The App Frontier.

This winter our professional development has two parts. Part one is learning to use a new App we’ve been developing with a local startup called Wiseyak. Part two will focus on treatment of older adults in a rural setting. 
Our still-to-be named App is designed for use with the Basic Package of Oral Care in Health Posts (or potentially any primary care center in a rural, limited-resource setting). Bethy and I have been meeting with the developer, Ravi, for a few months, discussing how an App can be most beneficial our environment, where public health needs are paramount.  What exactly is the role of technology in a Health Post in rural Nepal? Should it help with smart diagnostics? Facilitate “telemedicine” where midlevel providers in remote areas consult with doctors (a hot area of tech innovation that I feel some feelings about)?
We weren’t trying for either of these. I felt strongly that the greatest need in our rural clinics isn’t producing technical magic between provider and patient. For one thing, the logistics are scratchy: most Health Posts can’t rely on a stable cellular connection, much less fast WiFi. But the main reason is that dental technicians should have good training and expertise equivalent to their responsibilities. Why invest in an app instead of improving the skills and abilities of the operator? 
Instead, our App is simply designed to provide excellent documentation. Good digital record keeping offers a wealth of valuable opportunities.  It can help us track specific conditions at population level (in case you’re into dentistry, which I’m kind of not, that would be things like decay on first permanent molars in schoolchildren). Rather than medical technology to help to diagnose disease, it’s designed to facilitate documentation of treatment plans over multiple visits and make it easy for technicians to follow-up with patients in their villages. The App should also be able to spit out referral lists to higher care and provide urban centers with referred patients and contact information. And last but not least, as a health surveillance tool, it will allow us to scan aggregate data and identify specific needs in different areas–and because we are using a community-based and rights-based design, the issues we’re tracking are those that can be addressed with skills that the technicians provide right there in the primary care system (again, in case you’re in to dentistry, that would be things like silver diamine fluoride, ART and sealants).
So in a sense, our App is a much as social justice technology as a medical or public health technology.
It was kind of a thrill to kick off our training on the App yesterday. Bethy gave a great orientation and had meticulously prepared case studies and patient ledgers for the clinicians to practice entering in to the tablets that we acquired in a great feat of shopping conquery. As is becoming our usual training format, first clinical teams practiced applying the concepts using case photos, which they used to go through the diagnostic process, write the treatment note on paper, and then in this case transfer the note it on to the app. In the afternoon, real patients joined us and the teams worked at super slow speed with lots of time for questions, consultation, and App usage.

The next day, we went to Kaskikot to treat students at a primary school and field test the digital data entry process. Gaurab the Bear joined us and he was an enormous hit. I took some close up photos of young children with severe levels of disease in their mouths, and the next day, the teachers spent a few hours meeting with Bidhya and Shreedhar, our filed coordinators, about re-launching the school brushing program and junk food free school.

We left with a sizable list of adjustments to be made to the App, but it was incredibly gratifying to see how quickly everyone took to using the tablets. We’re aiming to use parallel paper and digital systems for about six months before – hopefully – switching over.

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Cash on Delivery

 

As the start of our winter Professional Development session approaches, it’s time for me to bite the bullet and shell out a bunch of cash for a pile of tablets for an App we’re developing. Teaching clinical teams how to use the app will be the focus of the first part of our upcoming workshop.

The problem is the tablet-acquiring part is…a bit intimidating. At home, I’d search options on the internet and then probably order a few different options, which would arrive at the door with an option for 30-day free returns. But I will shamelessly admit that when it comes to Nepal, I have no idea how to do this. I know how to do stuff that involves baskets, ropes, and misplaced stretches of mud…but I do not know how to do a normal officey thing I am in charge of, such as acquire some expensive pieces of unfamiliar technology.

I asked Muna, our Program Manager Who Literally Fixes Anything, how and where one buys a pile of tablets in Nepal. We were hoping for something with a little flexibility on standard retail price, since we’d be needing 5-7 of them to start.

Muna, did I mention she Literally Fixes Anything, told me about a site called Daraz.com where I could order things on the internet to my house. Or our office. I was floored. Internet ordering is a thing in Nepal? Where the heck have I been? Muna explained to me excitedly that they literally bring it TO YOUR DOOR.  Right to your very own door! And then, you pay for it there. If you don’t want it, you return it with the courier.

“The courier?”

“A person brings it.”

“You order it on the internet and a person brings it? But how do they find you?” I was pretty sure this wasn’t happening through the regular mail system.

“They call.”

I just want to point out that, while a postal service certainly exists in Nepal, most houses don’t have street addresses, and a minimum of streets go by name (that anyone uses or that command street signs), and a large percentage of the houses and streets that do exist were only recently built, and in the majority of the country there are a minimum of streets altogether.

“Are you sure this works?”

“I use it all the time,” Muna said, becoming excited again by the phenomenon of internet ordering. “It’s cash on delivery.”

We looked on daraz.com and ordered five $280 tablets to Ravi’s office in Kathmandu. I arrived in Kathmandu a day later, a week before our training was to start, intending to return with both our trainer (Bethy) and the highly necessary tablets. By this time Daraz.com had called Muna, and Muna began relaying messages between the company, Ravi, and me. At first everything seemed fine. Then Daraz explained that they had the five tablets, but needed to get them out to a store where the courier would pick them up and bring them to Ravi’s office. Or my hotel. Or wherever we asked them to come on the day that they would call us, some time soon, having secured the assets through the official processes.

