, so everything (even the need for glasses) gets labeled as “abnormal.” I’ve heard this in general, too – many people have told me that fitting in and maintaining the status quo is very important in Botswana, which I think makes sense with the neighborhood lifestyle here. In terms of medical problems, it all boils down to awareness and the importance of normalization. If more people wore glasses and it was seen as normal, there would be less stigma against vision impairments, and it would be easier to convince people to treat vision problems less like serious, scary medical issues.
I’ve really enjoyed getting to know Peek Vision throughout my time in Botswana. Including my interview with Maipelo, I’ve had many interactions with Peek – I’ve talked to people involved in different aspects of the company; I sat in on a government meeting where Peek pitched a budget to the Ministry of Health for a potential national rollout; and I’ve met health workers who participated in Peek screenings in very rural areas. When I started my project, almost all of my meetings were one-offs. I had hourlong chats about many different devices and technologies, definitely seeing more breadth than depth. There haven’t been so many examples of medical technology to explore in Botswana, so I’ve tried to dig deeper into the examples that are here, and it’s been cool getting to see Peek Vision from different sides. These diverse vantage points have also illustrated different challenges of getting an mHealth project underway in Botswana – such as how important hierarchy and social niceties are when dealing with government officials in the capital city, or how screeners in rural areas don’t think about how easy or difficult the app is to use if they’re not getting paid to do the screenings. I’m really grateful to Peek Vision for all that they’ve shown me here in Botswana.
As the drizzle started to fall on me in Pretoria, I thought about how neither I nor the rain was supposed to be there. I had ten days left on the Watson (six, now), and I had decided to go to Pretoria, South Africa, to meet a company there for my project. It’s winter in South Africa at this time of year, and in the northeast, where the capital of Pretoria is, that means dry season; rain is only supposed to fall there in the summer.
I wasn’t supposed to be in Pretoria because South Africa is not one of my Watson project countries. Beyond that, I’m technically not supposed to go there because I’ve already spent so time in South Africa, having studied abroad in Cape Town for 5 months my junior year of college. But Pretoria is on the other side of the country, far closer to Gaborone than to Cape Town, and I figured it would be worth breaking the rules for just a few days to see something relevant to my project (especially since I’ve nearly exhausted my project opportunities in Botswana by this point).
I arrived back in Gaborone last night after another 6-hour bus ride across the Botswana-South African border. Earlier in the Watson, I would have asked for permission ahead of time for this short weekend transgression. As I was visiting a monument in Pretoria enjoying the rain, weather I hadn’t felt in a long time, I realized that I had reached a new level of confidence – the confidence to make that judgement call and know, on my own, that it was still within the spirit of the Watson and still good for my project to break the rules just a little bit – a level of confidence that I could only have now, at the end of the Watson. You can only properly bend the rules once you’ve lived within them and respected their existence.
Of course I have been making my own decisions all year, but always within the bounds of what had already been approved for me – going to Pretoria was a decision that I made on my own basis of what was appropriate, confident that it would be worth it. I used to think “confidence” was simply being comfortable in yourself and your abilities. But that sort of confidence is so easily confused with arrogance. There’s a deeper confidence, I’ve found, that lies within the humble acceptance that you’re making it up as you go, that there is a lot to learn, and that you can still deal with everything in life anyway. The confidence of knowing yourself and having that be enough – not needing anyone or anything else to move forward. The confidence to be able to talk to anyone and not be better than anyone else.
Anyway, before this gets any sappier, I’m glad I went. My project contacts in Gaborone were the ones to suggest the trip to meet with HearX, an e-health start-up that spun out of the University of Pretoria. HearX’s main product is HearScreen, a mobile health solution that facilitates simple hearing screenings. With the HearScreen app and approved headphones, the screener plays 3 different tones in each of the listener’s ears. The listener is supposed to raise a hand when they hear a sound, and the screener notes whether or not the listener responds to all the tones played. At the end of the two-minute screening, the app alerts the screener if the listener has a hearing issue and needs to be referred to an audiologist. The audiologist can then determine why the listener failed the screening (HearX told me that the most common cause is wax blockage, a simple problem to fix) and if they need to go to the next step, such as receiving a hearing aid.
