This blog chronicles my travels as a 2016-2017 Thomas J. Watson Fellow exploring cultural attitudes towards health technology around the world. Starting from and returning to New York City, USA, I am traveling to Sweden, Qatar, India, Singapore, Japan, and Botswana over the course of one year.
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).
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).
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.
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.
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.
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.
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.
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!
In Japan, any time you walk into or even near the door of a shop, you’re guaranteed to hear “Irasshaimase!” It essentially means “welcome to the store and come on in.” I’ve heard it in so many iterations by now: the full, exuberant call to any visitors; the periodic, slightly robotic “irasshaimase” called out by shop workers to no one in particular; and the occasional, tired, not-quite-there “…shaimase.” Sometimes, the call of “Irasshaimase!” is so happy and charming that you can’t help but smile in return. Other times, I walk past a store and ignore the dully repetitive “irasshaimase” calls along with other Japanese passers-by.
For the most part, this welcome call is polite and lovely, and I see it as indicative of many trends I’ve noticed here: the feeling of a common collective, a strong work culture, perfectionism, and a charming consideration of the feelings of others. The way that every single shop and restaurant worker says it – whether they sound happy about it or not – means that every shopping experience starts with a welcome, and I feel like that fits in well with the strong collective culture I’ve felt here. Generally, once you figure out how these interactions go in Japan, they will always go the same way.
There’s also a surprising amount of talking that, in the shop example, might start with “irasshaimase” and continue at the register with far more Japanese than you’d expect when buying a pack of gum, as the shop employee hurries through a certain set of phrases (I wish I knew what they all meant). There’s an idea that someone is much more likely to carry out a task correctly – that is, perfectly – if they verbally reinforce each required action. This recent article perfectly describes this phenomenon as it applies to Japanese train workers, who call out what they’re doing even when no one is listening as a way to reinforce the performance of the required task. Of course, this is an example of the perfectionism and work culture.
I’m soon leaving Japan, and I’ve had many meetings here for which I haven’t written individual posts. I wanted to share some highlights from those meetings and focus more on the themes I’ve noticed from them, such as the perfectionism and work culture as I’ve already mentioned. Based on what I’ve seen, and of course in terms of health and medical technology, I think the most significant cultural trends are respect of hierarchy, conformity, and risk avoidance.
From what I’ve gathered, hierarchy is quite important in Japan, and hierarchy often correlates with age. I met with a Tokyo-based company called Allm (for “All Medical”) that offers a platform of multiple smartphone apps to increase efficiency in healthcare. Their main product, an app called Join, serves as a secure messaging service between doctors. Through Join, doctors in different areas can share ideas and expertise – for example, a doctor might send an X-ray through the private app to a more senior remote doctor, who can then give immediate feedback and advice about what to do next with the patient. The woman I was interviewing at Allm, Ms. Kudo, told me about the difficulties they’ve encountered when encouraging doctors to use the app.
When I asked her what specifically impacts the usage of the Allm app, she said “In Japan, we really care about hierarchy.” The younger doctors always follow the elder doctors, she explained. If the more senior doctors say no to something – such as the usage of a new app – “that’s it,” she said. Allm company members often travel to expos to promote the app, and if older doctors say it’s too difficult, they have a very hard time selling it. Adoption and acceptance of new medical devices can hinge on an influential decision maker – I’ve learned that medical technology companies often try to find these “ambassadors,” perhaps an influential doctor who is excited about the new technology and can convince their hospital to purchase it. Ms. Kudo told me that, for Allm in Japan, those ambassadors always have to be the most senior doctors (the highest in the hierarchy, who also often happen to be the oldest as well).
This respect for the hierarchy also complicates the group-chat aspect of the app, where doctors can discuss cases and share knowledge and advice. Ms. Kudo told me that the younger doctors become shy in the group, not wanting to ask questions, because they don’t want to seem foolish or ignorant in the presence of more senior doctors – their bosses – who are also on the chat. They’re very worried about screwing up, said Ms. Kudo, even if the senior doctors would have the answers they seek. I was sad to hear this since, of course, I would much rather have a younger doctor ask a somewhat silly question than never learn a crucial tactic; I feel like asking questions is seen as a necessary part of the education process in the US.
