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.

Health post: Tying the threads together

In Japan, any time you walk into or even near the door of a shop, you’re guaranteed to hear “Irasshaimase!” It essentially means “welcome to the store and come on in.” I’ve heard it in so many iterations by now: the full, exuberant call to any visitors; the periodic, slightly robotic “irasshaimase” called out by shop workers to no one in particular; and the occasional, tired, not-quite-there “…shaimase.” Sometimes, the call of “Irasshaimase!” is so happy and charming that you can’t help but smile in return. Other times, I walk past a store and ignore the dully repetitive “irasshaimase” calls along with other Japanese passers-by.

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This is Hakone Jinja. Over the weekend, I went to the nearby town of Hakone with my host family.

For the most part, this welcome call is polite and lovely, and I see it as indicative of many trends I’ve noticed here: the feeling of a common collective, a strong work culture, perfectionism, and a charming consideration of the feelings of others. The way that every single shop and restaurant worker says it – whether they sound happy about it or not – means that every shopping experience starts with a welcome, and I feel like that fits in well with the strong collective culture I’ve felt here. Generally, once you figure out how these interactions go in Japan, they will always go the same way.

There’s also a surprising amount of talking that, in the shop example, might start with “irasshaimase” and continue at the register with far more Japanese than you’d expect when buying a pack of gum, as the shop employee hurries through a certain set of phrases (I wish I knew what they all meant). There’s an idea that someone is much more likely to carry out a task correctly – that is, perfectly – if they verbally reinforce each required action. This recent article perfectly describes this phenomenon as it applies to Japanese train workers, who call out what they’re doing even when no one is listening as a way to reinforce the performance of the required task. Of course, this is an example of the perfectionism and work culture.

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While in Hakone, my host family and I went to this great open-air museum. This photo of my host mom and me was taken by the dad of the family!

I’m soon leaving Japan, and I’ve had many meetings here for which I haven’t written individual posts. I wanted to share some highlights from those meetings and focus more on the themes I’ve noticed from them, such as the perfectionism and work culture as I’ve already mentioned. Based on what I’ve seen, and of course in terms of health and medical technology, I think the most significant cultural trends are respect of hierarchy, conformity, and risk avoidance.

Hierarchy

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Jizo statues, little protectors at many temples.

From what I’ve gathered, hierarchy is quite important in Japan, and hierarchy often correlates with age. I met with a Tokyo-based company called Allm (for “All Medical”) that offers a platform of multiple smartphone apps to increase efficiency in healthcare. Their main product, an app called Join, serves as a secure messaging service between doctors. Through Join, doctors in different areas can share ideas and expertise – for example, a doctor might send an X-ray through the private app to a more senior remote doctor, who can then give immediate feedback and advice about what to do next with the patient. The woman I was interviewing at Allm, Ms. Kudo, told me about the difficulties they’ve encountered when encouraging doctors to use the app.

When I asked her what specifically impacts the usage of the Allm app, she said “In Japan, we really care about hierarchy.” The younger doctors always follow the elder doctors, she explained. If the more senior doctors say no to something – such as the usage of a new app – “that’s it,” she said. Allm company members often travel to expos to promote the app, and if older doctors say it’s too difficult, they have a very hard time selling it. Adoption and acceptance of new medical devices can hinge on an influential decision maker – I’ve learned that medical technology companies often try to find these “ambassadors,” perhaps an influential doctor who is excited about the new technology and can convince their hospital to purchase it. Ms. Kudo told me that, for Allm in Japan, those ambassadors always have to be the most senior doctors (the highest in the hierarchy, who also often happen to be the oldest as well).

This respect for the hierarchy also complicates the group-chat aspect of the app, where doctors can discuss cases and share knowledge and advice. Ms. Kudo told me that the younger doctors become shy in the group, not wanting to ask questions, because they don’t want to seem foolish or ignorant in the presence of more senior doctors – their bosses – who are also on the chat. They’re very worried about screwing up, said Ms. Kudo, even if the senior doctors would have the answers they seek. I was sad to hear this since, of course, I would much rather have a younger doctor ask a somewhat silly question than never learn a crucial tactic; I feel like asking questions is seen as a necessary part of the education process in the US.

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A band of robots at the Toyota Museum in Nagoya.

