Health post: Tying the threads together

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.

This is Hakone Jinja. Over the weekend, I went to the nearby town of Hakone with my host family.

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.

While in Hakone, my host family and I went to this great open-air museum. This photo of my host mom and me was taken by the dad of the family!

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.

Hierarchy

Jizo statues, little protectors at many temples.

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.

A band of robots at the Toyota Museum in Nagoya.

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).

Taking the escalator up to the huge Hie Shrine in the middle of high-rise Tokyo.

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.

Dr. Mukai of Meijo University and his ROBEAR, a healthcare patient-lifting robot that is used purely for research and will most likely never work in a hospital.

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).

This is Professor Nakane of Osaka University, who is trying to commercialize his idea of applying the mathematic theory of homology to the medical problem of tumor detection.

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.

Risk Avoidance

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).

At one of Hakone’s most sulphuric destinations, workers give you little cloths at the station: “To prevent accidents occurring due to volcanic gases, please be sure to cover your mouth and nose with the wet cloth.”

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).

Iridescent glass “leaves” at the Hakone Venetian Glass museum.

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.

The Zōjō-ji temple near Tokyo Tower.

Health post: Habits of Tokyo

I can’t stop thinking about this interaction I had yesterday. I had just come out of a museum in Tokyo, the Western Art Museum, and I was taking photos of the Rodin sculptures in the museum’s outdoor garden. An older Japanese man came up to me and asked me if I wanted my picture with one of the sculptures. Surprised by his fluent English, and figuring a picture would be nice, I handed him my camera and stood by the sculpture. He took the picture and handed it back to me, and he asked me where I was from.

The aforementioned picture – me with Rodin’s “Gates of Hell” sculpture.

I said, “From the US.”
“Oh, the US!” he said. Then, unprompted: “I’m a biotechnology professor.”
Did I hear that right? I was so surprised that his profession was related to my project that all I could do was echo what he had said.
“A biotechnology professor?”
“Yes,” he said. “And today is my day off, and I’m tired. Goodbye!”
He waved and hurried off.

I stood there, stunned. How strange. How could this random stranger have appeared out of nowhere, been relevant to my project, and then disappeared so quickly? The whole thing seemed more than coincidental, which is not something I usually say, but I had just watched the movie Your Name the night before – it’s currently Japan’s most popular anime film, and much of it takes place in Shinjuku, Tokyo, where I’ve spent a lot of my time. Among many other things, Your Name is about how the universe can throw people together for seemingly no reason in the strangest of ways.

I decided to go after this biotechnology professor. I didn’t have any plan of what to say, but I knew I’d figure it out when I saw him. Only I never found him – he had completely slipped away into the crowd, and that was that. I decided, if nothing else, that this was the universe’s way of telling me that I needed to get back to work on the project. My lack of blog posts lately has mostly been due to the Japanese class I started a week ago, which is four hours of class every day of the week. It’s been fun going back to a “regular work schedule,” but it also means that each day has been fairly routine (even with homework!), and the classes leave me with very little flexibility to schedule new project meetings.

So far my favorite photo that I’ve taken here – an alley in Yurakucho, Tokyo.

Anyway, I wanted to talk about a couple health-related things I’ve noticed since arriving in Tokyo. Japan is a famously healthy country, and there does seem to be a generally positive attitude towards exercise here. Even in the cold, I’ve seen people going out for runs, and I’ve spotted the occasional exercise or stretching group in a park. I’ve seen a lot of older people on these runs, though that might just be because I’m usually looking around during work hours. Tokyo is filled with bikers as well – the second-most efficient way to get around this city after the metro – and they seem to navigate the hills pretty well.

I visited Tokyo’s St. Luke’s research hospital, which has a full simulation training center for medical students. I was impressed by the quality of their dummy patients like the one you see here.

But it’s still not like Sweden, where people were exercising a lot, talking about exercise, and also happened to have fashionable outfits for exercising. Here, you don’t see a lot of gyms around, and my host family never works out, though they seem fairly fit. From what I can tell, it seems like a lot of people here don’t exercise frequently (I suppose walking in Tokyo and eating small portion sizes keeps them slim). Apparently no one in Tokyo has the time – people tend to work a lot here and quite late into the evening. I get the sense that work comes first, and everything else second.