Someone in Sweden once told me that, with technology being so pervasive, even grandparents were considered uncool or out of the loop if they didn’t have cellphones or use computers. In fact, the word they used was “hermit.” I expected the same in Japan – if Japan is known for being a technologically innovative country, with so much exciting technology everywhere (such as the robots in stores), why doesn’t that extend to, or influence, the older generations? (I asked Ms. Kudo this question, and she was decidedly stumped).
Now, I think it is because of this respect of hierarchies and the elderly in Japan – the younger people would not ask the elderly to keep up with all the new technology, as they are expected to in Sweden. There very well might be Japanese nurses and doctors that are eager and excited to use an app in their work, but if their older and higher-up bosses disagree, their voices might go unheard because the respect of the hierarchy is so strong. In Sweden, however, I noticed that there was little respect for hierarchy and more of an effort to treat everyone as a peer. One Swedish doctor who had been practicing for decades told me that, when a patient mentions something they read on the internet about their condition, he’s not going to tell them they’re wrong – he’ll sit down with them and have a conversation about it, and maybe learn something new himself. I don’t think that would happen here.
A subtler issue here is that, if you’re trying to sell medical technology to someone who has been doing their job well for the past 40 or 50 years, they might have a harder time seeing the use of an additional tool (or worse, be insulted by the implicit suggestion that a medical device would improve their work).
Since younger generations are typically more interested in using new technology than older generations, having the senior people be the decision makers with regard to medical technology probably means that adoption will be slower here than it could be. I thought the mere ubiquity of technology in Japan would lead to high acceptance of medical technology, but I was wrong. There might be cute robots in stores (which are very technologically advanced), but that doesn’t mean that all the less-advanced tech (like smartphone health apps) will be as popular. Using a cute robot at a store is a very different interaction from using a smartphone app every day, and maybe the culture here is more excited about the former rather than the latter. I was expecting some “trickle-down technology acceptance” – that because of the appreciation of robots here, people would want all areas of life to be technology enhanced. But that’s not how it works. Technology is not everywhere here, and there’s still a lot of value placed in tradition and ancient culture (for example, I see many young people visiting and praying at the many shrines and temples Japan).
Conformity and Work Culture
The collective sensibility is something I’ve noticed in many aspects of Japan, even walking the streets of Tokyo. For example, street fashion in New York City is all about standing out – doing something completely unique and bold and different. In Tokyo, I’ll see friends meet up with each other, and they’ll all be wearing iterations of the same outfit (really, it’s crazy how often I see this). Japan is not a particularly diverse place, and I get the sense here that fitting in – conforming to certain looks and roles – is highly valued.
It’s hard to know exactly how the sensibilities of a corporate culture and common collective impact reactions to medical devices; perhaps it’s simply that there are fewer individualist and innovative start-ups here adding many devices to the market. With a strong corporate culture, doing one’s job well in the same company for many years is rewarded. In the US, however, we reward individual success and the ability to quickly commercialize a new innovation.
In one meeting, I spoke with an American named Marty who has a start-up here in Tokyo called enTouch KK. He talked about how there might be fantastic research happening at universities, but that the results are not commercialized. The job of the professor is not to commercialize research ideas and move into business, but rather to write as many papers as possible and start working on the next research project. Marty said that since the professors are proud in what they do, they don’t feel the need (or want) to commercialize it. Their success is already measured by the research itself, and with that aspect of professorial work perfected, there’s no need to bring ideas beyond the university. (This is not to say that there aren’t professors trying to commercialize ideas and collaborate with businesses; I met a few professors in Osaka who are trying to do just that. They did, however, discuss the difficulty of being surrounded by professors who have no interest in business).
