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!

 

 

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Last week in Japan

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.

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At the ruins of Fukuoka Castle in Maizuru Park.
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Lantern at the Sumiyoshi-jinja Shinto shrine, just across the street from my Airbnb.
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A surprisingly beachy area at the outskirts of Fukuoka.

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!

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Fukuoka had beautiful flowers all over the city – lovely city planning.
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It’s also a canal city with many bridges.
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Looking at this building, I didn’t feel like I was in Japan anymore.

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.

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Fukuoka’s ACROS building.
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Sunset over Fukuoka’s river. Far off on the right are yatai, the canal-facing food stalls for which Fukuoka is famous.
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Each yatai has a simple Japanese menu and about 10 seats. The idea is that people will come here to eat and drink and mingle with the other diners. After waiting a while for a seat, I joined a stall full of Japanese customers and had a hilarious Japanese/English conversation with my nearby diners.

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.

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A short train ride from Fukuoka is Dazaifu, a city of mountains and temples that’s perfect for a day visit over the weekend.
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At Dazaifu’s main shrine.
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I had never seen a tree supported by wooden slats before.

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.

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A quiet area in Dazaifu.
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I managed to find my way to the top of one of Dazaifu’s nearby mountains.
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Overlooking Dazaifu city.

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!

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I loved the late-blooming pink-and-green sakura trees here (Dazaifu).
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Dazaifu had a lot of beautiful nature.

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On the way to RoboSquare, far from central Fukuoka.

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).

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Paro was “sleeping” when I first saw it, but after I petted its head (as the RoboSquare attendant instructed), it slowly lifted its head up and to the side, blinking its big eyes and making cute noises.

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.

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I also met this robot, which has nothing to do with healthcare but still caught my attention. This is the Japanese-made SR-01, a search-and-rescue robot that helped find missing people on 9/11 in NYC, over fifteen years ago.
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For some reason this was at the RoboSquare as well – a software platform that dresses you up in the outfit of your choice! I love space stuff, so I decided to be an astronaut.
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Last shot from the Fukuoka beach area. My guess is that this is a fancy resort, but I’m not sure.

Health post: Medtech Expo 2

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I ended up with a lot of stuff from this expo – mostly handouts advertising the participating companies (99% in Japanese, of course). Here you can see my business card, stapled onto my admission tag for the expo!

The second expo I went to at Tokyo Big Sight was called CareTEX, and it was all about health technology for the nursing industry. I saw a much wider range of health technology there than I had seen before, since CareTEX was specifically focused on technology for health and medical purposes (unlike the first expo I attended, which had many categories under the umbrella of tech and design). CareTEX even had a “special exhibit counter” with booths for all the companies making nursing care robots! I saw multiple different robots, wearable devices and patient monitoring solutions; hearing aids, sanitizing equipment for hospitals and clinics, special gloves for arthritic patients, and more. I also saw some of the same devices and equipment I had seen at the last expo, such as wheelchairs (although more varieties) and massaging machines.

(Note: This post is a follow-up to my most recent post, here, about the first expo I went to).

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Patient lifting systems for hospitals and home care.
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More patient lifting systems by another company for bathroom use.

I also saw some health products that were not so obviously related to technology, such as different brands of face masks, workout clothing with special fabric blends, underwear for incontinence patients, and even food. I was a bit confused by the food – there seemed to be a few stalls promoting healthy meals and giving out samples – and my guess is that they are food suppliers for hospitals. Another company was giving out mini paper cups filled with treated water (which was intriguing to me, as the tap water is drinkable all over Japan. That said, my host families here have both used water filters, so I suppose there’s something to being extra cautious).

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One of the food booths displaying set meals.

As at the first expo, much of the information was in Japanese. But still, since it was an expo showcasing Japanese companies for Japanese customers, I’m almost glad that it was difficult to navigate using only English. I wish I could have fully participated by asking people questions in Japanese, but the extent of my usage of the language at the expo was to say things like “Hello! Do you have any information in English?” Usually the answer was no, but I still tried out a few products and spoke to the English speakers I did come upon.