This “SaveMan” dummy, made by the Japanese company Koken, has all sorts of functionalities for medical students including two separate “lungs” and the ability to take ECG readings to test for the dummy’s arrhythmia.

In Sweden, it was the opposite. People often discussed work-life balance and the importance of finding time for wellness and exercise and being outdoors most days of the week. Everyday exercise seemed to be more of an ingrained idea there than it is here. Even in the US, if someone doesn’t exercise frequently, they’ll talk about it – “Oh, I should exercise more,” “I need to go to the gym,” and so on. We’re aware that we should be doing some sort of exercise most days, even if we don’t. But people here don’t say that. I’ve mentioned this to a few of my friends who have been living in Tokyo for a while, and for the most part, they’ve said the same – they haven’t heard ‘Tokyoites’ mention exercise, either to extol it or complain about it.

The mouth (especially the teeth) was the most realistic part of the SaveMan!

The main room of the St. Luke’s simulation center, with another medical dummy on the bed in the background. Of course, this room has never been used for real patients, but it’s still full with the necessary equipment and technology for all sorts of exams and procedures.

So I suppose a lot of the health here (or fitness, at least) comes from the food. Portions here are a lot smaller than in India or the US. Even the warm bowl of ramen I had the other day felt a lot lighter than it looked – I think the cooking methods are fairly light here – though of course there is unhealthy food as well. And even if you take the trains every day, there’s still a lot of walking to be done in terms of getting around Tokyo.

But there are surprisingly bad habits around too, such as smoking. There seem to be a ton of smokers in Tokyo (which might fit with the aforementioned long work hours – most of the smokers I see are businessmen). There are vending machines on the street where anyone can buy a pack of cigarettes, which I found fairly shocking when I first arrived. However, people are not allowed to smoke on the streets – no one walks and smokes. Instead, there are loads of designated smoking areas all over the city, even blocked out on the street outside buildings, and there will always be smokers there. I think this makes the issue of smoking seem worse than it is, as you always see smokers in big clustered groups rather than dispersed through the streets. Also, I suppose that smoking is more obvious when someone is standing by an ash tray doing nothing but smoking, as opposed to someone casually holding a cigarette where you might not notice it while they walk down the street on their phone, for example.

“No smoking while walking. No littering” sign right across the street from an outdoor designated smoking area with about 10 Japanese people smoking together.

Cigarette vending machines in Japan. (Not my photo; source here at the Japan Times).

I’m not yet sure what to make of all this. Someone told me that it’s very difficult to get drugs in Japan (other than alcohol and cigarettes, of course), which is why the amount of smokers seems inflated – but overall, drug use should be better here than in other countries. But then why doesn’t that extend to cigarettes as well, I wonder? “Money,” my friend replied. I suppose no country has escaped the influence (that is, the wealth) of tobacco companies.

The World Health Organizations lists only two risk factors for Japan: alcohol and tobacco (http://www.who.int/countries/jpn/en/). But perhaps I’m getting too focused on this – after all, the country still has a life expectancy of 80/87 years (male/female), which is incredibly high. I’m also aware that the super-urban, business-focused, and densely populated Tokyo is not at all representative of the country as a whole. My first stop outside of Tokyo will be Kyoto, and I’m really looking forward to that. But first, I need to complete my second and final week of this Japanese class. おやすみ なさい!

A cute “Jazzhaus” in my small residential neighborhood.

Health post: Cost & cooperative design

After meeting Dr. Maneesha, I talked to a few other interesting people at Amritapuri; here are some brief highlights. First, I met with Dr. Bipin Nair, who is working on a low-cost automated insulin pump for diabetes patients. Dr. Nair mentioned that his team is partnering with a company in Bangalore to develop an app for the device. I asked why a smartphone app would be appropriate for someone who needs a low-cost insulin pump, and Dr. Nair said that the target population for the device would be India’s middle class: people who are busy working and can’t afford automated insulin pumps, which could cost over $1000, but who also would certainly have smartphones – so that made sense. I think it’s always important to define the target population of a new device (the pump is still in development, so I couldn’t ask about public reactions to it yet).

Here is Dr. Bipin Nair with his patents (on the desk) for the automatic insulin pump as well as for a low-cost non-enzymatic glucose sensor strip.