In the US, however, we’re trained to take any idea farther and think: how can I commercialize this? How can I monetize it? Marty taught me an old saying from Japan: “The nail that sticks out gets hammered down.” I was so stunned, I started laughing at how absurdly dramatic the saying is. It describes an attitude that I see as a stereotype about Japan that may have been true a few decades ago, so I was surprised to hear that sentiment echoed in Tokyo in 2017. Marty did not mean that it applies to all scenarios, of course, and he did say that it was an old saying – but it’s still a sad one.
I had heard about Japan’s corporate culture before I arrived, and I had this 1970s scene in my mind of men all wearing the same black suits, walking through Tokyo with the same black briefcases. It’s not quite that intense, but the idea of the “salaryman” persists well into 2017. If not directly related to medical technology, I do think the corporate culture has an impact on health – a few people have told me that if there is anything unhealthy about Japan, it’s the work culture, the long hours and commitment to doing your job perfectly (as opposed to trying to stand out and jump up the ranks). At the very least, I do think it’s connected to the lack of more health start-ups.
The small number of medical start-ups here is also due to a fear of risk. The very first person I met in Japan, a doctor, told me that the most important cultural aspect of Japan with regards to medicine is that people are risk-averse. This manifests both in people, who take extra care to be safe in their everyday lives, and in companies, who seem hesitant to build invasive technologies (as most medical devices are).
The day to day risk aversion is evident in the stereotypes of Japan such as the wearing of face masks (which people do, but not everyone). People also avoid direct sunlight, and everywhere I’ve been has felt extremely safe. I honestly think that part of why people live so long here is because they avoid risky or dangerous activities, staying safe throughout their lives. (There are unhealthy habits as well, though, such as the prevalence of cigarette smoking; and yet Japan is not ranked as a country with high lung cancer rates, whereas the US is: source).
I interviewed someone at a big Japanese medical technology company that produces non-invasive equipment for hospitals and patients living at home – nothing invasive or implantable. He said that those types of devices are seen as too risky and that, for example, no Japanese company makes pacemakers – medical companies here want to avoid any potential of failure. Everyone he knows in Japan who uses a pacemaker, he said, has one from Medtronic (from Ireland) or some other globally recognized brand.
Professor Yoshizawa, of the bioethics department at Osaka University, told me the same thing – that while there are many robots in Japan, most of them are for communication and business because companies are reluctant to put a robot in a healthcare space where the risk and consequences of failure are much higher. He said that most medical devices in Japan (especially those that are implanted or provide treatment) are generally imported from the EU and US, while Japanese companies make non-invasive monitoring systems for diagnoses and check-ups because they’re safer. Professor Yoshizawa said that if one Japanese-made device causes any harm, the company will be attacked by the government, media, and general public and their whole image destroyed, so there’s no room for error – better to just avoid the risk altogether, and therefore Japanese medical companies focus on prevention and fitness. (Personally I find this a bit frustrating, because being at the forefront of medical technology does involve some trial-and-error. But it makes sense that a stereotypically perfectionist culture would want to avoid such errors – and perhaps this idea of only using extremely well-tested invasive technologies from abroad does make people healthier).
Risk avoidance also leads to fewer start-ups, which are inherently risky endeavors. Marty, of enTouch KK, said that start-ups are just beginning to become more popular in Japan (of course, they have been very important in the US for many years now). Investors in Japan are “very, very cautious,” he said. As opposed to the US, the idea of start-ups and angel investment is not normalized in Japan – though it’s starting to be – and there are not as many start-up success stories to inspire young entrepreneurs or give confidence to potential investors. Marty said that Japan’s most recent corporate success story was Sony (founded in the 1940s). Many of the small, innovative medical devices I’ve seen this year have come from smaller companies and local start-ups, so maybe in a few years, when start-ups are more common in Japan, there will be more medical devices in development – but for all that to be true, there would have to be more comfort with risk-taking.
Well, that’s that. It’s been fascinating seeing the interplay of these attitudes, and Japanese culture in general, and how some of it affects the way people approach medical devices.
