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.
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.
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.
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.
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.
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.
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!
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.
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.
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.
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.
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).
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.
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).
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.
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).
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).
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.
A week from today, I will leave Tokyo and travel to Gaborone. I don’t exactly know what to say or how to express my feelings (I’m not sure I know what I’m feeling), but I did want to post and share some photos from Fukuoka. I visited Fukuoka between project meetings in Osaka and Nagoya, and Fukuoka is the city from which I visited Hiroshima and Miyajima as well.
Fukuoka is a friendly town and quite small compared to the other Japanese cities I’ve seen. It’s easy to explore most of the city center in one day on foot, which was a refreshing change from the immensity of Tokyo, where even after many weeks here there’s still so much to see. I’ve spent the majority of my time in Japan in Tokyo, but as I’ve described before, my time in the capital city has been spent with host families and really trying to blend in with daily life. As I’ve avoided trying to be a tourist, I almost feel like I’ve seen less here than in the other cities. But I think it’s simply that Tokyo is more of a mega-city-complex than one city, and seeing everything (including the many possible day trips from Tokyo) was never going to happen over the span of a couple months, not with project meetings and language classes and host families thrown in the mix. I’d still choose the project and host families, though – this “Watson style” travel – over seeing all of Tokyo in one go!
It’s still hard feeling as though I’m leaving things unfinished, and I wonder if I could have made more of my first month here. That’s the Watson, though – you have to pack up and go, whether you’re ready or not. I’ve been quite ready to leave every country I’ve traveled to so far this year; I’m not sure I’m ready to leave Japan. Of course, I hope to come back, and I am beginning to get excited and curious about Botswana – a good sign that it is, in fact, time to move on.
Thinking about the project meetings I’ve had here, I’m fairly happy with the range (professors, doctors, people at start-ups, and people at larger corporations), but I still had a much wider range in India over the same time span (all of the former, along with ashram gurus, visits to hospitals, NGO workers, and more). I’ve wondered many times this year about order bias – how the order in which I’m visiting these countries is impacting my experience in them. I think my expectations get more defined (and thus more critical) as time goes on. As the year progresses, the end of each country visit fills in another detailed segment of the once-blank canvas of “What could this year look like?”. It’ll be a strange feeling at the end of Botswana when that painting is well and truly done – when I no longer have any questions about a year that once loomed before me in its uncertainty.
Also, I think it’s been a bit challenging to “break in” in terms of my meetings in Japan because of the language difference, which has been more difficult here than anywhere else. There are also simply fewer medical technology start-ups than I expected due to the ever-strong corporate culture. Maybe there’s something else, too, something I can’t quite put my finger on – but there’s some distance I haven’t always been able to break through when trying to schedule meetings and so on. I often get the sense here that Japan has such a unique culture and has so much figured out that it doesn’t need the rest of the world.
Of course, my time here has also been complicated by the fact that I’ve wanted to come to Japan for so many years – I was always going to have high expectations for my time here, as well as feel slightly pulled between wanting to see as much as I could, making the most of my time here, and figuring how best to approach my project. I suppose no span of time, then, would ever be enough!
While I was in Fukuoka, I made a point to visit the “RoboSquare,” a center showcasing various Japanese-made robots. I wanted to go because I had read that they had a Paro, a Japanese care robot made to look like a fluffy seal who has helped dementia patients worldwide. I contacted the government organization that made Paro a reality and was never able to get an interview, so I wanted to see it in person. (The agency is AIST: Advanced Industrial Science and Technology).
RoboSquare was a small room in a shopping complex, but it was still exciting to “meet” a robot I had read about months earlier. As far as robots go, it’s nice that Paro is soft and fluffy all over (though the big black eyes looked a bit creepy to me). There was an information card next to Paro that explained how the robot has been used in pediatric wards, nursing homes, and hospitals. AIST conducted studies that proved that both children and elderly patients had improved mental states and lower stress levels after interacting with Paro. The Paro robot has been around for over ten years now, so hopefully AIST can continue to sponsor more health technology projects in Japan.