Next, I met with Rahul, who showed me some prototypes for a wearable ECG monitor, which is one of the devices included in the remote patient monitoring system that I discussed with Dr. Maneesha. It was cool to see the evolution of the prototypes based on feedback received from Amma and other test users. The small controller, which turns the monitoring on and off, was designed to be worn around the waist as a belt. However, Amma pointed out that many Indians don’t wear clothes that could be worn with belts. Many men wear the traditional dhoti (fabric tied around the waist), which leaves no room for a belt or any belt loops. Amma suggested that the form factor of the controller be reduced to a smaller size so that it could be worn as a pendant around the neck, so that’s what Rahul and his team are working on now.

It’s not so easy to see on this background, but to the right you have the original design of the controller (you can see the 4 ECG leads coming out of it, which would be attached to the user’s chest). With user testing, the team found that the buttons were too close together and couldn’t be distinguished by the user, leading to many wrong button presses. On the left, you see an updated design with the buttons spaced farther apart. The next design will incorporate these button changes on a smaller controller, as mentioned above.

A day later, I met with engineering professor Dr. Rajesh Kannan to see his prototype for a wheelchair that can be controlled by partially paralyzed stroke patients, who are unable to use the joystick of a motorized wheelchair or the manual controls of a mechanical wheelchair. Dr. Kannan is working with various engineering students to develop software so that an app on a smartphone or tablet can be used to steer a motorized wheelchair over Bluetooth, bypassing the joystick. A patient rests their hand on the flat surface of the phone or tablet and uses simple gestures – sliding the palm forward to go forward, back to go backwards, etc. – to control the direction of the wheelchair. Shifting one’s palm on a flat surface like this is easier for many patients than manipulating a joystick. The wheelchair has only been tested with five stroke patients so far, but Dr. Kannan said that the reactions were highly positive, mostly for psychological reasons – these patients had always been dependent on others for movement, so finally having the independence to drive their wheelchair without help had great emotional benefits. The only problem with the wheelchair, of course, is cost – Dr. Kannan said that the motors for electric wheelchairs are imported, and so this type of product won’t be practically affordable until wheelchair motors are manufactured in India.

Here is the motorized wheelchair with the stand for a tablet or phone where the joystick would be.

Finally, I had a brief chat about villager attitudes with Ranjit, the point person for Amrita University’s Live-in-Labs program. Live-in-Labs allows foreign students to live in a rural village for a period of 2 weeks to 6 months, working with the locals to build sustainable solutions to various problems. I asked him what would make a medical device succeed in these sort of villages, and he mentioned many important considerations. Most of all, he said, the success of a device depends on how well it fits the lifestyle of a particular village (and village lifestyles can vary enormously throughout the country). Ranjit gave the following example: if a device that uses fingerprints for patient identification is used in a population where people’s hands are too callused to read fingerprints, that device needs to have a backup ID method such as retina scanning. Designers have to make their medical devices modular so that they can adapt to different conditions, and they have to be humble and flexible – realizing that if a villager can’t figure out the device, it’s a problem with the design and not with the villager. The designer has to keep working with the villagers to iron out the kinks of their design at each stage in the process.

Again, this is the theme of codesign, which kept coming up in my meetings at Amritapuri, along with the importance of making medical technology affordable. Since Amrita University is a non-profit, researchers don’t have to worry about making money off the devices they design. Almost every project connection I’ve made in India tells me that affordability is the main factor necessary for acceptance of medical technology here. Often, when I ask people for the second most important factor, they either mention cost again (really!), or they mention usability. It was great to hear so many people at Amritapuri talk about the important of codesign and working closely with the end user to develop something easy-to-use. I’m glad to have an academic visit to contrast with the visits I’ve had with various companies in Mumbai and Bangalore, which naturally have more corporate and cosmopolitan perspectives.

Is the project your life, or is your life the project?

I’ve been boasting to all my friends, especially my local Indian friends, that I have a stomach of steel. I’ve been drinking heavily filtered tap water since my arrival in India (along with bottled water as well) and eating Indian food nearly every day. After a couple weeks, I tried all the craziest street food including pani puri, which involves spiced water and ungloved hands.

And to my surprise, I still felt great! Well, you can see where this is going…fast forward a month to this Monday, when I was packing up from a weekend trip in Goa to fly back to Bangalore (Goa is a really pretty state in India known for its beaches). Just before the bumpy hour long drive to the airport, I started feeling nauseated, and that was the beginning to a tough day of travel.

