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!

 

 

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).

The Tropic of Capricorn

We stopped at the Tropic of Capricorn on the way back from Serowe. Serowe is a small town in Botswana, and I traveled with a group to visit the hospital’s vision center there and learn about the process of eyeglass making. The Tropic of Capricorn is a latitude in the Southern Hemisphere, and it traces the southernmost circle on Earth where the sun’s rays can hit from directly overhead (any further south, they always hit at an angle). The northern equivalent is the Tropic of Cancer.

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A Capricorn myself, though not a big astrology person, I was pretty excited to be there. It’s marked by a simple street sign and a small monument – a rock with a vertical metal rod on top. Every year, at 12:12pm on the winter solstice (December 22; summer in this hemisphere), the sun shines directly down onto the rod. The light beams straight through the hollow rod and onto the rock, creating no shadow. Since we weren’t there at the solstice, of course, the rod cast a shadow.

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Here is the rod with a description on the rock below.

That morning, we had visited the Vision Centre, an area of the eye health ward in Serowe’s hospital. Equipped and funded by a British charity organization, the Vision Centre includes all the facilities necessary for cutting glass lenses to make custom eyeglasses. That’s where we met Michael, a technician who makes 10-15 pairs of glasses a day. He walked us through the process of cutting a lens, showing us the 5 or so machines involved.

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This is Michael, about to cut the circular glass lens he holds in his hands. The many machines he uses to do so are behind him.
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A wheelchair in the Serowe hospital fashioned out of a plastic lawn chair and common bicycle tires. A worn-off sticker shows that they were donated by some charity or NGO (perhaps American?) but it’s too faded to read the name.
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The foyer of the hospital.

In Serowe, and every time I’ve been somewhere new, we did multiple rounds of introductions and hellos. Every day, I think about how important social norms are in Botswana. I think I’ve touched on this before – there is a well-established code of social interaction here, something like that small-town friendliness in suburban America. It’s at the same time my favorite and least favorite thing about Botswana. Everyone says hello (dumelang!) to each other on the street, even strangers, often continuing to ask “How are you?” and the like. It’s considered very rude to begin any interaction, even if you’re just purchasing stamps at the post office, without these pleasantries. I think it’s lovely, and in a capital as small as Gaborone, it’s important to be kind to people when you might be speaking to your brother’s neighbor or your friend’s mother. As a result, the Batswana seem far more socially adept than many people I know.

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If spaces could talk…what would they say? I see this almost every day in Main Mall, Gaborone.

At the same time, it drives me crazy. It slows things down. No one is ever in a hurry – to appear so would be rude. I grew up in Manhattan, where I perfected the style of speed-walking that signals “don’t talk to me.” It’s also a safety thing. Every time a random man or cab driver or stall owner calls “Hello” to me on the street, I’m conflicted between respecting Batswana culture and wanting to ignore it, as I’ve been trained to ignore any attention from random male passers-by. Usually I respond with a curt “Hello” in return and promptly ignore any ensuing conversation. On longer walks, I listen to podcasts or music, and hope that the earbuds serve as a defense against being rude – I smile at the people around me while conveniently being unable to hear them.

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More street art from Main Mall.
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A traditional Botswana meal from the food vendors seen in the background. For 15 pula ($1.50), you can get this little plate with your choice of starch, meat (seswaa is traditional – pounded beef), and veggie sides (I like the sauteed greens and mashed butternut).

Anyway, I’m off to Victoria Falls tomorrow, which I’m excited for since it’s considered one of the 7 natural wonders of the world. I’m hesitant as well because it will be a very touristy weekend, outside of Botswana, with other American travelers – none of that is very Watson-y. But it’s only a two-day trip, and I missed the opportunity once before (I could have gone when I was studying abroad in South Africa for 5 months), so I didn’t want to miss it again. I’m also feeling quite good about my project here. I’ve met with a few different groups by now, and a couple days ago I met with the only local medical device start-up in Botswana, so that was great. Plus, it’s been too long since I’ve taken a flight! (well, a couple months).

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Food vendors by the side of the road for watermelon, nuts, and crunchy worms (lower left).
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Advertising in Gaborone.
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The flower wall at Sanita’s Tea Garden, a plant nursery and café in Gaborone.
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More from Sanita’s.

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.

Last week in Japan

A week from today, I will leave Tokyo and travel to Gaborone. I don’t exactly know what to say or how to express my feelings (I’m not sure I know what I’m feeling), but I did want to post and share some photos from Fukuoka. I visited Fukuoka between project meetings in Osaka and Nagoya, and Fukuoka is the city from which I visited Hiroshima and Miyajima as well.

