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.
I arrived in Sweden on July 19th, 2016, which means that yesterday – June 19th, 2017 – I began my very last month of the Watson year. At the beginning of the year, I noticed the 19th of each passing month, these milestones that seemed enormous at the time: 1 month in! Two months in! Somewhere along the way, I stopped counting like that. Then yesterday, it hit me again: the 19th. One month left.
My first month on the Watson was long and difficult. After the first week, I thought to myself that this would be the longest year of my life. I had a large, unmeasurable swath of unknown ahead of me, which was scary and exciting and overwhelming. I wondered if I would ever feel like I was on my way home. Within the first month, I stayed alone in an apartment without wifi after four years of the intensely social college experience; I felt myself undergoing various changes as I learned how to be alone and love it; I lived in two different Swedish cities; I lost two of my grandparents, and heard the news over Skype; and I began my project, meeting with strangers kind enough to give me some insight into their medical device work.
Once I hit the one month mark, 1/12 of the way through the Watson, I felt like I had hardly made a dent in the year despite having already experienced so much. Now, at 11/12 of the way through, having one month left feels like nothing. It’s hard knowing that so much of the adventure is done, that the vast unknown has become something very known, measurable by photo albums and ticket stubs and friends left behind; but also thrilling knowing that this seemingly insurmountable year has been easier and far less lonely than I expected.
It’s weird how your perception of time changes so easily – how a month can go from being so long to being so short. Time flies by faster the older you get, and somehow the Watson has magnified that phenomenon.
The distance between NYC and Singapore is nearly 10,000 miles. That’s the farthest away from home I’ve been this year. But Tennessee Williams said that “time is the longest distance between two places,” and that feels far more accurate to me. I just want to make sure I make the most of the time I have left, but I’m not too worried about it – I think Botswana is a lovely place to be for the next month.
The Batswana – the people of Botswana – refer to the country as “Bots,” and I love that. Gaborone is pronounced Ha-borone-y, but this city has a nickname too: Gabs. I’ve already been here for ten days, and I can’t believe it. Time flies by faster as the Watson goes on, I’m sure.
Botswana is a huge change from Japan. The population here is about 2 million people; 10% of them, 200,000, live in Gabs. Japan has 127 million people with 13 million living in Tokyo alone. I knew that Gabs wouldn’t be nearly as urban or pedestrian-friendly as Tokyo, nor as safe. I even read a mildly alarming email from the US Government suggesting that visitors avoid walking around solo at all.
Luckily that email was over-cautionary (though I still won’t be walking around in the nighttime), and after a couple days in Botswana, I started to feel at home. The transition from Japan was quicker and easier than I expected. I don’t know if that’s because I’m used to transitions now, and better at adapting quickly to new and foreign places, or because the people here are so friendly and easy to talk to in English – probably both!
The surrealism of the Watson is often lost on me these days, though I frequently marveled at the lovely strangeness of it all in my first few months. It’s become an odd routine – of traveling, landing someplace new, figuring out how to get a local number, taking a couple days to figure things out and feel safe – that I’ve learned to repeat in each new country or even city. Each new destination gets easier to manage, and each unexpected interaction or step along the way seems less like a snag. That in itself is exciting and surreal, though, knowing that I now feel comfortable walking into pretty much any situation and making it feel like home.
Of course, this is the end of the proverbial road, and I won’t be traveling to another new country after Botswana. But that’s not to say the U.S. will feel exactly like the place I left, and maybe this new-country-routine is something I can apply, on a much smaller scale, to my return back home and whatever “reverse culture shock” awaits me there.
Speaking of home, I just extended my stay at an Airbnb here by an additional 7 weeks – the remainder of my time in Botswana. Though I might travel out of Gaborone over the next couple months (in fact, I just did yesterday), it’s always nice to have a home base. I can leave for a night or a few and come back while leaving some of my stuff in a place that I know is safe.
Anyway, this is a big milestone for me because it means that I’ve figured out a place to stay for every single night of the Watson year. Just before I left for Sweden, I only had a few weeks of housing figured out, and it scared me. I had to set up all my own accommodation for 365 distinct nights, and I didn’t know where I was going to be – and at the same time, my friends were moving into apartments with yearlong leases. I knew that I would be okay figuring things out day-to-day on the Watson year once I got over the hurdle of where to stay night-to-night. Now that I’ve booked these last 7 weeks, that’s it. I’ve done it – I found a safe place to stay every night of the Watson and stayed in budget while doing so. I’m tempted to say that it was easier than I expected, but maybe that’s just in hindsight.
