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