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

Fukuoka is a friendly town and quite small compared to the other Japanese cities I’ve seen. It’s easy to explore most of the city center in one day on foot, which was a refreshing change from the immensity of Tokyo, where even after many weeks here there’s still so much to see. I’ve spent the majority of my time in Japan in Tokyo, but as I’ve described before, my time in the capital city has been spent with host families and really trying to blend in with daily life. As I’ve avoided trying to be a tourist, I almost feel like I’ve seen less here than in the other cities. But I think it’s simply that Tokyo is more of a mega-city-complex than one city, and seeing everything (including the many possible day trips from Tokyo) was never going to happen over the span of a couple months, not with project meetings and language classes and host families thrown in the mix. I’d still choose the project and host families, though – this “Watson style” travel – over seeing all of Tokyo in one go!

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

It’s still hard feeling as though I’m leaving things unfinished, and I wonder if I could have made more of my first month here. That’s the Watson, though – you have to pack up and go, whether you’re ready or not. I’ve been quite ready to leave every country I’ve traveled to so far this year; I’m not sure I’m ready to leave Japan. Of course, I hope to come back, and I am beginning to get excited and curious about Botswana – a good sign that it is, in fact, time to move on.

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

Thinking about the project meetings I’ve had here, I’m fairly happy with the range (professors, doctors, people at start-ups, and people at larger corporations), but I still had a much wider range in India over the same time span (all of the former, along with ashram gurus, visits to hospitals, NGO workers, and more). I’ve wondered many times this year about order bias – how the order in which I’m visiting these countries is impacting my experience in them. I think my expectations get more defined (and thus more critical) as time goes on. As the year progresses, the end of each country visit fills in another detailed segment of the once-blank canvas of “What could this year look like?”. It’ll be a strange feeling at the end of Botswana when that painting is well and truly done – when I no longer have any questions about a year that once loomed before me in its uncertainty.

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

Also, I think it’s been a bit challenging to “break in” in terms of my meetings in Japan because of the language difference, which has been more difficult here than anywhere else. There are also simply fewer medical technology start-ups than I expected due to the ever-strong corporate culture. Maybe there’s something else, too, something I can’t quite put my finger on – but there’s some distance I haven’t always been able to break through when trying to schedule meetings and so on. I often get the sense here that Japan has such a unique culture and has so much figured out that it doesn’t need the rest of the world.

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

Of course, my time here has also been complicated by the fact that I’ve wanted to come to Japan for so many years – I was always going to have high expectations for my time here, as well as feel slightly pulled between wanting to see as much as I could, making the most of my time here, and figuring how best to approach my project. I suppose no span of time, then, would ever be enough!

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

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On the way to RoboSquare, far from central Fukuoka.

While I was in Fukuoka, I made a point to visit the “RoboSquare,” a center showcasing various Japanese-made robots. I wanted to go because I had read that they had a Paro, a Japanese care robot made to look like a fluffy seal who has helped dementia patients worldwide. I contacted the government organization that made Paro a reality and was never able to get an interview, so I wanted to see it in person. (The agency is AIST: Advanced Industrial Science and Technology).

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

RoboSquare was a small room in a shopping complex, but it was still exciting to “meet” a robot I had read about months earlier. As far as robots go, it’s nice that Paro is soft and fluffy all over (though the big black eyes looked a bit creepy to me). There was an information card next to Paro that explained how the robot has been used in pediatric wards, nursing homes, and hospitals. AIST conducted studies that proved that both children and elderly patients had improved mental states and lower stress levels after interacting with Paro. The Paro robot has been around for over ten years now, so hopefully AIST can continue to sponsor more health technology projects in Japan.

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

Health post: Beautiful capillaries

In Osaka, I met with Dan Takeno of Kekkan Bijin, which means “vascular beauty.” His company’s device is essentially a microscope that observes peoples’ blood flow in a non-invasive 5-minute procedure. The scope focuses on the capillaries under the thin skin around people’s fingernails, and it displays the nature of the blood flowing through them in real time (while also digitizing the image to capture information in numerical form). The idea is that this procedure will indicate health; healthier people will have straight, clear capillaries through which blood flows easily, and less healthy people will have twisted, jagged and/or thick capillaries (perhaps indicating a blockage in a particularly thick spot).

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Mr. Takeno with the device, plugged into an LCD monitor.

Takeno’s father developed the device in 2001 after being diagnosed with cancer. He decided to supplement his cancer treatment with alternative healing, taking supplements, and drinking more water. Takeno’s father wanted to know if and how these alternative treatments were affecting his health but could find no quantitative measure. He became frustrated that there was no easy, trackable indicator of his general health – something he could have been watching even before his diagnosis. Doctors always check blood pressure and body temperature, said Takeno, but this doesn’t add up to a simple, one-stop “health index.” To get a full snapshot, his father would have to go to the health diagnosis center, spend $500 for a complete checkup, and lose half a day’s worth of time. How could this be simpler, cheaper, and faster?