In Osaka, I met with Dan Takeno of Kekkan Bijin, which means “vascular beauty.” His company’s device is essentially a microscope that observes peoples’ blood flow in a non-invasive 5-minute procedure. The scope focuses on the capillaries under the thin skin around people’s fingernails, and it displays the nature of the blood flowing through them in real time (while also digitizing the image to capture information in numerical form). The idea is that this procedure will indicate health; healthier people will have straight, clear capillaries through which blood flows easily, and less healthy people will have twisted, jagged and/or thick capillaries (perhaps indicating a blockage in a particularly thick spot).
Takeno’s father developed the device in 2001 after being diagnosed with cancer. He decided to supplement his cancer treatment with alternative healing, taking supplements, and drinking more water. Takeno’s father wanted to know if and how these alternative treatments were affecting his health but could find no quantitative measure. He became frustrated that there was no easy, trackable indicator of his general health – something he could have been watching even before his diagnosis. Doctors always check blood pressure and body temperature, said Takeno, but this doesn’t add up to a simple, one-stop “health index.” To get a full snapshot, his father would have to go to the health diagnosis center, spend $500 for a complete checkup, and lose half a day’s worth of time. How could this be simpler, cheaper, and faster?
Takeno’s father ultimately collaborated with a man named Dr. Ogawa, who started research 6 years ago on the potential of capillaries being an indicator for health. Takeno’s father read his book and decided to apply the idea to a machine. He was successful, selling 2,000 machines to Eastern medicine (EM) pharmacies and eventually to doctors. “Eastern medicine?” I asked. Well, Takeno replied, the device is still based on non-Western ideas. Sitting in an office in one of Japan’s busiest metropolises, meeting about a health device that looked like a scientific instrument, I was surprised that we were discussing non-traditional medicine.
Takeno told me that Eastern medicine is quite popular in Japan and that many women he knows go to EM drugstores and healers (such as chiropractors). After our meeting, he showed me an Eastern medicine drugstore that was just a block away from the office, selling herbal ointments and the like. Across the street from the drugstore is the Sukunahikona Shrine, enshrining both a Japanese god of medicine and a Chinese god of medicine – the shrine also sells some of its own alternative treatments. I didn’t realize that alternative medicine was so popular in Japan, and it’s hard to find statistics about this. But I did learn that kampo is the name for Japan’s version of Chinese Traditional Medicine, and that a well-known university here in Tokyo – Keio University – has a center for kampo in its medical school.
For now, Takeno says, his device falls under the umbrella of alternative medicine. “Western medicine is science,” he said. “This machine is not science – yet.” But he expects that it will move into the realm of Western medicine, mentioning that the first researcher of capillary health was German – “and their history of building microscopes is good,” he adds (I couldn’t find any history of this type of capillary observation online, so I’m not sure). This reference to German medicine reminded me of my first meeting in India with the company that offers a homeopathy service. They also mentioned that the Germans invented homeopathy, which is true – a German scientist invented homeopathy in the 18th century, but the practice has long been written off as pseudoscience by Germany as well as many other nations. Still, based on some apparent global trust in German science, the homeopathy company used the German origins of their product as a way to legitimize it.
Next, we discussed Takeno’s ideal users for the device and the reactions he’s gotten so far. He said that he has received more enthusiastic responses to his product from women than from men. Based on his experience in Japan, men don’t want to hear bad news or learn about bad health, but many women do want to know. This is partially due to the media, he explained – many female-oriented magazines and TV shows in Japan advise women to get regular health checks. Some even specifically recommend getting arteries or capillaries observed (Takeno showed me a huge stack of these magazines in the office). These broadcasters and magazines, he explained, say that having a healthy blood flow is important for beauty and young-looking skin.
So Kekkan Bijin currently markets its device to women, but Takeno hopes that once many women start checking their capillaries, men will want to do it too. “I think people are comfortable” with the device, he says, and he’s gotten all positive responses so far. “People want less technology – this is easy to use and not expensive,” he said, almost as though he was distancing his device from the idea of technology (or at least from the idea of a complex medical machine, which would perhaps not fit so well with the Eastern medicine I mentioned earlier).