Goa was beautiful though.

I managed to throw up twice on a 50-minute flight, and I had to cancel a project meeting I had scheduled for that evening. I got to the guest house where I’m staying and Skyped my parents from the bed, sliding further into zombie-ness over the course of the call. The saddest part of all of this is the food that made me sick: a few bites of fruit salad! It’s true that people warned me against raw fruits and veggies, but I suppose I thought a fruit salad at a hotel restaurant would be okay since I’ve survived some serious street food.

I couldn’t afford to reschedule any more meetings, as the week was pretty booked and I probably won’t come back to Bangalore. So I had to get better, and while I did bring medicine for an upset stomach on the Watson with me, I left it in Mumbai for this short trip along with other things I haven’t needed much (of course).

I made it through Tuesday’s meetings and then found my way to a medicine shop. I walked up to the counter, scanning the wide array of products displayed in the floor-to-ceiling cabinets. It was definitely a counter service place, so I told the man behind the counter that I had a stomachache and a headache (probably from not eating or drinking much due to the stomach issue).

My super stealthy shot of the counter. This is one of the smaller pharmacy stores in Bangalore, though Mumbai has more of the tiny packed ones.

I think I expected some conversation about options. Instead, the man at the counter swiftly placed two boxes on the counter, removed a set of ten pills from each, and said “67 rupees.” (That’s just under $1).

“Umm…okay. Can I see the boxes?” He shrugged as I picked up the decidedly minimalist boxes that merely listed generic medicine names that I didn’t recognize. After 20 seconds of this, the man basically told me I wouldn’t learn anything from the boxes. So I gave him 67 rupees, took the pills in a small brown paper bag, and walked away.

I couldn’t believe how cheap and easy it was to get the pills. Of course, as soon as I had wifi, I Googled the generic medicines and found myself on some of the same websites that I had visited when looking for companies to interview for my project. I suddenly understood the need for all the websites here that help you look up individual generic medicines and find the best price and uses and so on. In the US, I never Google my medicines. I either get a prescription from my doctor and take that without question, or I go to a store like Walgreens and go to the aisle labeled “headache” and pick a brand I know, or the stores’ generic version of that brand, or read a few labels.

The pills were more labeled than the boxes they came in, which was helpful.

Going on the internet for that information makes the process so much more complicated; one site said that the stomachache medicine I got was for menstrual cramps (no), and another said the headache and stomachache pills might react with each other (but most sites said they wouldn’t). Anyway, I found out that the headache tablets were basically Tylenol, so I took one. The stomachache tablet medicine was something I hadn’t had before, so I waited a bit, felt better on my own, and decided to forgo the medicine.

And now I’m all better – back to the stomach of steel. Phew! (Though I will probably avoid fruit salad for a while).

Health post: Starting with startups

This past week, I spoke with a man named Shoibal about the general state of the medtech industry in India. He studied to be a doctor but hasn’t practiced medicine, instead going straight into the pharmaceutical industry – he currently works at an Indian pharmaceutical company here in Mumbai. For a while, he was also a consultant helping healthcare startups and small companies with the projects they wanted to do.

I asked him if the startups and small companies he worked with tended towards a main topic, and he said that most of them focused on smartphone apps that aim to simplify the doctor or the patient experience. There is a need for such apps, he said, because India lacks a universal EMR system (electronic medical records). Often hospitals have no EMR system at all, so patients go to a hospital and get records created on paper. As a result, the patient has no idea what’s in their record, and they might know about parts of their record but not all, and they have a hard time going to different doctors and hospitals. A lot of these companies, therefore, focus on providing electronic data capture for patients so that they can have some control over their records and not worry about forgetting important data. This also gives patients the flexibility to move between cities and share their records with new doctors.

Shoibal mentioned that in addition to EMR-focused apps, companies were working on fitness apps, which provide support and recommendations for maintaining good health – either for an already healthy person or someone with a specific condition. These are apps that are tailored to the user, giving detailed feedback based on input data. I asked Shoibal if these companies had specific target user groups. As I mentioned in my last health post, I think that India’s large and diverse population necessitates the strict definition of intended user populations; no company, especially a start-up, can have a set of offerings wide enough to suit everyone. Shoibal replied that the companies have had to focus on urban populations since they are developing smartphone apps, and the penetration of smartphones in India is mostly in urban areas (though they are slowly spreading into rural areas, and surely the companies ultimately want to widen their focus). Also, the apps are aimed towards educated people, as the uneducated population might not even be literate, said Shoibal.