Takeno’s father ultimately collaborated with a man named Dr. Ogawa, who started research 6 years ago on the potential of capillaries being an indicator for health. Takeno’s father read his book and decided to apply the idea to a machine. He was successful, selling 2,000 machines to Eastern medicine (EM) pharmacies and eventually to doctors. “Eastern medicine?” I asked. Well, Takeno replied, the device is still based on non-Western ideas. Sitting in an office in one of Japan’s busiest metropolises, meeting about a health device that looked like a scientific instrument, I was surprised that we were discussing non-traditional medicine.

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The nearby Sukunahikona Shrine, showcasing its health products for sale.

Takeno told me that Eastern medicine is quite popular in Japan and that many women he knows go to EM drugstores and healers (such as chiropractors). After our meeting, he showed me an Eastern medicine drugstore that was just a block away from the office, selling herbal ointments and the like. Across the street from the drugstore is the Sukunahikona Shrine, enshrining both a Japanese god of medicine and a Chinese god of medicine – the shrine also sells some of its own alternative treatments. I didn’t realize that alternative medicine was so popular in Japan, and it’s hard to find statistics about this. But I did learn that kampo is the name for Japan’s version of Chinese Traditional Medicine, and that a well-known university here in Tokyo – Keio University – has a center for kampo in its medical school.

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“Unhealthy” capillaries on the left and “healthy” ones on the right. (Source: Kekkan Bijin website).

For now, Takeno says, his device falls under the umbrella of alternative medicine. “Western medicine is science,” he said. “This machine is not science – yet.” But he expects that it will move into the realm of Western medicine, mentioning that the first researcher of capillary health was German – “and their history of building microscopes is good,” he adds (I couldn’t find any history of this type of capillary observation online, so I’m not sure). This reference to German medicine reminded me of my first meeting in India with the company that offers a homeopathy service. They also mentioned that the Germans invented homeopathy, which is true – a German scientist invented homeopathy in the 18th century, but the practice has long been written off as pseudoscience by Germany as well as many other nations. Still, based on some apparent global trust in German science, the homeopathy company used the German origins of their product as a way to legitimize it.

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The traditional medicine shop around the corner. The sign in the window advertises treatments for high blood pressure, diabetes, PMS, back pain, insomnia, and more. It also mentions the opportunity for an online consultation.

Next, we discussed Takeno’s ideal users for the device and the reactions he’s gotten so far. He said that he has received more enthusiastic responses to his product from women than from men. Based on his experience in Japan, men don’t want to hear bad news or learn about bad health, but many women do want to know. This is partially due to the media, he explained – many female-oriented magazines and TV shows in Japan advise women to get regular health checks. Some even specifically recommend getting arteries or capillaries observed (Takeno showed me a huge stack of these magazines in the office). These broadcasters and magazines, he explained, say that having a healthy blood flow is important for beauty and young-looking skin.

So Kekkan Bijin currently markets its device to women, but Takeno hopes that once many women start checking their capillaries, men will want to do it too. “I think people are comfortable” with the device, he says, and he’s gotten all positive responses so far. “People want less technology – this is easy to use and not expensive,” he said, almost as though he was distancing his device from the idea of technology (or at least from the idea of a complex medical machine, which would perhaps not fit so well with the Eastern medicine I mentioned earlier).

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Capillary length vs. age for men and women. (Source: Kekkan Bijin website).

Takeno told me that, due to the connection between healthy capillaries and younger skin, the device results can be used to predict someone’s age. The graph above shows the correlation between average capillary length in nanometers and age in years (the red line is for women and the blue line is for men). Takeno went on to explain the cultural consideration here, starting with the fact that age is very important in Japan. Since it culturally important to respect anyone older than you are, you should know the ages of the people with whom you interact. Takeno compared this to America, where age is less important – we care less about an age-based hierarchy, rather celebrating people based on merit, individualism, and innovation, especially if they’ve managed to accomplish a lot at a young age. However, in both countries, it’s rude to ask someone’s age. So in Japan, where knowing someone’s age relative to your own is important for navigating an interaction with them, what do you do? I had never thought about this being a potential issue in Japan!

Of course, it’s a very unlikely use case that you would have the opportunity to measure someone’s capillaries and use that result to determine their age – but it’s an interesting side benefit of the device.

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Here, Takeno is focusing the scope over my pinky finger.

Finally, of course, I had to test out this machine. Takeno adjusted the scope over the tip of my ring finger, but it wouldn’t focus (apparently because I had used hand lotion that morning). As he was focusing the device over my pinky finger instead, I began to get nervous. Well, as it turns out, my capillaries are definitely not perfectly straight, though they aren’t terrible either. I’ll have to ask my doctor about it when I get back to the U.S.!

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The strained smile here is a product of my uneasiness at seeing my own capillaries on display.

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.