Health post: Vision tests & witches afoot

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.

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A typical visual acuity “tumbling E” board.

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.

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Maipelo with the Peek Acuity app.

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.

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).

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A screenshot from the app showing the vision simulation feature.

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.

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One of the Peek Botswana employees demonstrates a screening with the Peek Acuity app.

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.

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This is Peek’s hardware product, Peek Retina. It wasn’t part of the school screenings, so it’s hard to talk about user responses, but I think it’s very cool. It’s a small device that can fitted over a smartphone camera for retinal screening, which can detect diabetic retinopathy and other issues.
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I had my pupil dilated to be the guinea pig in a hands-on Peek Retina demonstration. Here, someone is trying to screen my retina with the Peek device and a smartphone, with an optometrist looking on.
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Always a fan of cool hardware!

 

 

Victoria Falls

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Pretty amazing. With the “rain” coming from the rushing water misting up over us, plus the sun in the sky, we kept seeing rainbows all over the falls.
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On a tiny plane from Gaborone to Kasane.

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).

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My first time seeing a hippo in the wild! And that’s the Botswana flag in the background.
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Elephants on the water. Chobe must be the greenest area in Botswana.

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.

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Sunset on the Chobe River.

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.

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The bridge from the Zimbabwe side. Someone is bungee jumping off it in this photo!

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.

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“Beware – Hazardous Drop Ahead.” You can’t tell from the photo, but we’re both freaking out at this moment!
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I realize this photo is super corny but I was having a blast. The view was beautiful.

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.

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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.

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One of the Victoria Falls viewpoints on the mistier side: Horseshoe Falls, not too far from Rainbow Falls (the fog was too heavy for me to get a picture of that sign!).

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.

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Completely drenched at Rainbow Falls!
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Beginning to see more of the falls…

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.

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The largest falls in the world in terms of water flow!

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.

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Probably my favorite view of the falls, right at the end.

The Tropic of Capricorn

We stopped at the Tropic of Capricorn on the way back from Serowe. Serowe is a small town in Botswana, and I traveled with a group to visit the hospital’s vision center there and learn about the process of eyeglass making. The Tropic of Capricorn is a latitude in the Southern Hemisphere, and it traces the southernmost circle on Earth where the sun’s rays can hit from directly overhead (any further south, they always hit at an angle). The northern equivalent is the Tropic of Cancer.

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A Capricorn myself, though not a big astrology person, I was pretty excited to be there. It’s marked by a simple street sign and a small monument – a rock with a vertical metal rod on top. Every year, at 12:12pm on the winter solstice (December 22; summer in this hemisphere), the sun shines directly down onto the rod. The light beams straight through the hollow rod and onto the rock, creating no shadow. Since we weren’t there at the solstice, of course, the rod cast a shadow.

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Here is the rod with a description on the rock below.

That morning, we had visited the Vision Centre, an area of the eye health ward in Serowe’s hospital. Equipped and funded by a British charity organization, the Vision Centre includes all the facilities necessary for cutting glass lenses to make custom eyeglasses. That’s where we met Michael, a technician who makes 10-15 pairs of glasses a day. He walked us through the process of cutting a lens, showing us the 5 or so machines involved.

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This is Michael, about to cut the circular glass lens he holds in his hands. The many machines he uses to do so are behind him.
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A wheelchair in the Serowe hospital fashioned out of a plastic lawn chair and common bicycle tires. A worn-off sticker shows that they were donated by some charity or NGO (perhaps American?) but it’s too faded to read the name.
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The foyer of the hospital.

In Serowe, and every time I’ve been somewhere new, we did multiple rounds of introductions and hellos. Every day, I think about how important social norms are in Botswana. I think I’ve touched on this before – there is a well-established code of social interaction here, something like that small-town friendliness in suburban America. It’s at the same time my favorite and least favorite thing about Botswana. Everyone says hello (dumelang!) to each other on the street, even strangers, often continuing to ask “How are you?” and the like. It’s considered very rude to begin any interaction, even if you’re just purchasing stamps at the post office, without these pleasantries. I think it’s lovely, and in a capital as small as Gaborone, it’s important to be kind to people when you might be speaking to your brother’s neighbor or your friend’s mother. As a result, the Batswana seem far more socially adept than many people I know.

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If spaces could talk…what would they say? I see this almost every day in Main Mall, Gaborone.

At the same time, it drives me crazy. It slows things down. No one is ever in a hurry – to appear so would be rude. I grew up in Manhattan, where I perfected the style of speed-walking that signals “don’t talk to me.” It’s also a safety thing. Every time a random man or cab driver or stall owner calls “Hello” to me on the street, I’m conflicted between respecting Batswana culture and wanting to ignore it, as I’ve been trained to ignore any attention from random male passers-by. Usually I respond with a curt “Hello” in return and promptly ignore any ensuing conversation. On longer walks, I listen to podcasts or music, and hope that the earbuds serve as a defense against being rude – I smile at the people around me while conveniently being unable to hear them.

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More street art from Main Mall.
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A traditional Botswana meal from the food vendors seen in the background. For 15 pula ($1.50), you can get this little plate with your choice of starch, meat (seswaa is traditional – pounded beef), and veggie sides (I like the sauteed greens and mashed butternut).