Last week, I visited Panasonic’s headquarters in Osaka. Back in the US, I knew Panasonic mostly as a television company. But here in the company’s home country, they make all sorts of products including audio-visual equipment, home appliances, IT solutions, smart home and home security technology, and robots – specifically care robots. I was there to meet an engineer, Mr. Ando, who has worked on Panasonic’s hospital delivery robot HOSPI, among others.
Panasonic is working on care robots that work in pharmacies, hospitals, and personal homes. One splits in half to transform from a bed into a wheelchair (not your typical “robot,” but still an autonomous machine). This eliminates the possibility of injury to the patient during transference as well as injury to the nurse moving them from their bed to a wheelchair.
Panasonic has also built care robots that focus on improving the patient’s happiness. Ando showed me a video of a hair-washing robot: a station where immobile patients can have their hair sink-washed by robot “hands” that massage the scalp and do the washing and rinsing. It looked very relaxing. Ando said that this was in response to patients who were unhappy that they only had showers about twice a week. The nurses were simply too busy to spend more time manually washing patients’ hair, even if more frequent washing does contribute to the patients’ happiness. If a hospital installs a few hair-washing robots, however, patients can get their hair washed more frequently while the nurses focus on more pressing tasks. While this robot may not have a direct impact on their health, I think the impact on their feelings of dignity, independence, and happiness is important.
Ando described Panasonic’s robots as contributors to “assisted care” and “assisted independence.” I got the sense that he used these terms to give dignity to the patient and put the user’s needs first rather than focus on the robot’s capabilities. That is, there is a thin line between “assisted care” and “assistive technology,” but the former focuses on the patient while the latter focuses on the technology.
In our talk, Ando and I mostly discussed HOSPI – a waist-high robot that talks, listens, and transports items such as blood samples or medications throughout a hospital. One special version of the robot, the HOSPI Rimo, also has a communication feature that can be used for telemedicine. I asked about how Panasonic came up with all these robots, and Ando told me that when Panasonic develops new products, the most important step in that process, at least for hospitals, is task analysis.
The Panasonic team observes the staff performing various tasks at a hospital to see where the inefficiencies are – gaps that can be hard to notice when you’re in the middle of the workflow, but which become more evident from an outsider’s viewpoint. Based on this task analysis, Ando told me, Panasonic decides what type of product to develop in response to the observed problems.
In most cases, apparently, some type of robot is the best solution. The nurses don’t have enough time to wash patients’ hair? Let’s build a hair washing robot. There are issues associated with transferring a patient from their bed to a wheelchair? Let’s make the process robotic. And, of course, HOSPI, to make transport more efficient. I asked Ando for more details about the design process that led to the HOSPI robot.
He told me that, after Panasonic observed inefficiencies in the hospital, they discussed which solution would be best for the user. (I was glad to hear that – I’ve realized that, since going to Sweden as my first project country, the idea of a user-centered design process being a key factor of success has become really ingrained in my mind). Ando said that Panasonic quickly developed a prototype robot to solve the hospital delivery problem and then showed the prototype to the potential end users, nurses and doctors. The Panasonic team and potential users had a collaborative meeting about once a month, and after each meeting, Panasonic adjusted the robot in response to the users’ feedback.
“So when is that adjusting process finished?” I asked. “When the user says they’ll buy it!” said Ando, laughing.
I asked him if, with this user-focused design process, there are ever negative reactions to new products. His response surprised me: “All people react negatively to new products,” he said. “Especially in Japan.” Ando explained that certain particularities about Japanese ideas towards healthcare complicate the introduction of healthcare technology here.
He told me that the idea of healthcare in Japan is “humans supporting humans;” so robots as helpers for the nurses, then, are not part of the “philosophy” of healthcare. I asked him what he meant by the “philosophy.” Ando gave me the example of the kanji for “nursing care.” (Kanji is the Japanese character-based writing system – one of the language’s three alphabets). Ando reached for a nearby sheet of paper and quickly sketched it out. These characters often incorporate and combine pieces from more basic kanji that represent simpler ideas; so the characters can build on each other, becoming more complicated while representing more and more complex ideas. Ando pointed towards the kanji for “nursing care” and told me that it incorporated the kanji for “human hand” and “human eyes.” Thus the way that “nursing care” is written in Japanese necessarily focuses on the idea of human involvement – excluding the work of any automatic product from being part of the idea of nursing care. I absolutely loved this moment of learning how Japan’s ancient writing system influences reactions to medical devices today. That’s what this project is all about.
