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.

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.

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.

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.

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!

My street in Gaborone.

Health post: Cochlear implants

Back in Mumbai, I visited Cochlear Limited, the biggest producer of cochlear implants in the world. Cochlear implants are small medical devices for the deaf or severely hard of hearing, and they replace/bypass the damaged cochlea (the inner ear). Two-thirds of the cochlear implants in the world are made by Cochlear. Unlike a regular hearing aid, cochlear implants include a surgically inserted device, which requires a single surgery as well as an external piece that sits over the skin on the skull and contains a microphone and sound processor. The microphone picks up the sounds in the environment, the sound processor processes them, and then the device transmits the information to the implant. The external and internal parts connect via electromagnetic induction (the magnet is strong enough to hold through skin).

My contact at Cochlear, who did not want to be named, told me that while of course the implant itself is hidden, there’s a social stigma against the external part of the hearing aid. In the United States, Europe, and Australia, the mindset he’s observed is that “a hearing person is a normal person” – but not in India. Also, in comparison to the other health issues, he said that cochlear implants are the lowest priority of health here.

My contact said that the stigma here partially results from the fact that Indians are always focused on what others are doing. (I have definitely noticed this stereotype! I don’t get stares just because I’m a white woman; everyone seems to stare at each other no matter what.) So if you have a hearing aid or some other visual oddity, it could prompt your friends, relatives, and coworkers to point it out and ask questions. “What is that? Are you alright? How bad is your hearing?” and so on. Best to avoid it altogether, in that case. Of course, this is all per the stereotype and a large generalization, though it differs from the generalization about the United States that it’s considered rude to stare. I do think it’s true that most people might look and then glance away quickly, adopting a studied ignorance of the device (which could also perpetuate a stigma, but that’s a different discussion).

On the left, you can see an older model of the cochlear external piece, which has 3 separate parts to the microphone, processor, and transmitter. It comes in neutral colors but there is an array of caps in bright colors and prints to modify the over-the-ear part. (Far to the right is the newer Kanso 3-in-one device).

At Cochlear, the internal implant is the same size for everyone, while the external processor is a different size depending on the model. In response to the consumer feedback research done by Cochlear’s R&D team, they’ve developed different color caps for the processor in case people want to decorate it – they’re trying to make it into a cool gadget like any other wearable (such as how Fitbit sells wristbands in all colors). But they have had trouble selling these caps in India, as they’ve observed that no one wants to advertise that they have a hearing issue. Instead, most people go without any aid and try to manage without telling anyone, as I mentioned. Cochlear is always working to avoid this stigma, so they developed Kanso, a subtler hearing aid, in response to stigma in general, in India and around the world. Kanso, which means “simple” in Japanese according to Google Translate, has no wires and no parts that sit on the ear (unlike Cochlear’s previous models), hiding instead on the back of the head in neutral colors to match hair. It was launched 2 months ago, so it’s hard to tell how successful it’s been so far.

I asked about the factors that would influence someone to accept or reject a cochlear implant device (ie, my “big question”). One of the main factors was age; many of the cochlear implants are bought by parents for their young children. Older people, however, will prefer to buy a $1000-2000 hearing aid over a $12,000 cochlear implant, even if the latter is the only device that will really give them hearing. After a certain age, they decide that it’s not worth it to spend that much money on hearing (money that could go to their children or grandchildren, for example), or they’re used to living without hearing, or they’ve really internalized the stigma.

These are models of the internal part: the cochlear implant itself. This gets surgically inserted and never needs to be replaced. (If you look really closely, you can see a spiral shape at the end of some of the wires, and that’s what fits into the snail-shaped cochlear.

In addition to age and general stigma, Cochlear has noticed other barriers to acceptance of cochlear implants in India. One is a fear of surgery. I have heard this now from multiple people here in India, both project contacts and friends; most people would prefer to find a solution that does not involve anything invasive or surgical. Another barrier Cochlear mentioned is the desire to try traditional healing methods instead, such as working with babas and godfathers, which is somewhat common in the rural areas. Cochlear is especially concerned with tackling these barriers when it comes to children, who need auditory input before age 3 if they are to develop language skills properly.

I thought it was interesting that Cochlear’s R&D happens in Australia and the US, which means that when it comes to creating new products, most of their feedback comes from wealthy countries. This came up when I asked if Cochlear India was developing anything specifically for India that it wasn’t creating for its other markets. Though Cochlear sells all its products in all markets, they do try to erase the stigma in India with awareness campaigns. One way they advertise the need for cochlear implants is via the Cochlear India Facebook page. They also try to encourage people with a celebrity “hearing ambassador,” Brett Lee, a well-known cricket star in India who promotes Cochlear’s implants (

The new Kanso device, which comes in neutral colors to hide under the hair. It sits back on the head, magnetically connecting to the implant.

As a global company, Cochlear has offices in many countries, including Sweden, India, Singapore, and Japan. That’s four of my six Watson countries! (If I haven’t mentioned it yet, I decided a couple months ago to add Singapore as a Watson country, and I’ll spend two weeks there between India and Japan). Anyway, I wish I had known about Cochlear earlier so that I could have met their team in Sweden. Still, it will be good to meet them in Singapore and Japan. It’s quite hard to compare and contrast the countries I visit – even though I’m obviously doing the same project in each, they are all so different. I think it will provide a good point of comparison to see the same company in 3 of the different countries.

I’m particularly looking forward to meeting with Cochlear in Japan. My contact was telling me that Japan is a difficult market for Cochlear because the deaf culture is so strong there. That is, there is so much respect for the deaf and pride among that community that it is almost insulting to suggest that deafness is a disability that should be corrected. So Cochlear is finding it hard to break into that culture and sell cochlear implants. India is a difficult market too, but for completely the opposite reason! (Of course, this is a sweeping generalization that I can’t back with numbers, but it’s an interesting idea that I’ll look out for when I arrive in Japan.)

I was pretty impressed by Cochlear’s display packaging!

Lastly, a fun note for the engineers: I asked about the digital signal processing code on Cochlear’s sound processor. I learned about Cochlear’s SmartSound iQ sound processing system, which is designed to dynamically identify the type of sound in the surrounding environment (conversation, wind, music, etc.) before processing. The algorithms on the chip include a background noise reduction algorithm and a new wind noise reduction algorithm as well. For more details, check out