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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Health post: Solar-powered hearing aids

I went to the offices of the “Botswana Innovation Hub” to meet with Deaftronics, the only local medical device start-up I’ve found in Botswana. Deaftronics makes the “Solar Ear” unit, a solar-powered charger for hearing aids. The small, handheld device has a solar panel and a port for a digital hearing aid as well as ports for rechargeable hearing aid batteries. In 3 hours of sun exposure, the unit can fully charge the batteries, which can be used for up to a week without needing to be charged again.

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The Solar Ear unit with space for a standard hearing aid and two rechargeable hearing aid batteries.

Deaftronics’s mission is to provide hearing aids to all hearing-impaired people who need them, including people living in remote areas without consistent access to electricity. They emphasize empowerment of the deaf community not just by providing solar-powered hearing aids, but also by training and employing deaf people in their manufacturing and design processes.

Tendekayi Katsiga, the technical director of Deaftronics, is a firm proponent of co-design (participatory, user-based design) and believes that the best solutions come from the users. He told me that the idea of solar-powered hearing aids came from a school for the deaf in Botswana and that his role as the electronics engineer was to transform that idea into a product. For any sustainable project, he said, the process of “iteration and ideation” is key – improving upon the design of a product multiple times until it is exactly what the end users need and want.

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Tendekayi Katsiga with the device (the hearing aid is inserted for charging here).

In addition to the benefits of co-design, combating stigma is a great reason to employ deaf people, said Tendekayi. There is a stigma that hearing-impaired people cannot work or be productive, and Tendekayi believes that it’s important to highlight that the opposite is true – hearing-impaired people might even be more productive than the average hearing employee, he said, because they can focus on the work with fewer distractions. (It’s certainly a controversial idea, but an interesting change from the usual underestimation of the abilities of hearing-impaired people. I couldn’t find a ton of backing for this, but this book and some other articles support the idea).

Tendekayi mentioned that a challenge of selling the Solar Ear in Botswana is that the government can afford hearing aids and batteries for the few hearing-impaired members of its small population. Very few people would opt to purchase a private product when they can get something from the government for free – and since the government is such a large force in Botswana, it is hard to be a private business there. This moment reminded me of the health worker’s complaint in Sekhutlane that the government spoon-feeds its citizens too much. He believed that if Botswana’s government didn’t provide so many services for free, more people would be motivated to work as well as spend money, thus stimulating the economy.

Thus while some people are using the Solar Ear unit in Botswana, Deaftronics is focusing on potential users in places where it can have more impact: Zimbabwe, Zambia, Mozambique, and other areas in sub-Saharan Africa where hearing-impaired people cannot get aids from their governments or purchase more expensive options. Deaftronics has been endorsed by UNICEF, which could pave a pathway for providing Solar Ear units for free in such areas. In future designs, Deaftronics hopes to add a USB port to its Solar Ear unit so that users can also charge their cellphones via the device.

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Entrance to the Botswana Innovation Hub.

When I asked him why Deaftronics seems to be the only medical device start-up in Botswana, Tendekayi told me about another complicating local factor: the people of Botswana don’t believe in Botswana-made products. I’ve heard this a few times now, and it’s taught me the importance of local inspiration. Almost everything used in Botswana is imported from South Africa or further abroad. Botswana’s population is small; no great innovations, products, or companies have originated in the country. Of course, that doesn’t mean that great things cannot come from Botswana, but it isn’t exactly inspiring for Botswana’s citizens.

In America, we grow up with incredible success stories of companies like Ford Motors and Facebook as well as examples of revered entrepreneurs and so-called visionaries. These stories inspire generation after generation to keep building, to keep dreaming, and to keep trying, even after many failures. Part of this is due to the large population of the US; if there is a large enough number of start-ups, even if each has a very low chance of success, some of them will make it big. Representation matters: it’s hard to be inspired to make something in your country if there are no success stories to look up to.

I’ve heard this from a few Batswana now, and Tendekayi phrased it well – there’s a perception that when a product is home-grown or designed locally, it’s not the “real thing.” Now that Deaftronics has won a few awards, Tendekayi is confident that the perception will change. Especially with the establishment of the Botswana Innovation Hub, Tendekayi hopes that more Batswana will be inspired to innovate locally.