Takeno told me that, due to the connection between healthy capillaries and younger skin, the device results can be used to predict someone’s age. The graph above shows the correlation between average capillary length in nanometers and age in years (the red line is for women and the blue line is for men). Takeno went on to explain the cultural consideration here, starting with the fact that age is very important in Japan. Since it culturally important to respect anyone older than you are, you should know the ages of the people with whom you interact. Takeno compared this to America, where age is less important – we care less about an age-based hierarchy, rather celebrating people based on merit, individualism, and innovation, especially if they’ve managed to accomplish a lot at a young age. However, in both countries, it’s rude to ask someone’s age. So in Japan, where knowing someone’s age relative to your own is important for navigating an interaction with them, what do you do? I had never thought about this being a potential issue in Japan!
Of course, it’s a very unlikely use case that you would have the opportunity to measure someone’s capillaries and use that result to determine their age – but it’s an interesting side benefit of the device.
Finally, of course, I had to test out this machine. Takeno adjusted the scope over the tip of my ring finger, but it wouldn’t focus (apparently because I had used hand lotion that morning). As he was focusing the device over my pinky finger instead, I began to get nervous. Well, as it turns out, my capillaries are definitely not perfectly straight, though they aren’t terrible either. I’ll have to ask my doctor about it when I get back to the U.S.!
I spent last weekend in Fukuoka, a small city in the southwest of Japan. While I was there, I did a big day trip to Hiroshima and Miyajima, two relatively nearby destinations via the shinkansen bullet train. I didn’t think I would be able to go to Hiroshima while in Japan, but as the end of my time here got closer, the more ridiculous it seemed that I would miss it – I think its importance demands making the effort to go there. As I planned the day, reading online about day trips to Hiroshima, I decided it would be possible to spend the morning in the city and then take a ferry in the afternoon to the nearby island of Miyajima – the site of the Itsukushima shrine and famous floating torii. It was a packed day, but I am so glad I did it.
After arriving in Hiroshima, I went straight to the Peace Memorial Park, which is exactly where the atomic bomb was dropped – in the center of the city – on August 6th, 1945. The Peace Memorial Park has the Hiroshima Peace Memorial Museum on one end and the Atomic Bomb Dome on the other. I started at the Atomic Bomb Dome, the only ruin left from the war. The bomb exploded almost directly over this structure, which actually minimized its impact – as you can see, the frame of what was a dome in the center of the building was left standing. The building is preserved exactly as it was after the bomb hit. But as for the rest of the city’s buildings, Hiroshima is completely rebuilt and thriving with no evidence of the bomb.
On my way to the museum from the Dome, I saw this flame. My mom, who has been to Hiroshima before, told me to “look out for the eternal flame.” As I spotted it and walked towards it, my eyes teared up at the idea of a flame that’s been burning since it was placed there to honor the victims of Hiroshima. How much work to keep the flame burning for so long! As I read the plaque, I realized that the idea of the flame wasn’t exactly to be eternal. It reads: “Symbolizing the universal desire for a world free from nuclear weapons, the flame will burn until the day when all such weapons shall have disappeared from the earth.” A beautiful sentiment. Thus the idea of it being eternal – burning forever because we will never rid this planet of nuclear weapons – is all the more depressing.
I arrived at museum, which was already packed with tourists at 9am, and I spent 2 long hours there reading every detail. It was difficult and depressing, but its focus was peace. The museum was all about the horrors of the bomb itself, sadness about war and destruction, and the desire to rid the world of nuclear weapons. There was very little anger against America or the other countries involved in the war.
The Hiroshima Peace Memorial Museum taught me details of the war that made it even more depressing than I had realized. (Stop reading here if you don’t want to delve into these tragedies with me – but do keep scrolling for the photos). The first detail that struck me was about the demolition crews. These were groups of people who worked to safely demolish various buildings in Hiroshima’s more concentrated areas in order to minimize the effects of fires that might result from air raids during the war. That is, if there were fewer buildings all stacked up against each other, one catching fire from an air raid would not cause so much damage to the rest of them. I’d never heard of this tactic, but that’s what they were doing in Hiroshima. Most of these crews included young schoolchildren; innocent civilians as young as 8 years old. Maybe they lived far from the center of the city or came from surrounding neighborhoods, but they came to work in the center of the city where the buildings were densely packed. That means that when the bomb exploded that Monday morning, there were far more young children in the center of the city – right where the bomb hit – than there should have been. That was heartbreaking.