Finally, there is the issue of language. It’s very difficult to translate an app into multiple different local languages, so most of the companies make apps in English only. Even Welcome Cure, I noticed, had all of its information in English but not in Hindi, let alone any regional languages. So that means that these startups and small companies all have nearly identical target user groups: the educated, English-speaking people living in major cities who own a smartphone. In other words, the 1%. I see a potential for image-based apps here; even if they still require a phone, at least they would work for the uneducated and non-English-speaking members of the population.

I asked if any of the companies were making physical devices rather than just health apps (at the end of the day, I’m an engineer, not a computer scientist). Shoibal said that some were focused on connecting people to devices, but still via smartphone apps. Rather than these startups building and deploying their own glucose monitors, for example, they would have a licensed connection with another company (say a Chinese manufacturer) and sell that company’s device online. Shoibal pointed out that these were two different skill sets, engineering, manufacturing, and quality control vs. app development and IT, and only large companies with enough money keep both under the same roof.

He said that some of the companies that didn’t do apps would maybe do a website, such as Welcome Cure, and have a telephone number, focusing more on having some supportive back-end of people who communicate with the patients. These could be services that ease patient management for doctors, or help patients find the cheapest version of their prescribed medicine, or encourage medication adherence, for example.

Next, I asked one of my favorite big questions: what factors influenced the success of some of these medtech companies over others? Shoibal was ready with two main factors of success, the first of which is funding. Since there are so many tech companies and health startups (and it really does seem like India has a lot), “the ultimate success of these ventures is uncertain.” Even if they have a lot of success in an initial domain, such as childcare, it can be difficult to scale up the company and expand into other domains without a lot of upfront capital in addition to the money the company’s already made.

The second main factor of success is that companies have to have a good plan. They need to offer something that is actually valuable to their target group – something that the patients or the doctors need. The plan has to incorporate continuity as well, meaning that the company has to work to keep engaging its users and clients beyond the point of initial interest.

I wondered if Shoibal had any ideas of what new startups should focus on, or if there was some big need that they should address. He said that there was a lot of potential in the patient-doctor relationship – not that there was anything wrong with the relationship, but that both patients and doctors could use more support in terms of adherence, setting up meetings, keeping track of medical records, and so on. The healthcare space is quite “fragmented and disorganized in India,” said Shoibal. “Organizing it through technology really has potential.” With such a large population, it’s difficult to find doctors and the right kind of help, and it’s a big hassle to go to an overcrowded hospital just for a small health issue (I can imagine that this leads to many people avoiding care until their issue gets to be more painful or urgent, which is obviously bad for health). Shoibal also mentioned that there’s potential in rural areas, providing care by translating existing services, apps, and websites into the local languages there.

There’s clearly a large range of health issues in India (due to the large population and high socioeconomic inequality, I would say). Shoibal suggested that Indians might be a little more careless than the rest of the world when it comes to health, but even if they do want to be very careful about health, Indians are exposed to a particularly unhealthy environment. There is high pollution, the presence of environmental and biological pathogens, high levels of stress on the roads (Indian traffic!), and compounding all that, the healthcare delivery system is not well-equipped enough even to deal with normal levels of health issues. There’s a gap between what the people need and the healthcare that is available. Part of it is simply a numbers issue – that there aren’t enough doctors and healthcare professionals in India to accommodate the number of patients. I looked it up, and apparently there are 0.6 physicians per 1000 people in India, as opposed to 3.3 per 1000 people in Sweden, for example (according to Nation Master’s statistics, which has fairly old data). On top of that, the doctors are clustered in urban areas, so people in rural areas have to move whenever they have something more serious than a cold. Shoibal agreed that technology could do a great deal in terms of solving this problem, but only once the infrastructure improves. Right now, there simply isn’t a way to stream images, videos, and medical information out to the rural areas. Also, venture capitalists aren’t so eager to invest in startups that are trying to fix these particular issues. The affordability of the target population in these areas, at least to begin with, is very low (as opposed to the aforementioned 1%), and Shoibal said that many venture capitalists have too-high expectations, preferring to invest in companies with higher, faster returns.