I met the HearX people at the Innovation Hub, a set of offices for start-ups in Pretoria. From there, I went with Lelanie, a social worker at HearX, to Mamelodi, a nearby township. That’s where we visited the day care center and met with Charles, a local contact who has helped HearX do school screenings for children in the area. Charles brought in a young boy to show us how the screening worked, and he explained everything to the boy in his local language. I find that these “local ambassadors” are often key for encouraging the adoption and use of m-health and e-health products; Charles is clearly great with kids and made an effort to make the little boy feel comfortable. Lelanie also told me that the kids get more excited about the hearing screening when the screeners tell them that they have to wear the big headphones “like a DJ.”
I sat behind the kid we were screening so that he wouldn’t be influenced by my actions. Lelanie and Charles told me that when the HearScreen project started, they realized that kids could just watch the screeners using the app, raising their hands when they saw the screeners tapping the phone – anticipating the tone rather than actually responding to it. Otherwise, they haven’t had any issues. HearX is planning to expand into Botswana, which I think would be great. The main challenge there, as I’ve mentioned earlier, is that they’ll have to integrate with the Botswana government to an extent that they don’t have to with the South African government.
I went to the offices of the “Botswana Innovation Hub” to meet with Deaftronics, the only local medical device start-up I’ve found in Botswana. Deaftronics makes the “Solar Ear” unit, a solar-powered charger for hearing aids. The small, handheld device has a solar panel and a port for a digital hearing aid as well as ports for rechargeable hearing aid batteries. In 3 hours of sun exposure, the unit can fully charge the batteries, which can be used for up to a week without needing to be charged again.
Deaftronics’s mission is to provide hearing aids to all hearing-impaired people who need them, including people living in remote areas without consistent access to electricity. They emphasize empowerment of the deaf community not just by providing solar-powered hearing aids, but also by training and employing deaf people in their manufacturing and design processes.
Tendekayi Katsiga, the technical director of Deaftronics, is a firm proponent of co-design (participatory, user-based design) and believes that the best solutions come from the users. He told me that the idea of solar-powered hearing aids came from a school for the deaf in Botswana and that his role as the electronics engineer was to transform that idea into a product. For any sustainable project, he said, the process of “iteration and ideation” is key – improving upon the design of a product multiple times until it is exactly what the end users need and want.
In addition to the benefits of co-design, combating stigma is a great reason to employ deaf people, said Tendekayi. There is a stigma that hearing-impaired people cannot work or be productive, and Tendekayi believes that it’s important to highlight that the opposite is true – hearing-impaired people might even be more productive than the average hearing employee, he said, because they can focus on the work with fewer distractions. (It’s certainly a controversial idea, but an interesting change from the usual underestimation of the abilities of hearing-impaired people. I couldn’t find a ton of backing for this, but this book and some other articles support the idea).
Tendekayi mentioned that a challenge of selling the Solar Ear in Botswana is that the government can afford hearing aids and batteries for the few hearing-impaired members of its small population. Very few people would opt to purchase a private product when they can get something from the government for free – and since the government is such a large force in Botswana, it is hard to be a private business there. This moment reminded me of the health worker’s complaint in Sekhutlane that the government spoon-feeds its citizens too much. He believed that if Botswana’s government didn’t provide so many services for free, more people would be motivated to work as well as spend money, thus stimulating the economy.
Thus while some people are using the Solar Ear unit in Botswana, Deaftronics is focusing on potential users in places where it can have more impact: Zimbabwe, Zambia, Mozambique, and other areas in sub-Saharan Africa where hearing-impaired people cannot get aids from their governments or purchase more expensive options. Deaftronics has been endorsed by UNICEF, which could pave a pathway for providing Solar Ear units for free in such areas. In future designs, Deaftronics hopes to add a USB port to its Solar Ear unit so that users can also charge their cellphones via the device.