Someone in Sweden once told me that, with technology being so pervasive, even grandparents were considered uncool or out of the loop if they didn’t have cellphones or use computers. In fact, the word they used was “hermit.” I expected the same in Japan – if Japan is known for being a technologically innovative country, with so much exciting technology everywhere (such as the robots in stores), why doesn’t that extend to, or influence, the older generations? (I asked Ms. Kudo this question, and she was decidedly stumped).

Now, I think it is because of this respect of hierarchies and the elderly in Japan – the younger people would not ask the elderly to keep up with all the new technology, as they are expected to in Sweden. There very well might be Japanese nurses and doctors that are eager and excited to use an app in their work, but if their older and higher-up bosses disagree, their voices might go unheard because the respect of the hierarchy is so strong. In Sweden, however, I noticed that there was little respect for hierarchy and more of an effort to treat everyone as a peer. One Swedish doctor who had been practicing for decades told me that, when a patient mentions something they read on the internet about their condition, he’s not going to tell them they’re wrong – he’ll sit down with them and have a conversation about it, and maybe learn something new himself. I don’t think that would happen here.

A subtler issue here is that, if you’re trying to sell medical technology to someone who has been doing their job well for the past 40 or 50 years, they might have a harder time seeing the use of an additional tool (or worse, be insulted by the implicit suggestion that a medical device would improve their work).

Since younger generations are typically more interested in using new technology than older generations, having the senior people be the decision makers with regard to medical technology probably means that adoption will be slower here than it could be. I thought the mere ubiquity of technology in Japan would lead to high acceptance of medical technology, but I was wrong. There might be cute robots in stores (which are very technologically advanced), but that doesn’t mean that all the less-advanced tech (like smartphone health apps) will be as popular. Using a cute robot at a store is a very different interaction from using a smartphone app every day, and maybe the culture here is more excited about the former rather than the latter. I was expecting some “trickle-down technology acceptance” – that because of the appreciation of robots here, people would want all areas of life to be technology enhanced. But that’s not how it works. Technology is not everywhere here, and there’s still a lot of value placed in tradition and ancient culture (for example, I see many young people visiting and praying at the many shrines and temples Japan).

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Taking the escalator up to the huge Hie Shrine in the middle of high-rise Tokyo.

Conformity and Work Culture

The collective sensibility is something I’ve noticed in many aspects of Japan, even walking the streets of Tokyo. For example, street fashion in New York City is all about standing out – doing something completely unique and bold and different. In Tokyo, I’ll see friends meet up with each other, and they’ll all be wearing iterations of the same outfit (really, it’s crazy how often I see this). Japan is not a particularly diverse place, and I get the sense here that fitting in – conforming to certain looks and roles – is highly valued.

It’s hard to know exactly how the sensibilities of a corporate culture and common collective impact reactions to medical devices; perhaps it’s simply that there are fewer individualist and innovative start-ups here adding many devices to the market. With a strong corporate culture, doing one’s job well in the same company for many years is rewarded. In the US, however, we reward individual success and the ability to quickly commercialize a new innovation.

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Dr. Mukai of Meijo University and his ROBEAR, a healthcare patient-lifting robot that is used purely for research and will most likely never work in a hospital.

In one meeting, I spoke with an American named Marty who has a start-up here in Tokyo called enTouch KK. He talked about how there might be fantastic research happening at universities, but that the results are not commercialized. The job of the professor is not to commercialize research ideas and move into business, but rather to write as many papers as possible and start working on the next research project. Marty said that since the professors are proud in what they do, they don’t feel the need (or want) to commercialize it. Their success is already measured by the research itself, and with that aspect of professorial work perfected, there’s no need to bring ideas beyond the university. (This is not to say that there aren’t professors trying to commercialize ideas and collaborate with businesses; I met a few professors in Osaka who are trying to do just that. They did, however, discuss the difficulty of being surrounded by professors who have no interest in business).

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This is Professor Nakane of Osaka University, who is trying to commercialize his idea of applying the mathematic theory of homology to the medical problem of tumor detection.