Finally, the stars here are just beautiful – Gaborone must have the least light pollution of any city or town I’ve been in this year. (If I could capture them on my camera, I would certainly post a photo). I keep getting distracted by them at night. I don’t think most of the Batswana notice.
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.
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.
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!
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.
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.
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.
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!
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).
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.
Yesterday I submitted my report for the third quarter of the Watson: 9 months in, 3 to go. This is what I wrote (warning – it’s long!).
I’m writing this from a park in Kichijoji, a small trendy neighborhood on the outskirts of Tokyo, and it’s the calmest I’ve felt in a while. The cherry blossoms here have been in full bloom all week, and now their short period is ending – the trees are turning from pink into green, scattering their petals all over the ground. When I submitted my last quarterly report in January, I was still in India. Since then, I’ve participated in a health camp in rural India, closed the chapter on my long and demanding visit there, spent a quick two weeks in Singapore, and traveled to Japan. I’ve been in Japan now for nearly 8 weeks now, and I have another month to go.
One of my last weeks in India, I traveled with a company I had interviewed in Bangalore to the tier-two city of Bhopal up north. For five days, we joined a group of volunteer doctors who had traveled there to do “health camps,” one-day pop-up clinics in rural villages around the city. Each morning we got up early to pack a bus with basic medical equipment and travel the 1-2 hours to a predetermined rural village, where we registered villagers and gave them basic care based on their complaints. I was one of the few non-Indian and non-Hindi-speaking attendees, and along with my complete lack of medical training, it all made the event a hugely humbling one. My job was to administer blood tests using a small device, and it was my only time on the Watson actually operating a medical device rather than interviewing someone about one. I saw firsthand the fear that comes with a lack of awareness – adults scrunching up their faces in anxiety and pain in response to a little finger prick, the same way kids do with pediatricians. As many interviewees had told me, lack of awareness is one of the biggest barriers to acceptance of medical technology in India.
By the time I left India, I was exhausted. I had done everything I wanted to do, and I was ready to leave – or so I thought. It’s still hard to say goodbye, and I struggled with that my last day there, especially leaving Mumbai. I had left and returned to Mumbai so many times by that point that it was starting to feel like some kind of home. The further along the Watson gets, the more people I meet and the more friends I say goodbye to. I thought my presence in these places would be too transient to make real friends, and I’m thrilled that hasn’t been the case, but it certainly doesn’t make it easier.
Then I arrived in Singapore, a late addition to my project. I decided to go while I was in Qatar because I learned there that Singapore was ranked by The Lancet as the second-healthiest country in the world, and by the WEF as the world’s most “technology-ready nation,” and I wanted to know why. I allocated only two weeks there because Singapore is small and because I wanted to stick closely to my original Watson itinerary.
I was amazed by the nation-state when I arrived and a bit disillusioned with it when I left. First of all, I realized that two weeks is not long enough to spend in a country for my project (the four weeks I spent in Qatar were a good minimum). It takes time to grow these “connection webs” – the networks that form when you embark on interviews, when you finally meet the right person who connects you to an opportunity somewhere else, or links you to another person to interview, and so on. The opportunity to do the health camp in Bhopal, for example, was several months in the making. It was frustrating in Singapore to learn that two weeks simply isn’t enough. At the same time, Singapore is tiny, and I was fairly ready to leave after two weeks. I didn’t get a great sense of attitudes towards medical technology there, but I did learn some things through my few interviews. It seems that Singapore’s high health ranking is mostly due to the tight control of the government over its small population and the fact that Singapore’s nationals form an even smaller, high-income group that can afford good healthcare. I actually started to notice a lot of parallels between Singapore and Qatar, as both countries have many expats and migrant workers, as well as highly involved governments. Though Singapore is certainly “technology-ready” and a tech-enhanced city, most medtech companies there are using the city as a Southeast Asian hub, with large manufacturing facilities taking advantage of the low taxes. There are very few start-ups or products tailored specifically to Singaporeans.