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This is an assistive glove for people with arthritis or other problems causing weak grip. I tested the glove by putting it on and picking up a water bottle (pictured at the far end of the table here). Once the finger pads came in contact with the bottle, they gradually applied pressure to it until I was gripping the bottle and able to pick it up without any of my own effort. While this is cool and works well, the glove is very obvious when worn. I can’t imagine any arthritic person wearing it outside, and I think it would be a tough sell for anyone with a stigma against assistive devices.
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More on the glove and its potential uses.
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This is the Sanbot, a Chinese-made robot that is used in home and office settings in Japan. The team representing Sanbot at this expo was promoting its applications in health, such as Sanbot’s ability to detect someone falling at home and alert the appropriate resources. According to the website, Sanbot has the “power of cloud-enabled robotics and AI for Retail, Education, Healthcare, Hospitality,” and more. Also – this seemed very Japanese to me – the Sanbot has multiple LED “eyes” that are designed to show a range of oddly specific emotions such as “shy,” “wronged,” “dizzy,” and “sleep.”

I found a rare English speaker at the booth for Sivantos, a large worldwide hearing-aid company. This man at Sivantos told me that 14% of the people in Japan with hearing impairments have hearing aids – compared to 50% of hearing-impaired people in the U.K. I asked why, and he said that hearing aids in Japan are very expensive, with the government barely covering the reimbursement cost. He also added that there is a stigma against revealing that you have a disability. (If there is a stigma in Japan against small hearing aids, which I thought were pretty normalized across the globe at this point, I really can’t imagine someone using that assistive glove here).

In response to this stigma, Sivantos has made a range of colorful hearing aids to get people excited about using them, especially children. This reminded me of Cochlear, who offers a similar set of brightly-colored and patterned cases for the external part of the cochlear implant. The man I was talking to also pointed out Sivanto’s advertising – he gestured to a long banner depicting an older man with Japanese text and asked me “Do you know who that is?” I didn’t, but he is apparently a famous Japanese skier who wears hearing aids, which were invisible in the photo. The Sivantos man said that more Japanese people will feel comfortable with hearing aids if they know that this celebrity wears one and is okay with promoting it. It was cool to see a company adapting and responding to its cultural environment – that’s really what I’m looking for when I survey these companies.

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Maybe these colorful wheelchairs were trying to combat stigma the same way as Sivantos.
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This is the Telenoid, a small baby-esque robot made to mimic human presence. I’m not sure what the health benefit of that is (perhaps companionship for mental health patients?), but this guy totally creeped me out.

One of the biggest devices I saw at this expo was a large dining room table with an oversized tablet built into the surface. Loaded onto the tablet is a basic swiping-on-the-touchscreen game that gets faster and more difficult with each level (I tried it out). The company told me that the goal of the game, and the tablet in general, was to engage elderly people living at home. They said that elderly people at home often have limited mobility, so they end up spending large amounts of time sitting at the dining table with nothing to do, which can be lonely and frustrating (and of course in Japan, there is an enormous elderly population). The aim of this table, with this game, is to give those people something to do and also help them keep up their motor function.

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The people I talked to about the tablet-table, pictured at the bottom of the shot.
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Advertising handout for the tablet-table, with a cartoon of elderly people happily sitting around the table and playing the game.

It was a big operation – the table and tablet both looked custom-made, which would make the whole device very expensive, and of course it was physically large. While I appreciated the sentiment behind the tablet-table, I had never heard of anything like it, and I thought to myself that maybe there was a cheaper or simpler way of addressing the problem at hand. The table hasn’t hit the market yet and will apparently be ready in July, so it’s impossible to say how it’s been received by real users or if it will face success or failure in the market. I asked the people at this company if they had done any user testing (to see how potential users might react to the table and if they feel as though they would benefit from having one). I’m not sure if my question really got across the language barrier, but the company people said that they would do user testing in July – the same time as the product’s release date. If that’s right, that means no, they don’t know how people will react until they start selling the table. That is a ton of development for a large table that is probably quite expensive…and no user testing to verify that this is a product needed or wanted by the elderly population.

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This was an automatic plastic-packer for trash at hospitals and clinics so that the germs and odors of items such as adult diapers could be fully sealed before being thrown out. I saw it in action and it worked very well. This company was one of many focusing on infection prevention at the expo, which is definitely a cultural thing here (with all the face masks and so on). The person manning the booth told me that the device is currently mostly in Japan, but that’s because “Japan probably has more nursing homes than anywhere in the world,” which wouldn’t surprise me.

I saw an overwhelming array of products that day, many of them cool and some of them crazy. But by the time I left the expo, I was starting to become disillusioned about the amount of fancy tech I was seeing. There are so many competing companies that are all doing cool and interesting things. Once I saw my seventh care robot, I started to wonder: when is the market saturated? At what point do you stop?

