The Last Report (in which I discuss the conference and finally get sad about the end of the Watson)

It’s September 1st, and the cold morning air seems to be celebrating the beginning of fall. I’ve ducked into a nearby café for a warm coffee, and it turns out to be Scandinavian-themed, with surprising authentic kanelbullar and phrases written in Dutch that look almost identical to their Swedish equivalents. This will be my first fall in the US not consumed by back-to-school sales and the idea of new classes; by this time a year ago, I had already been living in Sweden for over a month. I can’t help but feel a pang of nostalgia for that time, a fitting emotion to go along with the bite of cold weather.

All the 2016-17 Watson Fellows. I am honored to be standing here with such an honest, lovely, and inspiring group of people.

My last reflection for the Watson year is due today, so I am sharing it here (fair warning – it is a bit longer than the other quarterly reflections). This will be the end of this blog, so I want to thank everyone who followed me and supported me throughout the year. Knowing that so many people were reading the blog is what kept me writing, and I love you all for that. Thank you.

Watson Final Reflection (Quarter 4)

New York City is a lot kinder than I remembered. After years growing up in Manhattan, I expected to come back to a place that seemed harsher and more foreign than ever before. But I find the city friendly and kind – maybe because I’ve been on the receiving end of so many kindnesses this year that I am more aware of the potential of kindness in everyone. Or maybe it’s because my Watson year was difficult and full of the unknown, and the mere fact that New York is familiar, with signs in English, makes it seem easy. Maybe it’s because I was so worried I’d be disillusioned with New York and the US as a whole when I returned, and it turns out that I’m not. That even with all my strange new definitions of “home,” New York City is, indeed, my home.

In typical New Yorker fashion, I have been riding the subway nearly every day since returning to the city. When I’m on the trains (which look the same as they have my whole life, for better or worse), I often feel like time doesn’t exist; that “now” could be 5 years ago, or 5 years in the future. I wonder if the Watson hasn’t happened yet or if it’s already happened many years ago. This sense of warped time is partially due to the nature of being in transit, frequently traveling amongst strangers – a state I’ve gotten quite used to. Riding the New York City subway is familiar, as something I’ve done all my life (certainly “pre-Watson”), but it is also very similar to much of my movement on the Watson.

This is all to say that I am still processing the end of the Watson. I avoid saying “since I’ve come back home…,” because it implies some circular nature to the events of the past year. The Watson was far more than a simple trip for which I left home only to come back a year later. It was a step forward, a continuation of the life I have been living, and a year in which I had many homes. Though I am in the same physical city now as I was before the Watson, the world has carried on in the meantime, and I feel different, older. So I haven’t exactly gone back.

The Watson conference was a wonderful place to start processing these strange feelings. Meeting my cohort of Watson Fellows was an emotional experience that far exceeded my expectations. For some reason that I can’t understand now, I was worried that it would be too overwhelming, with too many strong personalities in too short a time. But as the Watson Foundation promised, the few days we spent together felt more like a warm family reunion than a conference. The other Fellows, with their eloquent and thoughtful presentations, were able to describe emotions that I have felt deeply throughout the year but have been unable to voice. As one Watson Fellow put it, the conference felt like an opportunity to meet forty versions of the same passionate individual; a chance to see who we could have been if we had pursued different projects or chosen to live in other countries. Talking with the other Fellows, and discussing the more complex feelings and challenges we encountered this year, helped validate my experience and cement the Watson as a very real year.

The conference was also the first time in a few months that I let myself feel emotions again. About a month or two before I left Botswana, my last project country, I realized that I had been stemming deeper emotions, or at least compartmentalizing more than before. I thought it would hit me at some point that the Watson was ending, and that I would become overwhelmed and sad – but even just a week before my flight to the US, I didn’t feel as much of a sense of loss or even as much excitement as I expected. I said goodbye to my best friends in Botswana with more of a “see ya later” attitude than a real goodbye. I didn’t feel the depth of it when packing, or on the plane, or on my surprise 16-hour layover in Doha, even though I had the chance to meet up with my close friends from Qatar much sooner than expected.

Even at home, I didn’t feel it – not until the conference. Early into the Watson year, I happily realized that I was making more friends and forming deeper relationships than I ever hoped to, considering how little time I had in each place. But with all these lovely friendships came far more goodbyes than I could have predicted either. Fully feeling every goodbye, every loss, and every ending got harder and harder, only a few months apart each time, so I suppose I subconsciously learned to protect myself from those emotions. For that reason, I am glad that the Watson year is over. The lifestyle would have been become unsustainable. It was already emotionally exhausting, and now that I have finally let myself appreciate the end of the Watson and what I’ve lost, but also everything that I’ve gained, I find my heart quite a bit heavy. I feel like I’ve lived six full lifetimes over the past year, and that’s a lot to carry around, even though what I’m holding includes lots and lots of wonderful things. Maybe that’s why I can’t easily say that I’ve “come back” – because I can’t ignore that, while my one suitcase stayed the same weight all year, I feel heavier in other ways.