When I asked him why Deaftronics seems to be the only medical device start-up in Botswana, Tendekayi told me about another complicating local factor: the people of Botswana don’t believe in Botswana-made products. I’ve heard this a few times now, and it’s taught me the importance of local inspiration. Almost everything used in Botswana is imported from South Africa or further abroad. Botswana’s population is small; no great innovations, products, or companies have originated in the country. Of course, that doesn’t mean that great things cannot come from Botswana, but it isn’t exactly inspiring for Botswana’s citizens.
In America, we grow up with incredible success stories of companies like Ford Motors and Facebook as well as examples of revered entrepreneurs and so-called visionaries. These stories inspire generation after generation to keep building, to keep dreaming, and to keep trying, even after many failures. Part of this is due to the large population of the US; if there is a large enough number of start-ups, even if each has a very low chance of success, some of them will make it big. Representation matters: it’s hard to be inspired to make something in your country if there are no success stories to look up to.
I’ve heard this from a few Batswana now, and Tendekayi phrased it well – there’s a perception that when a product is home-grown or designed locally, it’s not the “real thing.” Now that Deaftronics has won a few awards, Tendekayi is confident that the perception will change. Especially with the establishment of the Botswana Innovation Hub, Tendekayi hopes that more Batswana will be inspired to innovate locally.
Okay, I did it. I went to Victoria Falls. It was a pretty touristy weekend, but so worth it – the falls are beautiful. I went with 3 other women, and we did it all in 48 hours: flew to Kasane, the north-easternmost town in Botswana where we stayed for 2 nights; saw animals in the national park from the water; day-tripped to the Zimbabwean side of Victoria Falls; and flew back home to Gaborone the next day. I think it was the best way to do the trip, at least from the Botswana side. If I ever go again, I’ll definitely want to see the Zambia side of the falls (Vic Falls is a bit like Niagara in that it can be viewed from one of two countries).
Kasane is essentially a tourist town, a name for where all the lodges line up along the Chobe River. The Chobe National Park, known for its wildlife, is one of the main tourist destinations in Botswana – Gaborone certainly isn’t (very few travelers hang around Gabs, as I have, but of course I’m not really a tourist). It’s very close to the borders of Namibia, Zimbabwe, and Zambia.
To get to the falls on Saturday morning, we took a van organized by the lodge with other travelers. First, we passed through the Botswana border patrol and got departure stamps in our passports. Next, we arrived at the Zimbabwe border patrol, where we had to get full-page visas to enter the country for the day (it’s actually really cool-looking!). This was quite the experience. We were told to leave our passports at the counter in this tiny office and walk away from them – never a good feeling – and leave our driver/guide to pick them up and bring them back to the van. After 20 minutes or so, we got them back…all except one. One German girl from our van didn’t get her passport back right away. Somehow it had ended up with a Korean man in a van ahead of us, and it took a long time to sort that out! A lot of tourists were coming through that border post.
My group was curious about the Zambia side of the falls. We saw a poster for a one-day Zambia-Zimbabwe visa and asked our guide about it. “Can we go to Zambia today too? We heard the falls are beautiful from that side.” “No, just Zimbabwe.” “But look at this poster!” “Well, we don’t bring people to Zambia.” “Why not?” “There won’t be time.” (It was clear by this point that our guide had a plan he wanted to stick to, and we should not try to deviate from that plan. I would have loved to do the day trip without a guide if possible, but this was the way to do it). “But we have all day – can’t we just pop over there?” “Uh…they won’t let you.” “Why not?” “You can’t re-enter Zimbabwe from the Zambia side if you don’t have proof that you’ve gotten the yellow fever vaccine.” Well, from my travels in South Africa, I did have the yellow fever vaccine, and I even had my yellow card with me to prove it because I keep it with my passport. So of course I took it out. “Well, I actually have that right here!” He gave me a look that clearly said “No.” I eventually walked out to the van and waited for my passport.