The museum displayed many pieces of clothing of the children who died as a result of the bomb while working in those demolition crews. Their parents had to search for them, and they were lucky if they found any clothes or belongings (bodies were far rarer). I find it much sadder that parents had to look for their children rather than the other way around, though of course both are horrible. With each item or clothing scrap, the museum included as much detail (including a name) about the previous owner as possible to give you a full picture of the people that died in the bombing. This went on and on. But in one glass box, the museum had put clothing from 3 different children onto one mannequin. It was as though all these individual scraps of things and clothing, all with unique identities attached to them, had fused into one image: the child who died because of the bomb.
Another fact I learned was that there were American prisoners of war in Hiroshima when we dropped the bomb. I can’t imagine there were that many, but it still surprised me. I never knew that. Also, there was a replica of the bomb in the museum. It was called “Little Boy” due to its fairly small, lanky shape. It was smaller than I imagined compared to the amount of damage it was able to inflict – 10 feet long. Of course, it only takes a tiny bit of uranium to cause mass destruction, but it was still unnerving to see a full-sized replica of the bomb, just sitting there like something harmless.
Lastly, it was stunning to realize just how much damage the bomb had done, and in which various indirect ways. Of course, I knew that the force of the bomb itself leveled the city and that the resulting radiation affected people for many years later. But there were other things, too. For example, the intense heat of the bomb burned people to death. Some people who weren’t killed by the bomb’s force, or heat, or radiation, were injured instead by glass – the bomb exploded so many glass objects and surfaces that it sent shards flying all over, into buildings and people’s clothes and into the people themselves. Some survivors had pieces of glass surgically removed from their bodies 20, 30, and even 40 years after the bomb. There were so many ways that the bomb hurt people.
One way that was particularly depressing was that some of the people who died as a result of the bomb were those who came to the city the next day as rescue. No one in Hiroshima was capable of leading or organizing a rescue effort, so any help had to come from outside the city, and it did. But the radiation levels were still so high the day after the bomb exploded that many of the people that came to help suffered as a result.
Okay – that is all I will say about the Peace Memorial Museum and the bombing. That museum is now a small part of the big, lively, healthy city that Hiroshima is known for today. After I left the museum, I had Hiroshima’s local specialty for lunch (a type of okonomi-yaki made with noodles) and visited a beautiful garden – though of course what I saw at the museum stayed with me.
On the island of Miyajima that afternoon, I saw just as much beauty as the sadness I had seen in Hiroshima. The famous “floating torii” is the torii gate of the island’s Itsukushima shrine. Built on a beach, it stands in the sand at low tide, and it appears to “float” on the water in high tide, when the water submerges its base. Of course, all the pictures I had seen of the torii were taken at high tide in perfect lighting, so it looked magical. When I was on the ferry approaching the island, not only was it evident that the tide was low, but also the torii looked tiny from the boat! I prepared myself to be disappointed by a small, non-floating sight.
Luckily there is more to do on Miyajima island than see this torii, and first I explored the rest of Itsukushima shrine. It was enormous and beautiful, and I couldn’t get enough of the bright red vermillion structure, all built on stilts over the sand. On the rest of the island, there are hikes to do, Buddhist temples to visit, village shops to see, and a surprising amount of deer to avoid.
I spent about three hours on the island, and as the day inched closer to sunset, the tide started coming in. The island’s visitors that day started to gather at a stone wall facing the torii, many of them sitting in silence sipping beers. I quietly joined them, and as we watched the sun disappear into the clouds behind the torii, the water level rose enough to truly make the torii appear to float. I have to say that it was one of the most magical moments I’ve experienced so far on the Watson, and the sight was extraordinary.
I’m thrilled that I was able to see the torii at both tides – I had the opportunity to walk up to it and touch it, and I also got to see it “float.” And that was really something.