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A rendering of the soon-to-be “Botswana Innovation Hub” – the space is moving to a completely new location to serve as a true hub for budding companies in Gaborone. (From this article).

To the village

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

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

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

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

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

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

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

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

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A home in Sekhutlane.

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

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A man on his way out of Sekhutlane.

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

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

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

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Sekhutlane.

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

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

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

Health post: App for Assistive Technologies

Last week, I visited the Botswana chapter of the South African Federation for the Disabled, SAFOD. SAFOD is an organization that supports disabled people in 10 countries in southern Africa, and the Botswana chapter is called BOFOD. They are currently working on the “AT-Info-Map,” a three-year project to develop a smartphone app with information about all the assistive technologies (AT) available in the country. It will be released to Batswana users in a year or two and ultimately made available in the other member countries as well (Angola, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe).

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Mr. Kayange (left) holds a smartphone with the latest version of the AT-Info-Map app. To the right is Mr. Chiwaula, Director General of SAFOD.

I met with Mr. Chiwaula and Mr. Kayange at the BOFOD office in Gaborone to learn more about AT-Info-Map. The app, aimed towards disabled people and their caretakers or other stakeholders, will inform users of the location, availability, and cost of the assistive technologies they seek. Assistive tech, AT, includes hearing aids and wheelchairs, as well as tools not often thought of as technologies such as crutches, prosthetics, and glasses.

Mr. Kayange told me that all assistive technology in Botswana is imported from South Africa, Europe, and other areas – there are no local manufacturers. Thus the AT suppliers in Botswana sometimes have minimum order numbers that make it unfeasible for one person to get just one or two crutches, for example. Even though the government would supply those low quantities for free, said Mr. Kayange, the demand is still higher than the government’s supply, and some people still need to purchase their own assistive devices. He said that, as it is, the only people who know where to find reliable assistive technologies are wealthy people with expat connections – people who can order specific devices from abroad if need be. At least with the app, anyone with a smartphone could access the same information.

(Of course, I asked them what happens if people in their target user group don’t have smartphones. They agreed that this is a potential problem – it’s unrealistic to assume that everyone has a smartphone, which SAFOD discussed. They decided that it wasn’t enough of a reason not to make the app; those that do have smartphones will still benefit).

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A close-up of the app’s home page. Clicking “Start” opens another simple page that allows the user to search for assistive technologies in their region or by category.

A lot of our conversation centered around the issues of access and awareness – words that came up many times during my time in India. Especially in Botswana, where the population is so sparse, people may live very far away from a hospital or clinic (an access problem) and may have no idea what AT might be relevant to their needs, let alone where to get it (an awareness problem). Mr. Kayange and Mr. Chiwaula told me that the government’s idea of AT is essentially just wheelchairs and crutches. If nothing else, AT-Info-Map could inform people of other types of AT, ultimately increasing demand for better services. The AT-Info-Map app will store usage data such as the most-commonly-searched-for assistive technology, and if that data demonstrates an unaddressed need (for prosthetics, for example), SAFOD could take that data to the ministries and advocate for more government-funded prosthetics.

Without engaging the government, said Mr. Kayange and Mr. Chiwaula, they can’t be successful. In Botswana, probably because the country is so small and centralized, the government is involved in all health endeavors – so it’s crucial to partner with them if a project is going to be sustainable. However, like in most countries, this involves dealing with a lot of slow bureaucracy and government officials who are very cautious about new ideas.

There’s not as much “activity on the ground” as BOFOD would hope, and the status quo for disabled people largely stays the same year after year. Mr. Chiwaula pointed out that, as Botswana is a relatively stable and well-off Southern African country, it’s not a popular recipient of donations. Since international organizations tend to focus their resources on the neediest places, Botswana’s economic advantage has become a disadvantage – because, as Mr. Chiwaula was saying, such donations would still be welcome. This made a lot of sense to me, though it was sad to hear.