Anyway, I’m off to Victoria Falls tomorrow, which I’m excited for since it’s considered one of the 7 natural wonders of the world. I’m hesitant as well because it will be a very touristy weekend, outside of Botswana, with other American travelers – none of that is very Watson-y. But it’s only a two-day trip, and I missed the opportunity once before (I could have gone when I was studying abroad in South Africa for 5 months), so I didn’t want to miss it again. I’m also feeling quite good about my project here. I’ve met with a few different groups by now, and a couple days ago I met with the only local medical device start-up in Botswana, so that was great. Plus, it’s been too long since I’ve taken a flight! (well, a couple months).

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Food vendors by the side of the road for watermelon, nuts, and crunchy worms (lower left).
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Advertising in Gaborone.
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The flower wall at Sanita’s Tea Garden, a plant nursery and café in Gaborone.
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More from Sanita’s.

To the village

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There’s not much to do in Sekhutlane, but we had some fun at this bakery.

Last week, I had the opportunity to visit the remote village of Sekhutlane (pronounced something like ‘Sek-qui-kla-nay’), a 5 hour’s drive from Gaborone. I was there with some members of BUP, the University of Botswana – UPenn Partnership, to meet government healthcare workers who had participated in a mobile health program to perform vision screenings on schoolchildren using a smartphone app (called “Peek Acuity;” more on that in another post).

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On the way to Sekhutlane.
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A welcome sight after waking up at 5:00am in Gaborone!

Sekhutlane is a village of about 700 people, and most people seem to farm or work in government-sponsored volunteering positions that provide food and water. There are hardly any shops, and the closest upper high school is in the next village, 70km away. Since the main mode of transport in Sekhutlane is a donkey-drawn cart, 70km is a prohibitive distance for most.

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Sekhutlane.
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This  is the car we took to get to the village. Four-wheel drive is a must; our last hour on the way to the village was along a bumpy dirt road.
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It’s pretty common to hire drivers for these sorts of trips and pay them in cash for their driving and the gas.
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The only shop in the village is a small shack of corrugated steel where you can buy basic items over the counter.

We hadn’t brought any lunch, and the only place to get ready-made food in the village is a small bakery that makes simple rolls and loaves in an outdoor oven. The bread was warm, soft, and delicious after such a long car ride. We learned from the healthcare workers, Kenewe and Kagiso, that the villagers eat canned food most of the time, especially canned beef and fish. Kenewe and Kagiso are not from Sekhutlane originally – the government assigned them there to work for two years. They are both far from home and hope to get reassigned to a less remote location in the future.

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One of the BUP team members enjoys a freshly-baked roll in front of the bakery’s oven.
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Kenewe (left) and Kagiso (right). They were so lovely to talk to.

Though we were there to learn more about a mobile health endeavor, the challenges in Sekhutlane rarely involve technology. There are vision problems in the village, often due to the dust, but the more pressing issues are HIV/AIDS management and teenage pregnancy. Kagiso said that, since junior high is the highest level of school in the village, many of them finish school at 15 and become parents. They don’t know what else to do, he said, especially since they aren’t exposed to a range of possible professions they might aspire to. Kagiso is also frustrated with the way the government “spoon-feeds” the villagers, providing them food and even housing for minimal work – he wishes the government would instead incentivize them to become self-sustainable in some way.

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A home in Sekhutlane.

The president of Botswana is experiencing a bit of backlash right now for a recent visit to Sweden, where he discussed Botswana’s military policy and its “need” for an air force. A few people I’ve met, including the healthcare workers in Sekhutlane, are frustrated that the president is talking about war in such a peaceful country. Instead, they say, he could be focused on bringing health and education to all areas of the country.

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A man on his way out of Sekhutlane.

We arrived on Sekhutlane’s “ARV Day” – the healthcare workers devote one day each week to providing the villagers with the newest stock of antiretroviral drugs for HIV/AIDS treatment – so the clinic was quite busy. Kagiso and Kenewe told us that HIV is so common, and the village so small, that they can usually figure out which villager is responsible for a new case. They said that since HIV/AIDS is so out in the open in Sekhutlane, there’s very little stigma about it there, and people feel comfortable talking about their partners and the disease.

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The clinic of Sekhutlane. Check out the spots on that goat!

When I was in Lobatse, someone said that a main contributing factor to the high rate of HIV/AIDS in Botswana is an attitude here of “I am my own boss.” I suppose it’s the flip-side – the lack of a common collective attitude – that is the real culprit, a mindset that doesn’t encourage thinking about how your actions affect others. Kagiso and Kenewe also happened to mention this individualism with regards to other issues in the village. Kenewe talked about a time she once tried to help a young child at school by providing him with new clothes. The other parents became jealous and angry with Kenewe, and they stole the clothes off of the child to put on their own children. She gave up after that.

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Sekhutlane.

Another example of this thinking came up in our discussion about the vision screening, the initial reason we went to Sekhutlane. As a result of the screening, two children were diagnosed with vision problems, and their parents needed to bring them to a specific site on a specific day to receive glasses. Only one family had the means to do this, so only one of the two children actually got their glasses. “Why couldn’t that family take the other child, too?” I asked. “You only take care of your own here,” said Kenewe. That’s the attitude: fierce independence, even to the disadvantage of other community members. I’m not sure what caused this “I am my own boss” culture, but it’s been fascinating to hear it come up in so many discussions about health here.

Overall, it was great to see Sekhutlane and understand rural Botswana as a contrast to Gaborone.

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A donkey cart in Sekhutlane.
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The most water and green I’ve seen since arriving in Botswana! Apparently this is South Africa, though, on the other side of the river.

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.