Last week, I visited Panasonic’s headquarters in Osaka. Back in the US, I knew Panasonic mostly as a television company. But here in the company’s home country, they make all sorts of products including audio-visual equipment, home appliances, IT solutions, smart home and home security technology, and robots – specifically care robots. I was there to meet an engineer, Mr. Ando, who has worked on Panasonic’s hospital delivery robot HOSPI, among others.
Panasonic is working on care robots that work in pharmacies, hospitals, and personal homes. One splits in half to transform from a bed into a wheelchair (not your typical “robot,” but still an autonomous machine). This eliminates the possibility of injury to the patient during transference as well as injury to the nurse moving them from their bed to a wheelchair.
Panasonic has also built care robots that focus on improving the patient’s happiness. Ando showed me a video of a hair-washing robot: a station where immobile patients can have their hair sink-washed by robot “hands” that massage the scalp and do the washing and rinsing. It looked very relaxing. Ando said that this was in response to patients who were unhappy that they only had showers about twice a week. The nurses were simply too busy to spend more time manually washing patients’ hair, even if more frequent washing does contribute to the patients’ happiness. If a hospital installs a few hair-washing robots, however, patients can get their hair washed more frequently while the nurses focus on more pressing tasks. While this robot may not have a direct impact on their health, I think the impact on their feelings of dignity, independence, and happiness is important.
Ando described Panasonic’s robots as contributors to “assisted care” and “assisted independence.” I got the sense that he used these terms to give dignity to the patient and put the user’s needs first rather than focus on the robot’s capabilities. That is, there is a thin line between “assisted care” and “assistive technology,” but the former focuses on the patient while the latter focuses on the technology.
In our talk, Ando and I mostly discussed HOSPI – a waist-high robot that talks, listens, and transports items such as blood samples or medications throughout a hospital. One special version of the robot, the HOSPI Rimo, also has a communication feature that can be used for telemedicine. I asked about how Panasonic came up with all these robots, and Ando told me that when Panasonic develops new products, the most important step in that process, at least for hospitals, is task analysis.
The Panasonic team observes the staff performing various tasks at a hospital to see where the inefficiencies are – gaps that can be hard to notice when you’re in the middle of the workflow, but which become more evident from an outsider’s viewpoint. Based on this task analysis, Ando told me, Panasonic decides what type of product to develop in response to the observed problems.
In most cases, apparently, some type of robot is the best solution. The nurses don’t have enough time to wash patients’ hair? Let’s build a hair washing robot. There are issues associated with transferring a patient from their bed to a wheelchair? Let’s make the process robotic. And, of course, HOSPI, to make transport more efficient. I asked Ando for more details about the design process that led to the HOSPI robot.
He told me that, after Panasonic observed inefficiencies in the hospital, they discussed which solution would be best for the user. (I was glad to hear that – I’ve realized that, since going to Sweden as my first project country, the idea of a user-centered design process being a key factor of success has become really ingrained in my mind). Ando said that Panasonic quickly developed a prototype robot to solve the hospital delivery problem and then showed the prototype to the potential end users, nurses and doctors. The Panasonic team and potential users had a collaborative meeting about once a month, and after each meeting, Panasonic adjusted the robot in response to the users’ feedback.
“So when is that adjusting process finished?” I asked. “When the user says they’ll buy it!” said Ando, laughing.
I asked him if, with this user-focused design process, there are ever negative reactions to new products. His response surprised me: “All people react negatively to new products,” he said. “Especially in Japan.” Ando explained that certain particularities about Japanese ideas towards healthcare complicate the introduction of healthcare technology here.
He told me that the idea of healthcare in Japan is “humans supporting humans;” so robots as helpers for the nurses, then, are not part of the “philosophy” of healthcare. I asked him what he meant by the “philosophy.” Ando gave me the example of the kanji for “nursing care.” (Kanji is the Japanese character-based writing system – one of the language’s three alphabets). Ando reached for a nearby sheet of paper and quickly sketched it out. These characters often incorporate and combine pieces from more basic kanji that represent simpler ideas; so the characters can build on each other, becoming more complicated while representing more and more complex ideas. Ando pointed towards the kanji for “nursing care” and told me that it incorporated the kanji for “human hand” and “human eyes.” Thus the way that “nursing care” is written in Japanese necessarily focuses on the idea of human involvement – excluding the work of any automatic product from being part of the idea of nursing care. I absolutely loved this moment of learning how Japan’s ancient writing system influences reactions to medical devices today. That’s what this project is all about.