As it turned out, we did go into Zambia, but only for a few minutes and very unofficially (no passport stamp). When you get to the falls in Zimbabwe, there are two parts: the main part where you enter the Vic Falls park and walk along the falls on the Zimbabwe side, seeing them from many different viewpoints, and then a short distance away, a big bridge for the activities (bungee jumping, zip-lining, and so on). The bridge is beautiful, and it actually does go from Zimbabwe to Zambia, though for the activities you only spend a few minutes on that side. Two of the girls I was with wanted to go bungee jumping, so we went to the bridge first before officially seeing the falls. We heard the falls in the background and saw part of them from a distance, which built up our anticipation of the falls.
Bungee jumping looked a bit too scary for me, as well as way out of my budget, but I did go zip-lining with the other person in my group! It was probably the most extravagant thing I’ve done on the Watson so far, but it was a blast. And now I can say that I zip-lined from Zambia to Zimbabwe – so that seems pretty worth it.
Finally, after our short stint in Zambia, all our activities, and lunch, we went to the Victoria Falls UNESCO World Heritage Site in Zimbabwe. We entered the gate and saw two paths, one to the right and one to the left. Someone told us that they started from the left but that both paths lead to the falls. We took the right.
We followed the tree-lined path for a while and eventually stumbled upon the falls, mysteriously shrouded in white mist. It was cold and damp, and the mist rose forcefully up from the falls and rained back down right on top of us. It was a sunny day, so we saw a lot of rainbows. As we moved further along the path, we got closer to the falls – and we got soaked! The water was rushing quickly and loudly and caused enough rain to drench us in minutes. It’s a wonder we were still able to take photos with our cameras and phones without damaging them.
At one point the fog lifted a bit, and we began to grasp the immensity of the falls. We couldn’t even see the bottom of the gorge where the water was falling. As the only four people standing at the edge of the falls, we were cold and dripping and giddy with excitement.
We then doubled back on the path to go towards the other end of the falls. At each viewpoint, the falls looked more and more beautiful. We realized we went through the whole thing backwards – if we had taken that left at the start, we would have begun with the traditional (and dry) view of the falls, and then ended at the misty Rainbow Falls viewpoint, where we started. But I’m so happy we did it in reverse. We got to see the mystery of Victoria Falls slowly unfold in front of us, beginning with our first glimpse from far away on the Zimbabwe-Zambia bridge. We got to discover Vic Falls bit by bit throughout the day until the full beauty of it was finally in front of us. If we had started with the classic, full view, we wouldn’t have had that slow, exciting build-up – and we wouldn’t have been so happy about getting soaked by the falls at the end when we couldn’t even really see them.
All in all, it was a really great trip, and I’m so happy I got to go. I want to see the rest of the natural world wonders now! I was also really content to return “home” to Gaborone. I was talking about the definition of “home” with my friends after we got back. How long do you have to stay somewhere before you can say that you lived there? What does it mean to have a home? One idea was that you live somewhere if you would give a friend that address so that they can write you a letter. Another idea was that when you buy groceries and cook for yourself in a place, you’re living there. The amount of time you spend somewhere definitely matters, but so does your relationship to that space.
I realized that my idea of home is a place that I leave and come back to. The weirdest aspect of traveling on the Watson is the way that it’s sustained; you hop from one strange place to another without ever going back to your true “home.” Most people travel in distinct trips, from home and then back. When I went from Stockholm to Doha and then onto Mumbai, I didn’t feel like I lived in Stockholm. I never called Doha “home.” But then I used Mumbai as a base while in India – I traveled out to other cities and states in the country but usually returned to Mumbai in between. By the end of my time in India, Mumbai felt like home. I could leave stuff there and return to it, just like a regular trip-taker; I created the illusion for myself that I wasn’t living the sustained nomadic lifestyle of the Watson, where you take everything with you every time you move. I’m not sure if any of that makes sense. But the point is that, on Sunday when I was flying back into Gaborone from Kasane, I felt like I was coming home.