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This guy was super cute and spoke to me in Japanese, but I have no idea what his function is.

Most importantly: how do you actually ensure that you’re improving people’s health? As amazing as these devices are, I’m not always clear on how they actually help people. These ideas and products cost a lot of resources and money, and I’m not sure if all that expense is justified. I wonder if some of those resources could be spent on effecting more direct change, like increasing government subsidies for hearing aids or lowering hospital fees. I’m reminded of an early project conversation in Sweden, in which a wheelchair company recommended that I ask medical technology companies the following questions: a) how do you verify that there’s a real need for your product (that your idea is good, and original, and address a real problem), and b) once you’ve made the product, how do you validate it to make sure that it works well and fixes that problem? Ideally a company would have good answers for both questions. Their methods for verification and validation, or lack thereof, can be quite revealing. In Sweden, the discussion of human factors or ergonomics came up often, and most companies seemed to care about doing user-based testing to keep in touch with their users’ needs at every step in the design process (which would be the verification step – the answer to question a) above).

So, it’s clear that Japanese companies are into cool innovation. But are they into ergonomics? That doesn’t seem to be the case. Does that mean that the care robots, and all the other fancy health tech I was excited about seeing, doesn’t really have an impact on people’s health here? It’s hard to say.

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Lastly, there was a Birkenstock booth at this expo! Since when do Birkenstocks count as medical devices?

Health post: Medtech Expo 1

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Tokyo Big Sight, a bit removed from Tokyo’s main neighborhoods, hosts all the big conventions and expos in the city.
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It’s definitely equivalent to the Jacob Javits Convention Center in New York. (I can’t help but compare every aspect of Tokyo to its equivalent in NYC!).

I like mixing up my project meetings so that I’m not always interviewing people in offices, and one fun way to do that is to go to expos (trade shows) to get a broad sense of what companies are currently doing in the field and what’s popular. My time in Tokyo has luckily coincided with two healthcare expos at the big exhibition hall Tokyo Big Sight, and I was able to attend both for free by pre-registering online (and, for the second one, by getting those business cards). There was a lot of technology for healthcare at these events – I was happy to see loads of “care robots”! – so I wanted to post about my experience.

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Nescafé was at the expo advertising its new, helmet-shaped espresso machine. At this expo, all new technology was welcome. I was just happy to get some free coffee while wandering around the booths.

I’ll use two posts to share some thoughts and photos from these expos. This post is about the first trade show I attended, which focused mainly on “retail technology” and technology design in general. Along with retail, this expo had subsections such as health, transportation, and home living.

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These people are discussing a set of exercise equipment for children.
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Lots of companies had booths where their products were set up for testing. These “medical chairs” look super comfy, and based on some browsing of their website in Google Translate, they use artificial intelligence and vital sign monitoring to help people with muscular issues via personalized massages. Their website mentions ‘shiatsu,’ which is apparently a Japanese preventive care method focused on applying ‘finger pressure’ to key points on the body.

Appropriately, then, I stumbled upon the “Good Design Award” area, which showcased various winners of the 2016 Good Design Award in Japan. There were nine award categories, each of which had a few winning products. The competition committee had outlined these “essential Good Design Award perspectives on design trends” to demonstrate that the winning products were not only well-designed, but also that they addressed a relevant social concern. The nine “focused issues” were: the environment, urban infrastructure, community, medicine and health, security, education, business models, culture, and technology (IT). Of course, I was on the lookout for well-designed technology in medicine and health, so I made a beeline for that part of the room.

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Perhaps another ‘shiatsu’ product? I loved to see that this elderly man was trying out the product.

In the Medicine & Health area, there was a big block of Japanese text printed on the wall. Luckily I found a small booklet with an English translation, and I read this text, which was an introduction to the topic and a discussion of the winning products by a man named Takahiro Uchida. I learned that he is a cardiologist who has consulted for medical device startups in Silicon Valley, and now he is the CEO of a Tokyo-based incubator for medical innovations.

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I tried out a product too: NTT Docomo’s fat-burning analyzer, intended for doctors’ offices. Though it looks like a regular scale, it doesn’t measure your weight – it senses the acetone emitted by your skin when you step on it while barefoot. Based on the amount of acetone detected, a number which is sent to the accompanying tablet over Bluetooth, the software can determine how well your metabolism is working. I got a terrible rating! The NTT Docomo employee who helped me try it out explained that it’s normal to get a low rating in the morning before any exercise and that the rating changes over the course of the day. All I had done that morning was take the train to the exhibition center, so hopefully he’s right! It’s definitely motivating for exercise, though.