But for the most part, it seems that nurses are grateful for the help that HOSPI offers. Ando stressed that HOSPI has separate tasks from the humans, which is a key factor of its success – it does the grunt, time-consuming work of sorting and delivering medications, allowing the nurses to focus on doing actual nursing work that only humans can do.
“What about the patients?” I asked. “Are they comfortable with the idea of robot care?” Ando said that, based on a survey done by Japan’s National Institute, 85% of people don’t hesitate at all with care robots. Ando said this is mostly due to positive representations of robots in Japanese media such as anime, but that when it comes to care robots, people want robots that are less human-like. He said that people have the impression that anthropomorphic or humanoid robotics are meant to be friends, and when they are in hospitals, they don’t want their friends taking care of them – they want the support and precision of tools. They respond better to simple-looking, machine-esque robots. HOSPI could have been designed to look like a human, but instead she looks like a clean, classic robot – well-suited to the hospital environment. I wonder, too, if patients would have a negative reaction to human-looking robot because of the uncanny valley phenomenon (which, by the way, was first tested by a Japanese roboticist in the 1970s).
Finally, I asked Ando what makes Japan so healthy and what that has to do with technology, if anything. He made a distinction here: the older, super-ageing generation is healthy, while the younger generations are less so. He said that the elderly are healthy simply due to their lifestyle of eating well and exercising enough. But in his opinion, the younger generations eat less healthy food and spend less time exercising – mainly because of the negative effects of technology, especially television and the internet and smartphones.
“So do you think technology helps people be healthy or not?” I asked – after all, Ando does work in the field of healthcare technology. He said that while the prevalence and popularity of technology has a negative effect on peoples’ health and fitness in Japan, it can have a positive effect on peoples’ illnesses. Once people are already sick and in the hospital, said Ando, technology can begin to have a positive effect, such as the effect of robots like HOSPI.
I arrived in Osaka on Easter Sunday, though of course no one celebrates it here. Wandering around Osaka that evening was my first time really being alone in Japan, and I wasn’t used to that, so it felt a bit odd and lonely. But soon I relaxed into the feeling, and enjoyed it. I remembered how it felt when I arrived in Sweden by myself so many months ago, or when I was off on my own in Kerala.
I was reminded that the only thing that connects all these random places, besides my project, is myself. I like being off on my own, and in those moments, sometimes I think I could quietly disappear into the Watson. I don’t know how else to describe that feeling, except maybe that’s my way of keeping this going forever.
I’ve been listening to the podcast S-Town as I travel around (it’s currently #1 on iTunes and I highly recommend it!). The podcast centers around the life of an “antiquarian horologist,” a restorer of antique clocks, and, appropriately, one of the podcast’s themes is time. The profession of antiquarian horology, as I’ve learned from S-Town, is dying because time is so accessible now on smartphones and watches.
It got me thinking – what does that say about the relationship between humans and time? Now that it is so easy to check, at any moment, what the exact time is down to the nanosecond, do we relate to time differently then we did before? Does this hyper-awareness of the passage of time at all affect the way we approach life? I realize these are ridiculous exaggerated questions, certainly the product of traveling solo and having too much time to think (heh). But what I’m saying is that what’s important here (to me, anyway) is not the measurement of time itself but the way people relate to it.
I don’t think it’s enough just to talk about medical devices, or embedded systems, or the topics of space and time; what’s interesting is how do people relate to these things, and why, and how can we make them in a way so that people have the most positive reaction? How is a medical device interesting if you’re not thinking about how people will use it and how it will impact their health? None of these things matter without that framing (and of course none of it would exist without the people to make it; even time would be a moot point without people to experience it, frame it, and measure it). I’m sure this all sounds obvious – my project has been about the “human response to medical technology” since I designed it over a year ago – but it’s still fun to think about, especially extending that thinking to other disciplines.
Anyway, that’s all, and if you celebrate Easter, I hope you had a lovely weekend!