In the US, however, we’re trained to take any idea farther and think: how can I commercialize this? How can I monetize it? Marty taught me an old saying from Japan: “The nail that sticks out gets hammered down.” I was so stunned, I started laughing at how absurdly dramatic the saying is. It describes an attitude that I see as a stereotype about Japan that may have been true a few decades ago, so I was surprised to hear that sentiment echoed in Tokyo in 2017. Marty did not mean that it applies to all scenarios, of course, and he did say that it was an old saying – but it’s still a sad one.

I had heard about Japan’s corporate culture before I arrived, and I had this 1970s scene in my mind of men all wearing the same black suits, walking through Tokyo with the same black briefcases. It’s not quite that intense, but the idea of the “salaryman” persists well into 2017. If not directly related to medical technology, I do think the corporate culture has an impact on health – a few people have told me that if there is anything unhealthy about Japan, it’s the work culture, the long hours and commitment to doing your job perfectly (as opposed to trying to stand out and jump up the ranks). At the very least, I do think it’s connected to the lack of more health start-ups.

Risk Avoidance

The small number of medical start-ups here is also due to a fear of risk. The very first person I met in Japan, a doctor, told me that the most important cultural aspect of Japan with regards to medicine is that people are risk-averse. This manifests both in people, who take extra care to be safe in their everyday lives, and in companies, who seem hesitant to build invasive technologies (as most medical devices are).

The day to day risk aversion is evident in the stereotypes of Japan such as the wearing of face masks (which people do, but not everyone). People also avoid direct sunlight, and everywhere I’ve been has felt extremely safe. I honestly think that part of why people live so long here is because they avoid risky or dangerous activities, staying safe throughout their lives. (There are unhealthy habits as well, though, such as the prevalence of cigarette smoking; and yet Japan is not ranked as a country with high lung cancer rates, whereas the US is: source).

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At one of Hakone’s most sulphuric destinations, workers give you little cloths at the station: “To prevent accidents occurring due to volcanic gases, please be sure to cover your mouth and nose with the wet cloth.”

I interviewed someone at a big Japanese medical technology company that produces non-invasive equipment for hospitals and patients living at home – nothing invasive or implantable. He said that those types of devices are seen as too risky and that, for example, no Japanese company makes pacemakers – medical companies here want to avoid any potential of failure. Everyone he knows in Japan who uses a pacemaker, he said, has one from Medtronic (from Ireland) or some other globally recognized brand.

Professor Yoshizawa, of the bioethics department at Osaka University, told me the same thing – that while there are many robots in Japan, most of them are for communication and business because companies are reluctant to put a robot in a healthcare space where the risk and consequences of failure are much higher. He said that most medical devices in Japan (especially those that are implanted or provide treatment) are generally imported from the EU and US, while Japanese companies make non-invasive monitoring systems for diagnoses and check-ups because they’re safer. Professor Yoshizawa said that if one Japanese-made device causes any harm, the company will be attacked by the government, media, and general public and their whole image destroyed, so there’s no room for error – better to just avoid the risk altogether, and therefore Japanese medical companies focus on prevention and fitness. (Personally I find this a bit frustrating, because being at the forefront of medical technology does involve some trial-and-error. But it makes sense that a stereotypically perfectionist culture would want to avoid such errors – and perhaps this idea of only using extremely well-tested invasive technologies from abroad does make people healthier).

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Iridescent glass “leaves” at the Hakone Venetian Glass museum.

Risk avoidance also leads to fewer start-ups, which are inherently risky endeavors. Marty, of enTouch KK, said that start-ups are just beginning to become more popular in Japan (of course, they have been very important in the US for many years now). Investors in Japan are “very, very cautious,” he said. As opposed to the US, the idea of start-ups and angel investment is not normalized in Japan – though it’s starting to be – and there are not as many start-up success stories to inspire young entrepreneurs or give confidence to potential investors. Marty said that Japan’s most recent corporate success story was Sony (founded in the 1940s). Many of the small, innovative medical devices I’ve seen this year have come from smaller companies and local start-ups, so maybe in a few years, when start-ups are more common in Japan, there will be more medical devices in development – but for all that to be true, there would have to be more comfort with risk-taking.

Well, that’s that. It’s been fascinating seeing the interplay of these attitudes, and Japanese culture in general, and how some of it affects the way people approach medical devices.

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The Zōjō-ji temple near Tokyo Tower.