I think, then, if startups are too small and risky, the money and drive to solve these issues will either come from big philanthropic organizations or from the government. Shoibal said that it would be great if the government invested in telemedicine in a big way, but that they’re not focusing on it at the moment (I’ll need to investigate this). They might be focused on technology, or on health, but not yet on both at once. One of the issues they are focused on is the concentration of doctors in urban areas but not in rural.

Shoibal was telling me that most doctors want to live in urban areas because that’s where they can create the life they want. Even though the need for doctors is in rural areas, they will make less money there, have worse infrastructure, have fewer things to do, have fewer options for schools for their children, and fewer options for jobs for their spouse. So even though the government has set up rural health centers, the doctors there are probably low-quality. Even then, Shoibal said that most qualified doctors will only visit the rural health centers a couple days a month, otherwise working at a private practice in an urban area. They do this to maintain a certain lifestyle and make enough money. There’s not much that the government can do in response, as it is better to have a doctor visit a rural health center for 1 day a month rather than not at all. The government could ramp up the incentives offered to these doctors, but that would require tons of money plus bettering the rural areas in multiple ways. Or, the government could try to force doctors to spend all their time in the rural health centers by making it illegal to have a private practice on the side; but then, given the choice, the doctors would all move to the private sector and not work in the public sector at all. Of course, there are some doctors that don’t care about money and really want to work where the need is. But still, the truth is that there aren’t enough doctors in rural areas, and it’s hard for the government to encourage them to move. If the government invested heavily in telemedicine, I think it could help enormously; but the first step would be building the appropriate infrastructure.

Health post: Cornell in Qatar

A few days ago, I met with a professor at Weill Cornell Medicine school here in Doha. There’s an area of Doha called “Education City,” which is a collection of American university campuses here – Cornell, Texas A&M, Carnegie Mellon, and more. Created by the government non-profit organization Qatar Foundation, Education City is part of Doha’s commitment to being “the best” and a step towards being a knowledge economy. The Weill Cornell school is Cornell’s third campus (with the second being the Weill Cornell Medicine school in New York City), and it is the first overseas campus of an American medical school. The Cornell professor, who is also a doctor, was brought in two years ago to establish clinical research in diabetes and its associated complications. Diabetes is one of Qatar’s most pressing medical issues.

As the doctor told me, “in a place like Qatar, there is a huge investment in wanting to be the best, and the hierarchy truly believes that.” That is, Qatar’s wealth – it is currently the richest country in the world – is quite recent, and the government is spending lots of money to have the best education, the best hospitals, skyscrapers, and so on. By the hierarchy, he meant the Qatari ruling family. They fund the Qatar Foundation, which has many projects in addition to the impressive Education City. The professor told me that the Qataris seem to be genuine in their vision to develop something long term rather than short term, aware that their wealth cannot always come from oil and that solutions have to come from within (thus Education City; it’s important to educate the younger locals so that innovation comes from within rather than from imports).

Walking up to the Weill Cornell Medicine-Qatar campus. It’s easy to feel dwarfed by such a large, monochrome box. I liked the desert-space-age feel of the architecture, though.

We spoke about how obesity and diabetes are the “mega health challenges” in Qatar. I asked what the main contributing factor is, and the doctor said “rapid modernization.” Qatar has developed from a population of a few hundred thousand 30 years ago to a population of 2.3 million people today, most of them expatriates. While some expats bring their diseases with them, the main reason diabetes is such an issue now is because of how much the local lifestyle has changed in those 30 years. The doctor told me that the previous generations – those that predate Qatar’s booming wealth – would often live off one meal a day and do physical work for a living. Now, there is a McDonald’s on every corner and no need to do physical work. The lifestyle changed far faster than genes change, and the locals’ genes are still adapted to the worker lifestyle. Thus the professor gave an evolutionary argument: years of genetic programming made the Qataris “fuel efficient” (that is, with a slow metabolism), and so now they are flooding their systems with an excess of fuel.

This argument came with a warning. Genetic profiles evolve very slowly, and one way genes get changed or renewed is when entire populations (gene pools) are killed off by disease. The doctor is worried that because of diabetes, heart disease, stroke, and other complications, newer Qatari generations will die before they are able to pass on their genes. “It’s Darwin’s finches,” he said.