But for the most part, it seems that nurses are grateful for the help that HOSPI offers. Ando stressed that HOSPI has separate tasks from the humans, which is a key factor of its success – it does the grunt, time-consuming work of sorting and delivering medications, allowing the nurses to focus on doing actual nursing work that only humans can do.
“What about the patients?” I asked. “Are they comfortable with the idea of robot care?” Ando said that, based on a survey done by Japan’s National Institute, 85% of people don’t hesitate at all with care robots. Ando said this is mostly due to positive representations of robots in Japanese media such as anime, but that when it comes to care robots, people want robots that are less human-like. He said that people have the impression that anthropomorphic or humanoid robotics are meant to be friends, and when they are in hospitals, they don’t want their friends taking care of them – they want the support and precision of tools. They respond better to simple-looking, machine-esque robots. HOSPI could have been designed to look like a human, but instead she looks like a clean, classic robot – well-suited to the hospital environment. I wonder, too, if patients would have a negative reaction to human-looking robot because of the uncanny valley phenomenon (which, by the way, was first tested by a Japanese roboticist in the 1970s).
Finally, I asked Ando what makes Japan so healthy and what that has to do with technology, if anything. He made a distinction here: the older, super-ageing generation is healthy, while the younger generations are less so. He said that the elderly are healthy simply due to their lifestyle of eating well and exercising enough. But in his opinion, the younger generations eat less healthy food and spend less time exercising – mainly because of the negative effects of technology, especially television and the internet and smartphones.
“So do you think technology helps people be healthy or not?” I asked – after all, Ando does work in the field of healthcare technology. He said that while the prevalence and popularity of technology has a negative effect on peoples’ health and fitness in Japan, it can have a positive effect on peoples’ illnesses. Once people are already sick and in the hospital, said Ando, technology can begin to have a positive effect, such as the effect of robots like HOSPI.
I like mixing up my project meetings so that I’m not always interviewing people in offices, and one fun way to do that is to go to expos (trade shows) to get a broad sense of what companies are currently doing in the field and what’s popular. My time in Tokyo has luckily coincided with two healthcare expos at the big exhibition hall Tokyo Big Sight, and I was able to attend both for free by pre-registering online (and, for the second one, by getting those business cards). There was a lot of technology for healthcare at these events – I was happy to see loads of “care robots”! – so I wanted to post about my experience.
I’ll use two posts to share some thoughts and photos from these expos. This post is about the first trade show I attended, which focused mainly on “retail technology” and technology design in general. Along with retail, this expo had subsections such as health, transportation, and home living.
Appropriately, then, I stumbled upon the “Good Design Award” area, which showcased various winners of the 2016 Good Design Award in Japan. There were nine award categories, each of which had a few winning products. The competition committee had outlined these “essential Good Design Award perspectives on design trends” to demonstrate that the winning products were not only well-designed, but also that they addressed a relevant social concern. The nine “focused issues” were: the environment, urban infrastructure, community, medicine and health, security, education, business models, culture, and technology (IT). Of course, I was on the lookout for well-designed technology in medicine and health, so I made a beeline for that part of the room.
In the Medicine & Health area, there was a big block of Japanese text printed on the wall. Luckily I found a small booklet with an English translation, and I read this text, which was an introduction to the topic and a discussion of the winning products by a man named Takahiro Uchida. I learned that he is a cardiologist who has consulted for medical device startups in Silicon Valley, and now he is the CEO of a Tokyo-based incubator for medical innovations.
A lot of what he wrote really resonated with me; Uchida stated that, when it comes to well-designed medical products, simply adding bells and whistles isn’t enough and can even undermine the goal. Health should be a basic right for all people. “Safe, effective diagnosis and treatment remains the goal of medical care, yet superficial design such as appealing drug packaging increases development costs and makes drugs or devices more expensive,” he wrote. “This undermines the social mission to expand medical care.” (Full text here).