A lot of what he wrote really resonated with me; Uchida stated that, when it comes to well-designed medical products, simply adding bells and whistles isn’t enough and can even undermine the goal. Health should be a basic right for all people. “Safe, effective diagnosis and treatment remains the goal of medical care, yet superficial design such as appealing drug packaging increases development costs and makes drugs or devices more expensive,” he wrote. “This undermines the social mission to expand medical care.” (Full text here).

But, of course, it is important to consider what will be most satisfying and comfortable for the patient, even if that means making cosmetic changes (though ideally without raising the cost). This is where I think co-design is most important – if you start by designing with the user, and generally making the design choices that will make them happy, you won’t lose money changing those choices down the road.

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Being a trade show intended for Japanese businesses, almost all the information was in Japanese. There were loads of questions I wanted to ask various companies, but I couldn’t because they had no English information and no English-speaking representatives (which is how it should be, so I have no problem with that!). Oddly, there was often one phrase written in English that would catch my eye, such as the poster pictured here titled “Health IoT – Clinical IoT”. I would think great, that’s my project! and peer closer only to realize that the rest of the information was all in Japanese. Why write the title in English, then?

Uchida was thus impressed by the devices that walked the line of satisfying users’ wants and needs while not getting bogged down by expensive or excessive additions. 2016 seemed to be a good year for well-designed patient monitoring systems and digital imaging systems, the latter of which Uchida said respond “to patient needs for smaller, quieter, and more visually appealing devices.” Also, any products submitted to the Medicine & Health category needed to be medically approved – Uchida wrote that there were many medical- or health-related devices that were designed very well, but which were removed from consideration for the award because they did not pass the stringent regulations necessary to qualify as a “medical device” in Japan (for a general example, the Fitbit is a type of health/fitness technology that cannot legally be called a medical device).

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The expo was well laid-out, with the red stripe indicating the section of “good design” in general and the blue stripe indicating the healthcare technology section.

Other winners of the Good Design Award 2016 for Medicine & Health included a wheelchair and an assistive device. There was the COGY wheelchair, which can be pedaled forward with minimal effort so that the user feels more self-sufficient and independent. It adds haptic feedback to the wheelchair experience, enhancing the limited pedaling power of the users so that they can engage with the wheelchair and have the sense of mobility, as though they are pedaling a bike.

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Different iterations of the COGY wheelchair.
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I’m not entirely sure what this poster was saying, but it seems to be promoting acceptance of wheelchair users and fun wheelchair racing events.

There was also the Ontenna, a bone-conduction device for people with hearing impairments or full hearing loss. According to Uchida, the Ontenna follows a general trend of new medical devices products that support minority and disabled populations to help change perceptions surrounding disabilities. As described by IT entrepreneur Dominique Chen in the IT section, the Ontenna is “worn like a hairpin…[and] conveys ambient sound in the form of vibration and light to hearing-impaired users. The thinking behind this product turns the tables on an unfair but common bias that those with disabilities trail healthy people in perception and cognition.”

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The Ontenna.

I noticed that many of these products (as well as health-oriented devices that didn’t go through the extensive regulation process) were also mentioned in the introduction text for the Information Technology section of the Good Design Award. In the intro text for IT, written by the previously-mentioned Dominique Chen, both the Ontenna and COGY come up again. Chen writes about them in the context of human-centric IT with glowing reviews. He seems to be hugely optimistic about the power of such products to change perception of bias towards disabled people: “It seems inevitable that, as some have already discussed in the context of sporting events, disabled individuals will be the first to venture into the realm of cybernetic existence as cyborgs, or cybernetic organisms. As the reality of physical and mental issues faced routinely by many with disabilities becomes more openly revealed, as shared knowledge in society, it will be easier to dismantle the binary division between healthy and disabled. Such openness shows the possibility of a middle ground in a dichotomy that has remained unequal, encouraging us to redefine the social image of reality and join a social movement not yet seen.”

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There was a lot going on at this expo that had nothing to do with health and medicine but that still revealed a lot about popular technology in Japan. That is, there were robots! This pair is part of an IoT security system.
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The biggest section of the expo was centered around technology used in retail. These blue robots wander around a retail space (in this example, a grocery store), and they scan the shelves to detect the quantity and price of various items in the store. They can alert the owner or a shop employee when a product’s stock needs to be refilled. I think they can help patrons shop, too.