I want to remember these wonderful things, so I will put some of them down here, in writing. I don’t want to forget the way my Japanese host parents kept waving as I went through airport security for as long as it took for me to disappear from view. I don’t want to forget singing along to Beyoncé with project collaborators in Botswana on the 4-hour drive back from the most remote village I’ve ever seen. I want to remember telling my parents over Skype about going to a Japanese hot spring with my host mom, sitting naked in the steam with her and speaking broken English, and not realizing how weird that sounded until I said it out loud. I don’t want to forget the names of anyone I’ve met, or the looks and smells of the 50 different rooms I stayed in over the course of the year. I like remembering the little moments – wandering around Osaka by myself on Easter Sunday, meeting a group of young entrepreneurs trying to cultivate start-up culture in Nagoya, and having so many difficult conversations about Trump, racism, and Christianity with cab drivers in Botswana.

Of course, I will also remember what I learned from all of my meetings. In the last quarter, my project focused more on grand themes than individual, illustrative products. Though there were many times in Japan when I thought I had heard all the possible answers to my questions, and that I wasn’t finding new insights, I was still struck by the patterns that developed. By the end of my time there, I had a clear sense of the importance of collective culture, which favors large established companies over innovative start-ups. Along with the high aversion to risk that I noticed in Japan – probably part of the reason why Japanese life expectancy is so high – it becomes evident why there is not a high acceptance or early adoption of new medical devices in Japan, especially those that are invasive or require extensive testing.

In Botswana, the key factors that influence reactions to medical technology turned out to be the population size, the influence of the government, and the importance of community. The small population, a sparse two million in Botswana’s landscape, means that very little comes from Botswana or is made there. The head of the Botswana chapter of the South African Federation for the Disabled told me that, since Botswana is relatively well-off, foreign donors overlook the country compared to others in the region – even though the Botswanan government is constantly seeking additional funds for health crises. The fairly centralized government is one of the country’s largest employers, so it is a big part of Batswanan life. Instead of fast-paced start-ups or private companies leading medical technology innovation, all ideas and projects must involve the government to have a wide reach, which means the development of healthcare products gets slowed down by layers of bureaucracy. Furthermore, since Botswana doesn’t have a history of invention or a critical mass of people working outside the government, there are very few success stories to inspire new innovators – and much of the older generation looks down on the quality of potential “made in Botswana” devices. Luckily that attitude appears to be changing with new generations.

With fewer distinct medical technology projects and products to pursue in Botswana than in other countries, I had to adapt my approach. I enjoyed this change, as I was able to delve further into the examples I did see rather than having many one-off hourlong meetings with different companies. I followed one mHealth start-up in particular – a company that started in Kenya and offers a smartphone app for easy eye examinations – and watched it evolve over the course of two months. I interviewed the project manager in Gaborone, attended a preliminary budget meeting with the government at the Ministry of Health, and went into the field to talk to community health workers in rural villages about the start-up’s pilot program in one of Botswana’s school districts. It was fascinating to see this mHealth project from different sides and add the dimension of time to my understanding of their work – especially how working with the government, while necessary in Botswana, can slow progress.

Thinking about all the countries I visited, human-centered (ergonomic) design is absolutely a key factor in creating positive reactions to medtech. Of course, each country and each community is unique, and I found different answers to my questions in every project country. User-focused development processes, however, naturally account for most of these differences since they involve working and designing with relevant local groups. I also found other, less anticipated factors that were important in most countries, such as the presence of an innovative environment; the importance of finding and working with the key opinion leaders of a community, whether patients or doctors or village leaders; and the need for a good business plan or supportive finances, as the discussion of ergonomic design is a privilege that comes after establishing the affordability of these medical technologies. I learned that the slightest difference between countries could manifest in completely different attitudes to medical technology – and that different attitudes to medical technology, such as in Sweden and Japan, could lead to very similar health standards. The only way to know the impact of those small changes is to really know a country – its healthcare and technology, and the interplay of its politics, culture, and society – and that’s a process I truly enjoyed.

I wish I could say that I am inextricable from my project, as many Fellows are. I would love to draw a beautiful connection between the findings of my project and my personal development on the Watson. While both surely evolved, I do think of them as two separate progressions.