By the time I came to Japan, I was excited to do something different. My time here has been characterized by homestays, far more so than in any other country. Nine of my twelve weeks in Japan are spent living in Tokyo with two Japanese host families that I found via a Swarthmore alum. My nightly fee includes both breakfast and dinner, and this complete immersion into family life (especially with families that speak minimal English) has been new and wonderful. I spend less time writing on the blog or setting up project meetings, but it certainly seems worth it for the way I’ve gotten swept up in day-to-day life here.
I’ve loved jumping into life here as though I’ve always been in Tokyo. I took a full-time Japanese class for two weeks, which was a great way to have structure outside of the project and feel like a Tokyoite commuting in the city. Those two weeks constitute my only language study on the Watson, so I’m happy that I was able to do that here. The week after my class ended, two of my best friends from home came to visit me in Japan and we had an amazing time traveling together – in addition to the week around Christmas when my parents were in India, that’s the end of visits for me. Immediately after they left, I traveled with my second host family to Okinawa.
With all this going on, and group travel unlike what I’m used to on the Watson, I’ve had fewer project meetings than in other countries so far. But since Japan is so different from anywhere else I’ve been, I think it has been helpful to go slow in terms of seeing my surroundings and setting up meetings (even though I wondered at first if it was too slow). Also, now that I’ve done so many interviews in general through the year, I feel like I know how they go. It’s been tough feeling like I don’t have as many revelatory ‘wow’ moments as I used to, either with myself or the project, but I suppose that’s natural. I’m getting answers to my questions that surprise me less and less frequently.
So at this point in the Watson, now that I have many meetings and travels under my belt, I rely less on one-on-one interviews than I used to and more on myself and my observations, trying to pick up on relevant nuances and how they compare to what I’ve seen. I’ve enjoyed this slow absorption of Japan, joining the population by being packed into a rush-hour metro train or making the pilgrimage to one of the many parks ripe with blooming cherry blossoms. I like living this way, spending time with my host family, learning the seemingly irrelevant attitudes – the very safe, low-risk style of life; the strong sense of a common collective; the appreciation for anything cute (kawaii!); the intense corporate culture – that do indirectly affect the way people respond to medical devices and the field of medical technology as a whole.
Now that I’ve done my project in four countries, I’m quicker at understanding how cultural trends complicate attitudes towards medical technology, which is good even if it makes interview experiences less novel for me. That’s why I like mixing up “project events” so that it’s not always the same interview after interview by going to trade fairs or even touring the showrooms of big tech companies. Although, one thing that’s nice about interviewing people in this stage of the Watson is that I can add something to the conversation, too. People are curious to know what I’ve learned so far, and now that I’m in my fifth country, it turns out that I have a lot to say! I definitely prefer having an exchange of information rather than a one-sided interview – I feel like I’m giving something back.
In summarizing my experience so far to my interviewees, I’ve realized that I’m so impressed with Sweden. It may be order bias with Sweden as my first country, but as a main point of comparison, few countries measure up to it. I thought Japan would blow me away in every project-relevant department – health, technology, quality of life, innovation – but Sweden is doing just as well in those areas, if not better. Japan does have a lot of fun technology, but I don’t think it’s very well integrated with healthcare. Traditional corporate culture and social hierarchies still reign in Japan, and combined with a risk-averse business mindset, that means that the cute robots here aren’t always being used for health applications, and those that are cannot prove that they are making a positive impact on the population. It’s definitely complicated, and it’s been fascinating to see all these contradictions in Japan that I wasn’t expecting – I feel like I’m really getting to know the place.
All that said, the pace of meetings here in Japan is finally picking up. I’ve done three interviews since returning from Okinawa, and I just planned two weeks of solo travel to meet with researchers in Osaka and Nagoya. It’s odd to me that I haven’t done any solo travel in Japan since arriving here – that’s the Watson bug! – so I’m looking forward to going off on my own again.
One thing that’s really hard about being at this point in the Watson is that it is hard to stay unaware of the end. I don’t want to think about going home, but it’s an unavoidable fact that this is the last quarterly report I will write while on the Watson. If I let myself go there, I worry about coming home, getting a job, and adapting to a non-Watson lifestyle. But that’s distracting, so I try not to think about it, and instead focus on how happy I am that it’s turned out so great so far. I have to say that I’m still stunned by how kind everyone is. People, even people I barely know, continue to be unendingly and exceedingly kind to me. That’s one thing I never want to get used to (or worse, come to expect). It’s all too wonderful and strange.
