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!

 

 

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.