In addition to factors of modernization and evolution, there are cultural and social reasons contributing to the diabetes epidemic. The professor said that food is how people socialize here: they leave their air-conditioned homes, get into air-conditioned cars, and meet their friends at air-conditioned restaurants. The lack of movement and focus on food leads to eating far more than necessary. Another aspect is a certain passivity to illness amongst the Qatari locals who get healthcare for free. The doctor said that, all over the world, very few people become motivated to make major changes to their diet and exercise until something serious happens, such as a heart attack. In Qatar, there’s an added element that the locals can get bariatric surgery for free. So they have this attitude that if something happens, they’ll just get the surgery and be fine. The doctor described a 35-year-old patient of his who is overweight. She isn’t obese, but she had gestational diabetes during her pregnancy and is now diagnosed with diabetes. She came into his office the other day, and “the only thing on her agenda was not to improve her blood sugar levels. It was ‘Doctor, I want to have bariatric surgery.’” He was a bit taken aback – while bariatric surgery works, it’s not something you should want to do within 5 months of a diabetes diagnosis. But since it’s so easy to get free bariatric surgery, there is less motivation to prevent yourself from needing that surgery.

It’s so interesting how the same structures can have completely different outcomes in separate environments. Healthcare is also free in Sweden, essentially, but people there don’t use the system to have extreme surgeries. This is why I’m doing this project – it’s so important to know how all these country-specific factors (social, historical, political, cultural, etc.) interact to understand why certain outcomes occur.

Close-up of the school’s entrance.

Overall, diabetes and obesity result from the lifestyle choices associated with rapid modernization. “They’re over-nourished, under-exercised, and that’s it,” said the doctor, saying that people even complain about walking from the parking lot. (Speaking of: I saw an IKEA truck the other day and found out that there is an IKEA just north of the city. I looked it up online, excited to see some of Sweden here in Qatar, and found a negative review of the place. With a summary of “Too much walking,” the reviewer explained how IKEA has arrows on the floor to show the path through the store and warned visitors to “be prepared for a workout.” Sure, IKEA is big, but I would never see such a review in Sweden!). The professor pointed out that there are obese people in the U.S. and the U.K. too, though, for similar reasons – with money and constant access to food, it can be hard to avoid that burger or those chips, and people find all sorts of reasons not to go to the gym. Even though they have open access to technology, and communication and education through the internet, it can be hard to make the healthiest lifestyle choices.

One reason I wanted to go to Cornell specifically is its relationship to Hamad Medical Corporation (HMC), the main hospital system in Qatar. The professor said that the Qatar Foundation is trying to replicate the setup in New York City, where the Cornell medical school shares knowledge, patients, and resources with the NewYork-Presbyterian hospital nearby. The professor said that all good clinical health centers require academics and research in order to accelerate drug discovery, diagnostics, testing of novel treatments, and more. However, he finds that the research drive is missing in Qatar. While Hamad is a very good hospital providing a good service, it’s behind in terms of state-of-the-art clinical research. The doctor stressed that this was a fact and not a criticism – “they don’t like it when we say it” – but as a clinical academic, he gets frustrated that he doesn’t have a method of doing cutting-edge clinical research and developing and testing new technologies and treatments for patients. It’s not a lack of money, and rather a lack of seeing the bigger picture; but by bringing in clinical researchers like the doctor I met, HMC seems to be moving in the right direction.

The Texas A&M Qatar campus (TAMUQ), just next to Cornell. I couldn’t get over these immense stony buildings. It felt like I was on another planet.

I find it fascinating that the government is investing so much money in being “the best,” and yet this doctor runs into people at HMC who don’t like to hear about the areas that need improvement. I think a full commitment to being the best in something requires being open to external constructive criticism. It’ll be interesting to see if this comes up in areas other than health.

Health post: AstraZeneca

Just over a week ago, I went to the medical company AstraZeneca. I met someone at their Mölndal research facility, south of the Gothenburg city center. I’ve been trying to meet with AstraZeneca since arriving in Sweden, and it took me 2 months, but I finally found a way. The company is too big to contact by cold-calling or cold-emailing; my messages via their “Contact Us” page received no response. I ended up talking to a Swattie who has a family friend that works at AstraZeneca Mölndal, and with this friend’s direct email address I was able set up a meeting.