It’s hard to say exactly what will become of my findings this year, or my blog. I am happy to do all of this to wrap things up – the conference, this last report, closing up the blog – but I also don’t want to say that this all ties up in a neat little bow. It wasn’t the easiest year, of course, and not all of my meetings were thrilling or elucidating. Some were contradictory. Some seemed really exciting at the moment but turned out to be outliers or one person’s exaggerated experience. It’s difficult to package this up and neatly put it away, and I’m not sure I want to; all of my Watson year experiences are now part of who I am today, and that will stay with me. I think having this project has helped me think even more broadly than my liberal arts education. Observing so many “sustainable” design projects has inspired me to not only consider these elements in my future engineering work, but also to ultimately move from engineering to design.

As far as my own personal developments, I’m sure they will be evident more and more as the years pass. But one clear change is the fact that I enjoy and seek out alone time more than I ever have before. It sounds like such a small thing, but it does matter to me. I never needed alone time in college, and though I didn’t realize it at the time, that desire to be around people all the time was somewhat indicative of my own insecurities. I’m really fond of this change because it means that I am more comfortable with myself – happier spending time with myself and generally more confident in who I am as a person. I feel less reliant on others to give me advice and suggest how to be happy, and I have less of a need to fill my time with other people and other things. I have a new (or re-discovered) sense of completeness in being alone. I don’t want to lose my new appreciation of alone time now that I have the opportunity to be surrounded by people all the time. I want to make a conscious effort to keep that.

Similarly, I now feel comfortable going into situations without too many plans or expectations because I trust myself to deal with whatever might come up. I’ve gained more from being patient and seeing what will happen, knowing that either way things will be different from what I could predict and that I will be able to handle it anyway.

Another change I wish to hold onto is the way that this year has pushed me to be better. The Watson Foundation’s immense trust and investment in each year’s Fellows forces us to rise to the occasion, and I found myself particularly motivated to add something positive to people’s lives in order to be a worthy recipient of the grant. It’s impossible to ignore the privilege of mobility and the pangs of imposter syndrome that can accompany such a grant, and I think the only way to mitigate those feelings is to try to make some sort of positive impact while on the Watson and pay it forward in the future.

On the other hand, I’m sure some of the changes I’ve adopted this year are temporary, like so much about the Watson. I won’t always feel super comfortable living out of a suitcase, or be so used to hellos and goodbyes, and that’s okay. One of my favorite parts of the Watson conference was when we discussed what we want to take with us from the year as well as what we want to leave behind. I’m tempted to live the Watson lifestyle forever, and it was a good reminder that it’s okay to leave certain things behind from the year, to lighten that load a bit. Of course, there are many things I want to keep forever, such as that newfound appreciation of alone time, the ability to maintain steady emotions in the face of the most unexpected events and setbacks, and how to say “Cheers” in a few different languages.

For now, I feel like it’s time to redirect my energy to the US, where I do understand the culture and can act in my own context – at least for a little while. I haven’t yet figured out exactly what that will look like, and I’ve been getting impatient, likely because I’m still on the Watson time pacing. I got used to living full lives in spans of a few months, so it’s strange to me to have far more time than that to figure things out. But then I look at my Watson conference list of things I want to bring with me from the year, and the only word I underlined – amid self-confidence and minimalism and paying kindnesses forward – is “patience.”

All in all, I am filled with love and gratitude and humility after the Watson year and the conference. Thank you.


Last night abroad

I leave Botswana tomorrow, and even though the date of July 18th has been in my head all year, it still doesn’t quite feel here.

Some people in the departments of Computer Science and Engineering at the University of Botswana were interested in what I’d seen this year, so I gave them an informal presentation. Here I am with some of the attendees.

My trip home will take 28 hours, including a couple hours in Doha (hello again!) on the way to NYC. Thanks to the new electronics restriction on flights coming into the US from the Middle East, I was going to have to pack my laptop away in my checked bag for the whole trip (and worry about it not breaking – a nice welcome home from the new president). But just now as I went to check in with Qatar Airways, I saw that the ban was lifted, so that’s good news! Now I’ll be able to take my Kindle on the plane with me and finally finish the book I started ages ago (The Goldfinch).

Wire animals at Princess Marina Hospital, the main public hospital in Gaborone.

I’ve been packing for the last time today, and I’m definitely ready to stop living out of my suitcase. I’ve somehow accumulated a extra bag’s worth of stuff over the year – I packed so tightly when I left that I didn’t leave room for the few clothes, small trinkets, and many papers that I would acquire throughout the year. My packing right now is a bit sloppier than most of the times I’ve packed this year, but this time I just have to get my stuff home instead of setting up someplace new.