But, of course, it is important to consider what will be most satisfying and comfortable for the patient, even if that means making cosmetic changes (though ideally without raising the cost). This is where I think co-design is most important – if you start by designing with the user, and generally making the design choices that will make them happy, you won’t lose money changing those choices down the road.
Uchida was thus impressed by the devices that walked the line of satisfying users’ wants and needs while not getting bogged down by expensive or excessive additions. 2016 seemed to be a good year for well-designed patient monitoring systems and digital imaging systems, the latter of which Uchida said respond “to patient needs for smaller, quieter, and more visually appealing devices.” Also, any products submitted to the Medicine & Health category needed to be medically approved – Uchida wrote that there were many medical- or health-related devices that were designed very well, but which were removed from consideration for the award because they did not pass the stringent regulations necessary to qualify as a “medical device” in Japan (for a general example, the Fitbit is a type of health/fitness technology that cannot legally be called a medical device).
Other winners of the Good Design Award 2016 for Medicine & Health included a wheelchair and an assistive device. There was the COGY wheelchair, which can be pedaled forward with minimal effort so that the user feels more self-sufficient and independent. It adds haptic feedback to the wheelchair experience, enhancing the limited pedaling power of the users so that they can engage with the wheelchair and have the sense of mobility, as though they are pedaling a bike.
There was also the Ontenna, a bone-conduction device for people with hearing impairments or full hearing loss. According to Uchida, the Ontenna follows a general trend of new medical devices products that support minority and disabled populations to help change perceptions surrounding disabilities. As described by IT entrepreneur Dominique Chen in the IT section, the Ontenna is “worn like a hairpin…[and] conveys ambient sound in the form of vibration and light to hearing-impaired users. The thinking behind this product turns the tables on an unfair but common bias that those with disabilities trail healthy people in perception and cognition.”
I noticed that many of these products (as well as health-oriented devices that didn’t go through the extensive regulation process) were also mentioned in the introduction text for the Information Technology section of the Good Design Award. In the intro text for IT, written by the previously-mentioned Dominique Chen, both the Ontenna and COGY come up again. Chen writes about them in the context of human-centric IT with glowing reviews. He seems to be hugely optimistic about the power of such products to change perception of bias towards disabled people: “It seems inevitable that, as some have already discussed in the context of sporting events, disabled individuals will be the first to venture into the realm of cybernetic existence as cyborgs, or cybernetic organisms. As the reality of physical and mental issues faced routinely by many with disabilities becomes more openly revealed, as shared knowledge in society, it will be easier to dismantle the binary division between healthy and disabled. Such openness shows the possibility of a middle ground in a dichotomy that has remained unequal, encouraging us to redefine the social image of reality and join a social movement not yet seen.”
I suppose it’s already telling that the Medicine & Health entry overlapped with the Information Technology entry. So many of the best, new medical devices designs are in fact technology designs. Still, it’s clear that there is an issue with stigma against disabilities in Japan. Both Chen and Uchida mentioned it, and the success of the Ontenna is a sign – it is designed to disguise the disability and the need for assistive technology (though pretty much everyone around the world seems to appreciate small, subtle devices).
That’s all for now. I’ll cover the next week’s expo in a follow-up post. (Edit: part 2 is here).
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.
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.
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.
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.
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.
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.
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!
Last week, I met with a man named Liang, a Chinese Singaporean who was born profoundly deaf (the highest possible level of deafness) in both ears. Liang now has bidirectional hearing due to his cochlear implants from Cochlear Ltd, one in each ear. I met with Cochlear Ltd, the Australian cochlear implant company, at their Mumbai office in India. It was cool to see their office here in Singapore as well and actually meet one of their clients. I wanted to know how Liang made the decision to adopt this invasive medical technology and what features of the implants mattered most to him.
(Click here for my first article about Cochlear Ltd, which explains what cochlear implants are and surveys Cochlear Ltd’s various external processors, including the minimal Kanso model, which is near invisible when worn).