I suppose it’s already telling that the Medicine & Health entry overlapped with the Information Technology entry. So many of the best, new medical devices designs are in fact technology designs. Still, it’s clear that there is an issue with stigma against disabilities in Japan. Both Chen and Uchida mentioned it, and the success of the Ontenna is a sign – it is designed to disguise the disability and the need for assistive technology (though pretty much everyone around the world seems to appreciate small, subtle devices).

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More from the health section: “bio-surfactant through fermentation” products such as laundry powder and dishwashing liquid. Though not quite related, my host mom was telling me that fermented foods are considered to be an important part of a healthy diet in Japan: fermented tofu, fermented soy beans (natto), yogurt, and so on. Of course, in the US we consider yogurt, kombucha, and other ‘fermented foods’ to be healthy as well, but we rarely use the word ‘fermentation’ to describe them.
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Of course, Japanese toilets are infamous, so I was amused but not surprised to see a toilet brand on display in the health section (this is apparently another winner of the Good Design Award 2016, though I’m not sure if there is technology involved here).

That’s all for now. I’ll cover the next week’s expo in a follow-up post. (Edit: part 2 is here).

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In the living section, this colorful “donut” furniture for kids speaks to Japan’s kawaii (super-cute) culture.

Health post: Singaporean Incentives

I was interested to come to Singapore because it is apparently the 2nd-healthiest country in the world (after Iceland and just before Sweden; The Lancet) and was rated by the World Economic Forum as the world’s most technology-ready country. It’s also been rated by the World Bank as one of the easiest countries in the world for doing business. There are expats here from all over the world, and over 200,000 people come here every year for medical tourism. Singapore is known as an innovation hub, and rightly so, it seems; as far as I can tell, everything here seems to be lively and modernizing.

My project centers around what factors influence positive reactions to medical technology, but that depends on the general attitudes towards health and technology in a country. Even a topic as generic as “technology innovation” is relevant as a jumping-off point for why a country might be particularly positive towards medtech. For that reason, I wanted to do a little bit of research into why business thrives here, and how that might relate to attitudes towards new technologies in all sectors, including health.

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The ArtScience museum, observation wheel, and Marina Bay Sands (left to right), viewed from the Central Business District.

A friend recently shared an article with me that details the Singaporean government’s plan for maintaining a successful economy in the today’s uncertain future. The report lists seven key sectors, one of which is healthcare (Tech in Asia; see sources list below). According to the article, the government hopes to improve “Singapore’s startup ecosystem” by paving the way for more venture capital firms; improving access to technology for new businesses; and becoming more of a tech-enhanced city as part of a “Smart Nation” goal.

I read that Singapore has this plan to become a “Smart Nation,” similar to various “smart city” plans that aim to use improved technology infrastructure to tackle present and future challenges in all categories such as transit, WiFi connectivity, housing, growing and aging populations, etc. One of the “Smart Nation” goals is increased telemedicine, in fact, in response to Singapore’s increasing population. A few of Singapore’s public hospitals already track patients at home using remote patient monitoring techniques, using telemedicine to care for these people while freeing up space in the hospitals for additional patients.

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A 1992 sculpture called “Reaching”. The plaque reads: “‘Reaching’ symbolizes our progress and infinite possibilities of growth. Just as ‘Reaching’ builds up from a small base and reaches out beyond itself, so has Singapore, a small country, progressed beyond its shores.”

Apparently, the factors that make Singapore so good for business have much to do with technology, such as new online systems for litigation proceedings and property transfer, along with the ability to deal with most business taxes online (Forbes). It is also possible  to register a new company online (and complete tax registration in the same step) via an electronic system, all in one day. Singapore has no minimum wage, which is good for business but bad for income inequality (The Middle Ground).

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Many photos of Singapore, as I’ve mentioned, show a complete and glittering city of the future, but I think it’s cool to see the amount of development and construction happening as well (the construction here is for a new subway line).