SAFOD was able to build the AT-Info-Map by collaborating with Washington University in the US for technology support, the international organization Dimagi for the mobile app design, and AfriNEAD, a network for disability research. Throughout the design process, SAFOD has also consulted with professionals, government officials in the Ministries of Health and Education and the President’s Office, and potential users. They went back and forth with potential users, performing user-centered design by returning to the field with multiple prototypes. Now, they are satisfied with the version they have and will begin deploying the app for use. Mr. Kayange and Mr. Chiwaula told me that their current concerns at the moment are how to get people to use the app once it’s available, as well as how to incentivize AT suppliers and service providers to register their information on the app. I was glad to hear that their final design is the result of several rounds of user feedback – hopefully that’s enough to guarantee a positive response on a more national scale. It will be interesting to see if the availability of AT in Botswana changes at all in the next few years once this app is in use.

 

Health post: Botswana Overview

Things have been going on faster than I can write about them – my handwritten notes are starting to pile up! – so I wanted to do a quick catch-up. I really feel like time is flying by now, mostly because of end-of-Watson pressure, but also because there’s more going on in Botswana than I thought.

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At the University of Botswana, which has a beautiful campus.

I’ve already had a few project meetings, and there are some very cool mHealth (mobile health) endeavors here. Many of these projects come from the University of Botswana, which has a campus in Gaborone and a partnership with UPenn back in the US. From the Botswana-UPenn Partnership (BUP), I learned about TB-PEPFAR, their project to improve TB screening and testing in Botswana. One aim of the project is to provide community health workers (CHWs) with phones to collect data on TB patients. The phones use a mobile application called RedCap, which provides secure data capture for researchers and also allows CHWs to fill out digital forms rather than paper ones.

PEPFAR, or the US President’s Emergency Plan for Aids Relief, focuses on the diagnosis and treatment of TB because the infectious disease is so common in HIV patients – it was the cause of one-third of AIDS-related deaths in 2015 (source). This is particularly relevant here in Botswana, where the biggest public health crisis is HIV/AIDS (it is the leading cause of death, accounting for 32% of all deaths according to the CDC).

A week ago I traveled with a doctor of the TB-PEPFAR team to Lobatse, a small town an hour south of Gaborone. He was there to oversee a small conference for nurses and doctors from clinics in Lobatse and surrounding areas. As it turned out, the attending health workers were not users of the RedCap app – the conference was really a training session to update the health workers on the best methods for TB screening. Even though the training day wasn’t about entering data with RedCap, I was still curious to see if technology would come up in another way.

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At the beginning of the training day, all the participants had to take a “pre-test.” Their scores get compared to the results of the “post-test” they take at the end of the training.

Also, I learned a lot about TB. I became interested in medtech via the technology, not the medicine, so I still have a lot to learn about basic medical topics. During my stay in Lobatse, I learned about the importance of ‘sputum’ for TB diagnosis (I had never heard that word before, but sputum is the name for the mucus-y fluid that you might cough up when you’re sick, and testing this sputum is essential to TB testing). I learned that alcohol, overcrowding, and HIV/AIDS all contribute to TB. I also learned that while sputum induction (SI) is one way to diagnose TB patients, there is another method, gastric aspiration (GA).

The day’s training included “how to”s for both methods, SI and GA. GA was the more complicated and time-consuming method presented, requiring more equipment than SI – including a nebulizer. The presenter of this section had a nebulizer on the table and began demonstrating how to use it. One of the conference organizers, sitting in the back, called out: “Is this the nebulizer you all have in your facilities?” Everyone shook their heads or said “no.” The presenter went on with the nebulizer demonstration, though it seemed obvious to me that everyone would prefer the SI method. He later told me that since there were so many stakeholders in this TB-PEPFAR project (including both the US and Botswana governments), it was difficult for them to change or skip slides from a pre-approved presentation.

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The nebulizer demonstration.

One of the topics of conversation throughout the day was, of course, how to diagnose patients who have both HIV/AIDS and TB. The same organizer who asked about the nebulizer above told me that TB in HIV/AIDS patients manifests quite differently than TB alone. She said that it frustrates her when medical students from American universities come into Botswana and try to diagnose TB just based on the theory they’ve learned (without recognizing that in some cases, she said, HIV/AIDS patients with TB will test negative for TB). She said that it’s a feeling you have to develop about HIV/AIDS patients – whether they have TB or not – and treat for it even if there’s no conclusive evidence. I thought that was a fair frustration and a good example of why it’s important to know the medical particularities of a place before you treat, diagnose, or develop medical devices for various conditions.