Well, it’s that time of year again. I’m about halfway through the Watson, meaning that I left home 6 months ago and that my second quarterly report is due. So far, this year has been easier, safer, and more fun than I could have ever expected (knock on wood) – here’s hoping the next half goes just as well! Anyway, here’s the report if you’d like to read it.
A week ago today, I got my cheek pinched by a spiritual master who founded the ashram where I was staying, as well as the university where I’ve been having project meetings to learn about their interesting work in medical devices. Who knew I’d ever say such a sentence!
A lot has happened since my last report 3 months ago. I finished my time in Qatar and traveled to India; I watched Trump win the presidential election; I had Thanksgiving, Christmas, New Year’s, and my birthday abroad; my parents came and visited me for the latter three events; and then they left. Now I’m halfway into the Watson and I could say the time has flown by, but I know that’s only an illusion of hindsight; those first few days in Sweden really do seem far away, and I feel like I’ve been in India now for ages (just over two months, really; in terms of the Watson, maybe that is ages). Second halves are always easier than first ones, though, and I’m sure the passing of time will seem to accelerate, though I certainly don’t wish for that.
This past quarter has been characterized by more challenging experiences than the last, including the challenge of expanding the scope of my project from one country to multiple; leaving behind the easy and comfortable life of Sweden for the unfamiliarity and activity of Qatar and India; flying nearly every week to see different parts of India; and getting direct challenges about my project from various people.
I’ll start with Doha, where most of my project meetings were at hospitals. The bulk of Qatar’s medical technology comes from purchases made by the government for the country’s hospitals, and there are very few independent medtech companies. I met with one of the few medical start-ups, an online doctor-finding service for patients organized by ratings and location. I learned that innovation in individual companies is stagnant in Qatar because of the government’s rule that any new start-up must be at least 51% Qatari-owned. Since Qatar’s population is about 85% expatriates, and they do not mix with the local Qataris that make up the remaining 15%, such business deals are unlikely (and it seems that the drive for start-ups comes from the expats rather than the locals). However, the rule certainly makes sense coming from a government trying to protect its small group of nationals.
Instead of companies, then, I met with doctors, and I also had the unique experience of interviewing patients at Doha’s main cancer hospital. I realized while I was in Sweden that it would be very challenging to gain access to real patients for my project, so I was thrilled that it worked out in Qatar. Since I had mainly interviewed people at medical device companies and researchers in Sweden, I had to adjust my questions for the doctors and patients. The technology changed, too, as I focused on the larger-scale tech and procedures that are more common to hospitals and specifically to cancer patients: MRI machines, endoscopes, CT scanners, biopsies, and more. Hardly anyone discussed the need for these devices to be well-designed and ergonomic. Rather, I found that what mattered to patients in Qatar was knowing that the hospital had access to the best (that is, the most expensive) technology in the world, and most importantly, that their doctor recommended its use. Since I interviewed mainly doctors and patients, perhaps the importance of trust in doctors seemed inflated, but it was still clearly key for patients to feel comfortable with medical technology. It also makes sense that sick patients in hospitals would be less picky about technology and more focused on a cure than medtech users outside of the hospital, who are more focused on fitness or long-term self-management of a chronic condition.
I got a sense that while the Qatari government is excited about medical technology and has the ability to purchase and import any technology, there is a lack of enthusiasm on the user end. Many doctors told me that, despite the best technology being available, it sits unused in hospital rooms with no technicians trained to operate it. Also, without independent companies making other medical devices, you see very few people focusing on their health outside of the hospital setting. From a meta-project perspective, I realized how hard it is to compare and contrast countries on my Watson when my project has to adapt for each country that I visit. If I had known in advance that I would be meeting mainly doctors in Qatar, I would have made an effort to interview more doctors in Sweden. Instead, I have mostly companies in Sweden to compare to doctors and patients in Qatar, which makes that comparison challenging.
Here in India, I spent my first four weeks in Mumbai and have been jumping around ever since. I’ve now visited 7 states and I’m visiting my 8th next week, which has been a bit exhausting but fascinating. My project meetings started erratically; I only had one meeting over my first three weeks, and I found it very hard to convince people to talk to me. But these things snowball, and I made connections that led to other contacts, so that by the time I went to Bangalore, I had 14 meetings over 8 days! In my last report, I mentioned that 2 meetings a week is my ideal pace. I haven’t hit that pace once in India; though I had a slow start, I’ve now far surpassed that mark. I never want to say no to a project meeting, and that’s the part of the project I love most – talking to as many people as possible, even if I do have the occasional lackluster conversation. But when I have meetings every day, I don’t have as much time to process what I’ve learned and write about it.