AstraZeneca is probably the biggest medical company in Sweden. When I first arrived here, I kept hearing about it when discussing my project. Later, as I mentioned to people that I wanted to visit AZ, everyone seemed to have heard of it. AZ self-describes as a “research-based biopharmaceutical company,” developing drugs to treat people with asthma, heart failure, diabetes, cancer, and more. Beginning in Sweden over a hundred years ago, the company is now party British-owned, with its headquarters in the UK. The Mölndal campus is the center of its Research & Development in Sweden with 2500 employees.

The AstraZeneca R&D facility in Mölndal, Sweden.

 

The man I met there – I’ll call him J, for privacy reasons – explained the AstraZeneca product pipeline to me. The timeline for a product is 10-12 years from conception to sales. This is divided into two main phases: discovery (5-6 years) and development (5-6 years). J works at the beginning of the discovery phase, when scientists work in labs to improve upon or develop new treatments for various diseases. Once a compound is discovered as a treatment for a disease, it must be tested in the development phase. The development phase starts with animal testing and then proceeds to 4 stages: a clinical trial with healthy people, just to make sure that the drug has no negative side-effects; a clinical trial with a small group of real patients; a clinical trial with a large group of patients from different countries; and finally the post-release stage, when AstraZeneca follows up with its products that are on the market. Though I was curious about this stage, it is about 10 years down the pipeline from J’s work. He told me that in the beginning of the discovery phase, the biologists like him aren’t thinking about end products or users; they work on a molecular level. His group is focused on CVMD, cardio-vascular and metabolic diseases, which include heart failure, diabetes, and kidney failure.

J described this as a streamlined and compartmentalized pipeline with the flexibility for researchers to return to various steps along the way and iterate solutions until they were completed, which is of course necessary if something goes wrong. Unsure of how to learn about cultural attitudes towards medtech from a biochemist working in early drug discovery, I asked J what he pictures as the future of his work. He said that the future of medicine will be more personalized health care; he has seen in some AstraZeneca clinical trials that the same drug can work wonders for one group of genetically similar people but do little for another group with the same illness. He thinks that future medicines will be developed accordingly, with a certain genetic profile in mind.

AstraZeneca’s main entrance. J gave me a quick tour of one of the floors inside, and it was beautiful. It felt like a very fancy and well-designed university campus on the inside.

The funny thing about this whole meeting is that I realized, after months of wanting to meet someone at AstraZeneca, that I actually wasn’t interested in their products. I’m interested in cultural factors that lead to the success of medical devices and, in Sweden, how the Nordic ergonomic design tradition might lead to user-focused medical technology that directly improves the user experience and patient outcome. But AstraZeneca is a life sciences company, focused on the biology of creating new drugs and medicines, and not on how the patients get those treatments or if there is patient-doctor compliance. I started to realize that a couple days before meeting with J, when I went onto the AZ website to look at various products I could ask him about. When I saw that they were all pharmaceutical drugs, I knew that I would only be able to ask him about biology, not tech design.

To put it another way, I was partially inspired to do this Watson because I had been working on a “smart” pillbox design in my last engineering internship. I’m more interested in how people take their pills – and how we can encourage people to be better about taking their pills, and thus healthier – than how those pills are actually made. However, it would be amazing if pills could be combined. I saw in my internship that people taking 5 or more pills a day have to deal with pills that can only be taken at night along with ones that can only be taken in the morning, pills that need food and others that don’t, and so on. So if all 5+ pills could be wrapped up into one, that would make everything much easier. I asked J about this, and he said that AstraZeneca is definitely working on combining drugs for such patients, but that it takes a long time. A combination of 2 drugs is a new drug and thus requires a full 10-12 years in the pipeline of discovery and development. Adding a third drug to the mix adds another 10-12 years, and so on.

It might seem like a waste, but it was actually relieving to realize, after trying for months to meet with one of the biggest medical companies in Sweden, that I didn’t need them for my project. Even though AstraZeneca’s medical products do not fit the type of medical technology I’m interested in for my project, I’m still glad I met with them.

Just for fun, this is the AstraZeneca employee parking lot. Even this part of the campus looks cool!