There are developments specific to the medtech sector as well that give Singapore an edge over other countries. Of the ten states that constitute the Association of Southeast Asian Nations, ASEAN, Singapore spends the highest percentage of its GDP on health: 4.9% (WHO; ASEAN Briefing). The government has measures in place to spur medtech development such as the “Partnerships for Capability Transformation” (PACT) act to encourage partnerships between manufacturers and suppliers – this is especially important for medical products, which need to adhere to strict quality control measures and regulations. There is also a mandatory government health insurance program called MediSHIELD Life, which has the result of incentivizing the healthcare sector because it guarantees that medical treatment will always be paid for, either by the patients or the government, and so the medical industry should provide a steady source of income.

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Another helpful factor is that there are dedicated medical technology parks such as the Biopolis research and development center, which houses various biomedical companies in Singapore (EDB). This sort of tech park can provide medical technology companies with resources such as access to hospital facilities for testing and the opportunity to collaborate with other companies and institutions. Also, the government has committed about $50 million (US dollars) to an accelerator program that is supposed to invest in new medical technology start-ups (EDB).

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On a giant screen outside a small shopping center in Chinatown, this man discusses the importance of investing in industries that focus on women, while the screen itself wishes passers-by “good health and abundant wealth” in the new year.

Despite its small size, Singapore is clearly already a global hub for medical technology; in fact, over thirty global medical technology companies now have their southeast Asian regional offices and/or research and development centers in Singapore (EDB, ASEAN Briefing). These global companies will most likely set examples for or inspire local companies in the same field; in Sweden, I noticed that various local companies seemed inspired and encouraged by the history of medtech innovations that have occurred in the country over the years. Singapore is already considered one of the healthiest countries in the world with an average life expectancy of 83 years, though the rapidly growing and ageing population also puts pressure on the medtech industry (ASEAN Briefing). From what I can tell, Singapore’s high-income economy and highly involved government seem to be the main drivers for the booming medical technology sector in this city-state, though whether Singapore’s “good for business” rating has much to do with its high health rating is difficult to say.

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Colorful buildings on a rainy day.

Sources:

-Summary of government report on future economy at https://www.techinasia.com/singapore-future-economy-committee-report

-The Lancet study of healthiest countries at https://www.weforum.org/agenda/2016/09/there-s-a-new-ranking-of-the-healthiest-countries-how-is-yours-doing/

-Medical Tourism at https://www.pacificprime.sg/medical-tourism

-“Singapore: An Emerging Hub for Medical Devices” at http://www.aseanbriefing.com/news/2016/04/20/singapore-an.html

-Medical Technology in Singapore from the EDB (Economic Development Board) at https://www.edb.gov.sg/content/edb/en/industries/industries/medtech.html

-Singapore Smart Nation at https://www.spring.gov.sg/Inspiring-Success/Enterprise-Stories/Pages/Setting-the-standard-worldwide-intelligent-city-Smart-Nation.aspx

-“Singapore Remains The Best Place In The World To Do Business” at http://www.forbes.com/sites/philipsalter/2015/10/28/singapore-ease-of-doing-business/#245297b06bf3

-“What is the Gini coefficient, and how bad is our income inequality?” at http://themiddleground.sg/2015/08/21/gini-coefficient-bad-income-inequality/

-Singapore, World Health Organization at http://www.who.int/countries/sgp/en/

-“Singapore’s Medical Devices Industry – ASEAN’s New Development Hub?” at http://www.emerging-strategy.com/article/singapores-medical-devices-industry-aseans-new-development-hub/

Health post: Medical Camps in Rural Villages

Last week I traveled to Bhopal, the tier-two capital city of Madhya Pradesh, a state in central India. I was there to participate in a health camp called Medical Yatra, which is an annual event to bring healthcare services to rural villages across the country. Each year, the Medical Yatra team convenes in a new city and spends ten days traveling out to neighboring villages. It’s a joint effort by an association of India physicians based in the states, local hospitals, the non-profit foundation Aarogya Seva, and the Rotary International club (http://www.aarogyaseva.org/medical-yatra-2017/).

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Aarogya Seva’s slogan is “Promoting Healthcare Volunteerism.” While I wasn’t planning on doing any volunteering on the Watson, I felt humbled to be included in the group and able to contribute in some way.

I heard about the camp because a company I interviewed for the project, MyCliniCare, was going to attend for a few days to bring their technology along with the medical supplies. MyCliniCare provides a telemedicine solution in the form of a suitcase for on-the-go healthcare. The suitcase, which can be brought to any rural area, has many small medical devices and monitors along with a laptop that synthesizes the collected data and connects to a trained doctor over a video call.