When Liang was young, his deafness was untreated until he received hearing aids around 8 years old. However, the hearing aids simply amplified sounds that he still could not hear, so they were ineffective. Up through university, Liang was surrounded by a fully hearing family and hearing students in mainstream schools; he eked by with lip-reading, but he struggled. By the time he was 21 at university, Liang was thinking about the future and how much he would be hurt by his inability to hear. He could never pick up the phone and have a conversation, for example, and he felt as though the best job he could hope for would be manager at a fast-food restaurant. (Today, Liang works for the Singapore government in the Treasury Department.)
Liang did some research and realized that his only path to hearing was the cochlear implant surgery, as it would address the root cause of his deafness. He visited the hospital by himself; his parents were never too fond of the idea of implants because of the surgical risks. They also figured that Liang could manage without – he was doing okay in school and hadn’t flunked out – but he was unhappy, even if he wasn’t showing it at the time. Those first few years of university, he said, were the darkest years of his life.
There was a doctor at the hospital, Dr. Low Wong Kein, who Liang said is the pioneer for cochlear implants in Singapore. Meeting someone with such a positive view of cochlear implants helped Liang feel more comfortable with the idea, implying that having doctors as advocates is key for the general acceptance of new medical technology (10 years ago, cochlear implants were still considered new tech, at least in Singapore). Through testing, the hospital determined that Liang was a good candidate for cochlear implants, and he had to decide from which company to get the implants since there were a few choices at the time. I asked how he made the decision.
Clearly a finance man, Liang said that he picked Cochlear Ltd because it was the market leader at the time. He went through their financial statements to see if they were making good investments, as he wanted to make sure that they would still be the market leader in 5, 10, and 15 years; cochlear implants are (ideally) a lifelong commitment, with various upgrades throughout the years.
Liang also searched online for some consensus of which company had the best tech, perhaps an article with a non-biased analysis of the specifications of the different cochlear implants on the market. However, at the time he could only find publications from the individual companies marketing their products – not so helpful. Also, at 21, Liang was both image-conscious and cost-conscious. He wanted the smallest size processor available, worried that he would stand out, and he wanted to know if his hair would grow over the spot of the implant after the surgery and hide the scar. He went to Google looking for answers, but couldn’t find any – he was surprised that so little was known about cochlear implants at the time that he couldn’t get answers to what he considered to be very practical questions. He was also concerned about the reliability of the device, but ultimately decided that the potential benefits of a successful surgery were worth all the risks and worries.
Finally, at 21 years old, Liang got his first cochlear implant in one ear. On “switch-on day,” after Liang had gotten the surgery and first had the implant turned on, he experienced good hearing for the first time. The thought occurred to him that he could now hear better than moderately deaf people, who always heard far more than he did pre-surgery. For this reason, he finds cochlear implants to be a far more disruptive and innovative technology than hearing aids.
At the time of his first cochlear implant, Liang said that the cost of the implant was almost $30,000 US. After the government subsidized the cost, it went down to about $7,000 US – still expensive, but far more doable. That was just for one side. Now, Liang is 30 years old and just received his second cochlear implant on the other side. This time the subsidy was less generous but still fair, as it was means-adjusted based on his current salary.
Over the past 9 years, Liang said, a lot has changed in the world of cochlear implants and what he cares about. He summarized that when he was 21, his decision was based 50% on the hearing quality and 50% on the form factor of the device. Now, at 30, Liang is focused 90% on the hearing quality, 5% on the form factor of the device, and 5% on comfort or ease of wear. As he’s gotten older, Liang has become more used to having a cochlear implant, less image-conscious (especially now that he has the near-invisible Kanso model), and more aware of the benefits of hearing. Since he’s already made the decision once to get a cochlear implant, his decision about the second one was more based on the benefits of bidirectional hearing vs. hearing in one ear. Now that he has bidirectional hearing, said Liang, he’s been aware that his hearing is far better.