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Part of “How to Diagnose TB in Children.”

Finally, there was a moment where the nurses and doctors discussed what might contribute to Botswana’s high TB rates – the possible social, cultural, biological, and policy factors – and I wonder if these factors also affect medical device acceptance here. The interesting answers included: high HIV prevalence (of course); migration; non-adherence to policy; not enough people in healthcare management due to the small population; and the use of traditional medications and going to church instead of seeking immediate treatment at a hospital (I have noticed that religion is quite important here – more on that later).

At the beginning of this year, I would start with examples of individual devices and only focus on cultural factors once I could generalize trends across those conversations. Now I find myself approaching both at once, looking for those cultural trends right away so that I can keep them in mind as I encounter various medical technologies. I suppose it’s a good thing because it means that I’ve gotten faster at identifying the important factors for medical technology adoption – the “big picture” stuff – without needing so many small steps to get there. That said, I’m still looking forward to learning more about specific medical device and eHealth projects here!

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My street in Gaborone.

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.

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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.

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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

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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.

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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).

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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.

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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).

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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).

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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).

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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.

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The Zōjō-ji temple near Tokyo Tower.

Health post: Japanese care robots

Last week, I visited Panasonic’s headquarters in Osaka. Back in the US, I knew Panasonic mostly as a television company. But here in the company’s home country, they make all sorts of products including audio-visual equipment, home appliances, IT solutions, smart home and home security technology, and robots – specifically care robots. I was there to meet an engineer, Mr. Ando, who has worked on Panasonic’s hospital delivery robot HOSPI, among others.

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Mr. Ando with the HOSPI robot.

Panasonic is working on care robots that work in pharmacies, hospitals, and personal homes. One splits in half to transform from a bed into a wheelchair (not your typical “robot,” but still an autonomous machine). This eliminates the possibility of injury to the patient during transference as well as injury to the nurse moving them from their bed to a wheelchair.

Panasonic has also built care robots that focus on improving the patient’s happiness. Ando showed me a video of a hair-washing robot: a station where immobile patients can have their hair sink-washed by robot “hands” that massage the scalp and do the washing and rinsing. It looked very relaxing. Ando said that this was in response to patients who were unhappy that they only had showers about twice a week. The nurses were simply too busy to spend more time manually washing patients’ hair, even if more frequent washing does contribute to the patients’ happiness. If a hospital installs a few hair-washing robots, however, patients can get their hair washed more frequently while the nurses focus on more pressing tasks. While this robot may not have a direct impact on their health, I think the impact on their feelings of dignity, independence, and happiness is important.

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One of Panasonic’s numerous buildings in Osaka – when I got here I thought I had arrived at the location for the interview, but I was still 10 minutes away from the right building. Ando told me this area is called “Panasonic Village” since the company’s headquarters comprise so many buildings.

Ando described Panasonic’s robots as contributors to “assisted care” and “assisted independence.” I got the sense that he used these terms to give dignity to the patient and put the user’s needs first rather than focus on the robot’s capabilities. That is, there is a thin line between “assisted care” and “assistive technology,” but the former focuses on the patient while the latter focuses on the technology.

In our talk, Ando and I mostly discussed HOSPI – a waist-high robot that talks, listens, and transports items such as blood samples or medications throughout a hospital. One special version of the robot, the HOSPI Rimo, also has a communication feature that can be used for telemedicine. I asked about how Panasonic came up with all these robots, and Ando told me that when Panasonic develops new products, the most important step in that process, at least for hospitals, is task analysis.

The Panasonic team observes the staff performing various tasks at a hospital to see where the inefficiencies are – gaps that can be hard to notice when you’re in the middle of the workflow, but which become more evident from an outsider’s viewpoint. Based on this task analysis, Ando told me, Panasonic decides what type of product to develop in response to the observed problems.

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HOSPI hangs out in Panasonic’s lobby. She gives tours to guests and shares information about the company’s history.