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The MyCliniCare team and me in our volunteer t-shirts! The MyCliniCare suitcase is in the shot as well.
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Dr. Dayaprasad, founder and director of the Aarogya Seva foundation, giving a presentation to medical students in Bhopal about the various medical diagnostic devices included in the MyCliniCare telemedicine kit.
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Here, Gururaja of MyCliniCare is demonstrating the telemedicine setup by pointing the multipurpose otoscope into his mouth. The resulting image of his throat is displayed on the projection screen, which is what a doctor would see remotely.

One new addition to MyCliniCare’s set is the iBreastExam device, a handheld sensor for breast tumor screening. Using piezoelectric sensors, the device checks for lumps in a patient’s breasts and delivers a result in 5-10 minutes; if it finds anything, a mammogram follow-up is required. In each village that we visited, the MyCliniCare team set up a private place for their technician to screen women with iBreastExam.

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The iBreastExam handheld device is pink and white, and it delivers real-time results to the connected app.
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In the same room as the breast tumor screening, we performed ECGs with this portable device (which also sends its results to a smartphone app, connected via WiFi).

Though I initially intended to tag along with the MyCliniCare team and simply observe, I ended up becoming a full volunteer for a few days since the health camp needed the help. For the first two days, I teamed up with a doctor to run the blood-test station. The doctor spoke to the patients in Hindi and pricked their fingers to get blood, and I took the samples and ran the tests with the devices we had brought. We had a small hemoglobin device to test for anemia and a small glucometer to test for high blood sugar.

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The HemoCue hemoglobin meter that we used. Incidentally, it is made by a Swedish company!
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Medicines set up by the pediatricians in the same room as the blood testing.

After months of interviewing people about attitudes towards health and medical technology in rural India, it was invaluable to see those very attitudes in front of me. It felt like all of a sudden I had gone from using secondary sources for my information to primary sources. Most of the villagers were comfortable getting their blood drawn and tested, as it was a simple and quick procedure that was explained to them in Hindi. However, they rarely reacted to the results due to a general lack of awareness of how much blood sugar was too much and what that meant, as well as what the purpose of hemoglobin testing was.

A few of the villagers, especially the children, were scared to get their fingers pricked and found it quite painful (making very familiar cringing faces!). One woman in the village of Tumda sat down for a blood test, had her finger swabbed with alcohol, took one look at the little lancet that was about to pierce her fingertip, and started cursing in Hindi and nearly ran out the door. I was stunned that she hadn’t realized what a blood test entailed. Her reaction reminded me of a few interviews I’ve had here in which people have told me that many Indian patients, especially in rural areas, are resistant to invasive procedure from finger-pricking to surgery.

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Tumda Village.
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As things quiet down in Tumda, the volunteers show each other how to read a classic blood pressure monitor.

As part of the camp, I traveled to the villages of Seoni, Tumda, and Berasia. I was happy that my fellow volunteers were mostly Indian; I wonder if the villagers were a bit put off by my presence (being an obvious foreigner), and it was challenging not knowing Hindi. So it was good to stay useful, and it was fascinating for me to be around so many doctors volunteering their services. Of course, the question of sustainability is always important: how do these one-off health camps help the villagers if we can’t come back to the village? The doctors I asked told me that some care is always better than no care, and the big problem is awareness – many villagers are not aware of their medical issues or how to address them. At least with a visit from specialists via this type of health camp, patients can get the right information and seek the appropriate care at a more accessible (and permanent) health center or hospital. The Medical Yatra team keeps track of all the patients that need to be referred to specific hospital departments, and they send those lists to the nearby hospitals, who then send vans to the villages to pick up the patients for free treatment at their facilities. Also, most patients do have a mobile number, so we can at least call to follow up.

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The school in Seoni where we set up camp.
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Medical Yatra volunteers registering patients for treatment.
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In Bhopal, we visited this government center making prosthetic limbs and offering rehabilitation techniques. Professor Schull, on the left, was interested in comparing their design to his 3D-printed prosthetic designs.
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One of Professor Schull’s 3D-printed prosthetic prototypes.
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The internal medicine room that we set up at Berasia village. The hallway just outside the room was packed wall-to-wall with patients all day.
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Dr. Ramesh Shah, a volunteer from Ohio.

I’m very grateful to MyCliniCare and the Aarogya Seva foundation for letting me join their effort for a few days. It was inspiring to meet so many hard-working doctors and actually operate the type of medical devices I’ve been thinking about throughout my project.