Most of what I brought with me is coming back, except for pants I managed to rip yesterday (oops) and the travel quick-dry granny panties I unceremoniously tossed a few days ago. A few other things got tossed and replaced throughout the year, but for the most part I’m very happy with what I packed.

I went to a cafe in Gaborone that had this framed Swedish bill (it’s 100 Swedish kronor, about $12). It completely took me by surprise, and all of a sudden I was thrown into a bunch of memories from last fall. I feel like this will be how I know that the Watson has been real, that I’ve really been to these places and left little bits of myself in them – when these random reminders appear out of nowhere and pull at my emotions and my memories.

Today is President’s Day in Botswana, and as presidents are apparently very revered here, everything is closed. Botswana will stay quiet until Wednesday (after I’m gone), and the one meeting I had scheduled for late last week was canceled because the doctor started his holiday a bit early. It’s been nice to slowly wrap things up and not worry about any more meetings, but now I’m getting antsy to go home (I wish, at least, my Zumba class were open today, or the cafe where I have a free coffee that I’ll never redeem). The journey home will be long enough that I want to get it started!

I’m very excited to finally come home and return to NYC after the longest continuous time I’ve spent away from the city. I’m sure the end-of-Watson feelings will kick in a bit later, maybe on the plane – I’ve said a lot of goodbyes these past few days without actually feeling them. (I think that after a certain number of goodbyes, you just go through the motions because it would be too emotionally exhausting to really feel them all. That will all sink in eventually, too). For now, I’m excited to have one last crazy long journey and go home to my friends, family, and of course, the dog.

Of course, this isn’t my dog – this is Butters, one of the dogs at the Airbnb where I’ve been staying in Gaborone. He’s a goofy troublemaker.

P.S. This is my last post written from abroad on the Watson, but not my last post on this blog – I’ll keep writing for a little while longer to cover coming home, the Watson conference, and the final Watson report.

Last month

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 favorite building in Gaborone: the Parliament.
A statue of Sir Seretse Khama, the first president of Botswana.
The winter sky of Botswana is so beautiful and clear.

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.

On the campus of the University of Botswana.
A sign on the university campus.
Have you ever seen a wild monkey eat a homemade bagel? This monkey grabbed a bagel in a matter of seconds and scurried up the tree to enjoy his new and unusual treat.

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.

Street-side stalls in Botswana sell hard candies, sausages, and the local “fat cakes,” dense doughy bread rolls.
A pedestrian bridge in Gaborone, at the city’s main train station.

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 white tiered building down the road is the Ministry of Health, where I sat in on a meeting to discuss funding for the national rollout of an mHealth project.

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.

World War II memorial.
More Gaborone street scenes.

Botswana: First impressions

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.

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I flew from Tokyo to Doha (back to Qatar!), then from Doha to Johannesburg, and finally from Johannesburg to Gaborone on this little plane.

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!

Botswana is quite sparsely populated.

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.

Cracking up in this teacup at an empty amusement park here called “Lion Park.”

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.

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The Central Business District of Gaborone. It’s really mostly buildings under construction.

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.

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.

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.

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.


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.

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).

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.

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).

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).

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).

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.

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.

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

Fukuoka had beautiful flowers all over the city – lovely city planning.
It’s also a canal city with many bridges.
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.

Fukuoka’s ACROS building.
Sunset over Fukuoka’s river. Far off on the right are yatai, the canal-facing food stalls for which Fukuoka is famous.
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.

A short train ride from Fukuoka is Dazaifu, a city of mountains and temples that’s perfect for a day visit over the weekend.
At Dazaifu’s main shrine.
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.

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

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



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).

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.

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.
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.
Last shot from the Fukuoka beach area. My guess is that this is a fancy resort, but I’m not sure.

That time of year again…

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!).

Tokyo’s Midtown area.

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.

Sakura petals have been blanketing everything lately.

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.

Art at Nittele Tower, Tokyo.

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.

Not what I expected to find in Tokyo! An American apple pie restaurant appropriately named “Granny Smith.”

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 went on a nighttime boat tour of Sumida River with my host family. This is the Tokyo Skytree building disappearing into the fog!

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.

A beautiful green walkway that stretches for many blocks – very close to where my homestay is.

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.

Speaking of Japanese culture…See the young woman he’s holding in his hand?

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.

Mt. Fuji as seen from the window of the shinkansen bullet train. It took two months of being in Japan for me to see it, and then I whizzed past it at 160 mph!

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.

Speaking of wonderful and strange, this enormous clock was designed by director Hayao Miyazaki (and it definitely looks like something from his films). Four times a day, it grinds, whirrs, and clanks to life on the hour, and it’s so much fun to watch all the little pieces move – like the people in the bottom right tending to the mini fire.