India has been challenging for my project because it’s a much bigger country, with far more diversity and people, than either Sweden or Qatar (both of which were homogenous and small in comparison). Many people here have told me that I could spend my whole Watson year in India, treating the states as different countries for the project. My methods, and where I’ve chosen to spend my time, have been directly confronted by various project contacts. I’ve been asked more than once why I don’t yet speak Hindi, and I’ve also been told many times that I’m not seeing the “real India.” That last point, which I heard from multiple corporates in Bangalore, bothered me the most. Of course, anywhere in India is part of the real India, but I knew what they meant; with roughly 70% of the population living in rural areas, talking to English speakers in Mumbai and “the Silicon Valley of India” (Bangalore) meant that I was only interacting with a tiny fraction of the population. Since then, I’ve traveled a lot more within India, seen more rural areas, and pushed myself to seek out more diverse opportunities here. While it would take far longer than 3 months to understand the intricacies of each state, I feel like I’ve gotten a much better picture of “real India.”
In terms of my findings here, I’ve learned a lot from meeting with a variety of companies (mostly in Bangalore) as well as researchers, faculty members, and doctors (mostly in Kerala and Mumbai). I’m trying to have a diverse set of meetings so that I can more easily compare my experience here to the other countries I see this year. In all my meetings in India, people have said that the number-one barrier to acceptance of medical devices is cost. It’s the headliner of the three “As” of acceptance: affordability, access, and awareness, which I keep getting as answers to my big question of “What factors lead to acceptance or rejection of a medical device in India?”. The device has to be affordable; it has to address the fact that a majority of the population has limited access to healthcare; and people have to be aware of it and its benefits, especially if it’s competing with alternative medicine, which is prevalent here. Also, since the population is so diverse, I think that anyone making a medical device here would have to have a clearly defined target user group in mind ahead of time – even just to know which of the local languages, if any, they should use for the device.
Personally, I’ve had more ups and downs this quarter; I started missing both home and Sweden while in Qatar, and I entered into a slight funk when I arrived in India. The frequency with which I posted on the blog took a dive, which bothered me a lot at first. I simply wasn’t inspired, and I felt like I wasn’t taking enough photos or having enough meetings to justify posting. Then I started having loads of meetings, and no time to write about them! I decided that, as long as I’m still having project meetings and keeping my own notes, it’s okay to leave the blog for a while if I’m not feeling inspired to put a post together. I also realized that another reason I haven’t posted so often is because I’ve been spending more time with new friends, which is a good thing – I feel less of a need to post and reach out when I’m spending less time alone.
I’ve been thrilled to be able to make a group of friends here, partially as a result of spending so much time in India (and, miraculously, finding a group of Mumbai swing dancers). A few weeks ago, I was at a friend’s house for a get-together and met someone new. I told her about the Watson and my experience so far, and her response was, “Have you always been so extroverted? I think you would have to be really extroverted to do that.” That meant the world to me, as I haven’t always been so extroverted but always wanted to be seen as outgoing. I feel like I’ve finally learned the lesson that part of being confident is simply acting like it, and the Watson makes self-confidence a necessity. Well, that’s enough for now. All I can say is, once again, I owe much of my success to the kindness of others, and for that I am eternally grateful.
This past week I met with two women, Sireesha and Vyoma, of Access Health International, an organization that works to provide quality, affordable healthcare in India and other countries around the world. Both Sireesha and Vyoma are based in Bangalore but travel for their work with Access Health, so I was glad for the opportunity to ask them about what factors in India (as opposed to other countries) influence the adoption of medical technology.
First, we talked about the attitude towards health in India in general. Sireesha said that, in her experience, there is no concept of an annual physical check-up – except for those who have private health insurance. Only 17% of the population has health insurance, so that is a small number, but it’s growing as more people are provided insurance by their companies in employment packages (http://www.thehindu.com/news/national/only-17-have-health-insurance-cover/article6713952.ece; however, most people I’ve talked to seem to think the number is closer to 7%). Overall, though, preventive promotive care is not something that really happens in India. Sireesha’s example was that unless there’s a wound in your foot and it’s not healing, you won’t go to the doctor and learn about your diabetes. Since many medical devices are for preventive care and/or self-management of a condition, these devices won’t easily succeed in such a market.