In most cases, apparently, some type of robot is the best solution. The nurses don’t have enough time to wash patients’ hair? Let’s build a hair washing robot. There are issues associated with transferring a patient from their bed to a wheelchair? Let’s make the process robotic. And, of course, HOSPI, to make transport more efficient. I asked Ando for more details about the design process that led to the HOSPI robot.

He told me that, after Panasonic observed inefficiencies in the hospital, they discussed which solution would be best for the user. (I was glad to hear that – I’ve realized that, since going to Sweden as my first project country, the idea of a user-centered design process being a key factor of success has become really ingrained in my mind). Ando said that Panasonic quickly developed a prototype robot to solve the hospital delivery problem and then showed the prototype to the potential end users, nurses and doctors. The Panasonic team and potential users had a collaborative meeting about once a month, and after each meeting, Panasonic adjusted the robot in response to the users’ feedback.

“So when is that adjusting process finished?” I asked. “When the user says they’ll buy it!” said Ando, laughing.

I asked him if, with this user-focused design process, there are ever negative reactions to new products. His response surprised me: “All people react negatively to new products,” he said. “Especially in Japan.” Ando explained that certain particularities about Japanese ideas towards healthcare complicate the introduction of healthcare technology here.

He told me that the idea of healthcare in Japan is “humans supporting humans;” so robots as helpers for the nurses, then, are not part of the “philosophy” of healthcare. I asked him what he meant by the “philosophy.” Ando gave me the example of the kanji for “nursing care.” (Kanji is the Japanese character-based writing system – one of the language’s three alphabets). Ando reached for a nearby sheet of paper and quickly sketched it out. These characters often incorporate and combine pieces from more basic kanji that represent simpler ideas; so the characters can build on each other, becoming more complicated while representing more and more complex ideas. Ando pointed towards the kanji for “nursing care” and told me that it incorporated the kanji for “human hand” and “human eyes.” Thus the way that “nursing care” is written in Japanese necessarily focuses on the idea of human involvement – excluding the work of any automatic product from being part of the idea of nursing care. I absolutely loved this moment of learning how Japan’s ancient writing system influences reactions to medical devices today. That’s what this project is all about.

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It might be really cheesy that I kept this piece of paper and photographed it, but here you go.

But for the most part, it seems that nurses are grateful for the help that HOSPI offers. Ando stressed that HOSPI has separate tasks from the humans, which is a key factor of its success – it does the grunt, time-consuming work of sorting and delivering medications, allowing the nurses to focus on doing actual nursing work that only humans can do.

“What about the patients?” I asked. “Are they comfortable with the idea of robot care?” Ando said that, based on a survey done by Japan’s National Institute, 85% of people don’t hesitate at all with care robots. Ando said this is mostly due to positive representations of robots in Japanese media such as anime, but that when it comes to care robots, people want robots that are less human-like. He said that people have the impression that anthropomorphic or humanoid robotics are meant to be friends, and when they are in hospitals, they don’t want their friends taking care of them – they want the support and precision of tools. They respond better to simple-looking, machine-esque robots. HOSPI could have been designed to look like a human, but instead she looks like a clean, classic robot – well-suited to the hospital environment. I wonder, too, if patients would have a negative reaction to human-looking robot because of the uncanny valley phenomenon (which, by the way, was first tested by a Japanese roboticist in the 1970s).

Finally, I asked Ando what makes Japan so healthy and what that has to do with technology, if anything. He made a distinction here: the older, super-ageing generation is healthy, while the younger generations are less so. He said that the elderly are healthy simply due to their lifestyle of eating well and exercising enough. But in his opinion, the younger generations eat less healthy food and spend less time exercising – mainly because of the negative effects of technology, especially television and the internet and smartphones.

“So do you think technology helps people be healthy or not?” I asked – after all, Ando does work in the field of healthcare technology. He said that while the prevalence and popularity of technology has a negative effect on peoples’ health and fitness in Japan, it can have a positive effect on peoples’ illnesses. Once people are already sick and in the hospital, said Ando, technology can begin to have a positive effect, such as the effect of robots like HOSPI.

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I really had a blast talking to Ando and meeting HOSPI in person.