I asked Liang how people reacted to him once he first got the implant. He said that people see the external processor of a cochlear implant and assume it’s a hearing aid, which they’ve seen before, so they don’t ask questions. Especially now that he has the Kanso model of the external processor, most people don’t know that he has any hearing issues at all. In fact, Liang is getting married in two weeks, and he was originally wondering how he would manage with wedding photos – whether or not he’d remove his external processors. Now it’s no question with Kanso, said Liang. He’ll keep them on and they won’t show in the photos, and he will be able to hear the photographer. Now that the processors have gotten more comfortable to wear over time, Liang cares more about ease-of-wear when it comes to medical devices.
The cost does add up, though. Over the past decade, Liang has paid about $17k USD on both his implants, which has been a considerable sum for his family. Now that he’s getting married, he thinks about his future family, and he worries. “What if I want to have three kids, and they all turn out deaf?,” he said. Liang would want to give them all cochlear implants, but then he has to find a way to afford six very expensive implants along with all the other costs of raising kids.
Liang supports the use of cochlear implants for the moderately deaf as well as the profoundly deaf. He works at Singapore’s Association of the Deaf to promote cochlear implants and has worked on their newsletter. I asked him if anyone seemed resistant to the idea of implants and if so, why. He said that many people are deterred by the high cost, especially if they are already in low-paying jobs due to being moderately deaf (a spiral effect). Liang stressed that to combat this downward spiral, it’s crucial for deaf children to receive cochlear implants as young as possible. From the doctor’s perspective, that’s better for hearing performance and speech development, and from a practical perspective, they will end up with better, higher-paying jobs.
Generally, despite the cost, Liang experienced positive reactions to the idea of cochlear implants from the deaf community – especially from hearing parents of deaf children, who are very invested in giving their kids “normal” lives. Liang said that he successfully promotes cochlear implants with such parents because he “walks the talk,” essentially, serving as a successful example of what they can do. His testimonials, and those of other implant recipients, build momentum for cochlear implants. Liang said that he imagines a future in Singapore without deaf children. All Singaporean children get a mandatory hearing test these days, so deafness is found immediately. Liang said that every deaf child would thus get implanted early on, and the government, recognizing the value in hearing, would help subsidize any parents who struggle to pay. With this normalization of the technology, the “anti-implant culture” will go away.
Liang has lived in the US, and I wondered if he had any thoughts as to why Singaporeans might be more receptive to cochlear implants and why Singapore is ranked as such a healthy country generally. He said that some of the resistance to cochlear implants comes from strong Deaf communities that embrace being deaf and have no desire to be “fixed.” In Singapore, the overall population is quite small, so there isn’t a large or strong Deaf culture. Also as a cultural reason, Liang said that Singaporeans are generally very pragmatic. While it doesn’t come from a stigma against being deaf, said Liang, Singaporeans recognizes that the deaf have a harder time in school, in jobs, and life in general, so it’s simply more sensible to give them a path towards hearing (and they will probably make more money and become less of a burden to government over the years).
As to why Singapore might be ranked as so healthy, it’s not just the availability or acceptance of medical technology, though Liang did mention that the hospitals are very well-equipped. Liang said it might be due to diet and good portion control (though of course that varies person-to-person), and Singapore’s mandatory 2-year military service, which forces everyone to get in shape. There’s also the fact that Singapore is very pedestrian-friendly and safe. “Crime rates matter,” Liang pointed out, saying that more people will walk all over Singapore at all hours if they feel comfortable doing so. The government also has a National Steps Challenge to incentivize people to take 10,000 steps a day (4-5 miles), with the opportunity to win certain prizes (National Step Challenge).
As I saw in Sweden, there can certainly be a lot more to a high health rating than positive attitudes towards medical technology, though I still think that’s an important factor. It was great to hear Liang’s story, as the connection recipients have with cochlear implants is more longterm and emotional than that formed with many other medical devices; the process of getting a cochlear implant is long and costly but has an enormous impact. I think all over the world, people would have a positive reaction to cochlear implants (or any other medical device) if they could hear such stories from people whose lives were positively changed.