The most important factor in India that determines whether or not someone accepts a medical device, though, is purchasing power. Sireesha and Vyoma are two of many people here to tell me that cost is first and foremost what influences peoples’ attitudes towards medical technology. Beyond cost, we talked about who might use medical technology and why. The main health issues in India are NCDs (non-communicable diseases) such as diabetes and hypertension, which would require devices like glucometers and blood pressure monitors.
Sireesha and Vyoma suggested that elderly people would be more likely to use medical devices, as they are the ones with chronic illnesses that have progressed further and therefore have a greater need for devices. I’ve heard the opposite from everyone else, so I thought this was an interesting view. Most people have told me that elderly people would not want to use medical devices, either to save money for their children or due to a lack of comfort with technology in general.
Sireesha mentioned that the availability of traditional medicines (Ayurveda, homeopathy, and so on) takes some of the market share away from medical devices. Lack of awareness of medical devices is not the only reason besides cost that someone might choose against using a medical device. If people see the technology as too complicated or prone to glitching, they might prefer traditional medications, which don’t have batteries that die or readings that fluctuate.
What I found most valuable about our meeting, however, was that we also discussed the challenges with my project and my approach – mainly the need to normalize my experiences so that I can compare the countries. My project topic, which is already so broad, is complicated by the fact that it has to morph with each country I visit. How can I make sense of all my meetings at the end? How can I put them all into a framework so that these meetings don’t each disappear into one-off experiences? Obviously, I can’t see everything everywhere I go, so each meeting does have to be its own little unique example. Can I make generalizations based on these individual meetings? In addition, I have a time constraint: I only have a matter of months each in these countries with multifaceted histories, cultures, and populations, so I can only see various slivers of each country in this limited time. But maybe taking out the factor of time – seeing each country at a snapshot in time – simplifies the normalization problem.
The other issue is bias. Everyone I meet speaks from their own individual experience, which is biased based on where they’re from and what they’ve seen. Many of the people I talk to are quick to point out that “this is just my perspective and I don’t know for sure” (which is how I feel all the time). Then their perspective gets filtered through my own when I write about my meetings, meaning that I’m adding my own subconscious bias to each experience. Vyoma called a problem of “counter factors,” which I thought was a really cool way to put it. I’m trying to understand and collect these factors for acceptance, but as I do that, I have to be careful to consider the “counter factors” – the biases – that work against my complete and objective understanding of what influences someone to use a medical device.
On top of that, there’s bias that results from the way I travel on the Watson, mainly that I tend to stay in urban areas. First of all, it’s easiest to find housing in urban areas; if I have a family friend offering a place to stay in a country, chances are they live in one of the bigger cities of that country, and if I’m looking for an Airbnb or a guesthouse, I’m looking for one in a city. Many of the companies I research have offices in cities. For safety reasons, I stay in cities. And finally, I stay in urban areas just because that’s what I know about a country in advance – its cities – and I’m ignorant of its rural areas (and how to get there and stay there). Of course, this means that I miss out on a big part of the experience, and my meetings tend to be biased towards the urban upper class, and an even more elite minority of that group – the English speakers. In Sweden and Qatar, where I saw most of the population by traveling to Stockholm, Gothenburg, Malmö, and Doha, this wasn’t a problem. However, most of India’s population lives in rural areas. So my experience here to date has definitely been skewed.
One reason I wanted to spend more time in India and Japan compared to the other countries I’m visiting on the Watson is to explore the differences in urban and rural areas. So far in India, I’ve mostly been staying in Mumbai and Bangalore, two of the most urban and cosmopolitan cities in the country (so, not at all representative of India, not that any one place here would be representative of the whole country – Vyoma mentioned that I could do my entire Watson in India, and it would still be like visiting a bunch of different countries). Still, the urban vs. rural conversation has come up far more in my meetings in India than it ever did in Sweden or Qatar, either by my prompting or that of my project interviewees. That’s good, but I am also hoping to plan some sort of field visit to a rural area for the project to understand these issues first-hand. It will be tough to plan and get approval, but of course it would be a hugely valuable experience, so hopefully I can work something out.
Anyway, as I continue having meetings, it’s good to keep this in mind so that I think of each meeting as a part of the framework, a piece of the puzzle, rather than an isolated experience.