“Are these going to get here on time?” I asked Muna. She knows things. Admittedly we’d ordered the tablets at the last minute, and even on-time things are almost never fast things. And I seriously doubt that Daraz often receives orders for a heap of five tablets at once.

“Let’s see?”

While the tablets whereabouts remained uncertain, Bethy did arrive as planned from Cambodia.  We spent an afternoon with Ravi to map out our training plan for next week. By Sunday, I was starting to worry. I started calling around in Kathmandu to see about buying some tablets from a show floor, something that in my mind was randomly assigned as a more feasible activity in Kathmandu than Pokhara.  We ended up locating a completely obvious strip of cell technology stores around the corner from New Road. I called Muna and told her we were going on an expedition to find the tablets ourselves.

“If I find them, we can cancel the order, right?” I asked her.

“I called to ask, and they said that when the courier shows up, we just say we don’t want them.”

My mouth opened and closed for a few seconds. “It’s seventeen hundred dollars of merchandise!”

“I know, it doesn’t make any sense, but that’s what they said.”

Just to be clear, I’m not telling this story as a lesson in how things don’t work in Nepal. To the contrary, this is exactly how things work in Nepal. The internet company wasn’t trying to give us the run around, they were just trying to figure out how to find a guy who could get his hands on the pile of pricey tablets we wanted and get them to our guy in a short period of time. Without street names. In a cash economy.

Bethy and I set off to New Road to begin the in-person search. If I’d been more savvy, I’d have known from the start that we should have gone to New Road: as we rounded a corner, there before us, like Oz, was a fairlyand of Samsung and Oppo and Huwaei stores packed together for a block and a half. We walked in and out of them pricing out different tablets, including the one we’d possibly or possibly not ordered online, and when we thought we’d settled on a winner, we wandered in to one last alley for a final try.

There we met Ravi #2, who presented us with our final and ultimately champion tablet, a simpler and smaller version than everything else we’d located. At about 40% of the price.

“I’m a movie star,” Ravi #2 said.

He is. Look him up.

“Here’s a video of me,” Ravi #2 said offhandedly, handing us his phone, his Bieber coif spilling over his brow glamorously but without obstructing his vision. We bent our heads over the small screen, which showed our tablet salesman serenading a beautiful woman on a bridge.

“I’m not the singer,” Ravi #2 admitted. “Just the actor.”

I withdrew a heap of cash from the ATM and forked it over. While five separate people bustled about unpacking our tablets in order to fill out warranty cards, add screen covers, and repack them, we waited and chatted with Movie Star Ravi. He reclined on his stool, a physically not possible thing that only Nepali movies stars can do.

“Do you know my pal Mahesh? He’s a movie star also,” I volunteered.

Why yes, Ravi #2 did know Mahesh, the brother of our field officer Gaurab (the human). Gaurab and Mahesh are both from Kaskikot and I’ve known Mahesh since he was a kid, and even produced a radio story about his robot-making career before he was a movie star with Ravi #2. His father Thakur was one of the founders of Jevaia Oral Health Care back when it was Kaski Oral Health Care, a bazillion years ago.

“Small world,” I said. “You should consider a further discount, considering that Mahesh’s family is closely involved with the very worthy project that these tablets are for.”

“Sorry,” Ravi the Movie Star said. “But here’s my number. Call if you have any problems with the tablets and I’ll get them fixed right away.”

We needed tablet covers.

Ravi the Movie Star didn’t have any tablet covers, but he gave us the name of a shop in another part of the city about a mile away. Obediently I put it in my GPS and Bethy and I set off at a fast clip, racing against the gathering dusk, the new tablets in my bag. In no time the main thoroughfare of Cell Phone Oz had narrowed, then faded away behind us and deposited us in to the heart of Kathmandu’s old, cloistered Newar alleys. Ornate wooden windows leaned precariously in over our heads, while vendors presided over every vegetable and shoe and devotional item imaginable, and as we dashed alternately through crowds and crowded passageways it seemed unlikely that we were headed closer to tablet covers. Night fell, and the cobbled paths and squares became lit by yellow squares falling out of spice stalls, flickering lamps dotting the pavement where vendors had spread out their treasures. We sped through, dodging colored blobs in our path like marbles rolling through a game.

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Out the mouth of a maze we arrived, suddenly, at the destination on Ravi the Movie Star had directed us to, and Lo and behold, there before us was a shop with exactly the name he had provided.

It sold a lot of stuff, but none of the stuff was tablet covers.

We turned around and went back in to the din. We wove about, passing up vacuum cleaners and suitcases and incense and frilly skirts. Surely, somebody, somewhere among all these objects, had some simple tablet co—-

And there it was. Bending off the laid stone path and its hoard of pounding feet was a harshly lit corridor of electronic gadgetry shops that contained four bazillion types of cell paraphernalia. At the end of it, positioned in such a way that suggested anybody arriving must surely be doing so at the end of a great pilgrimage, was a casual shop crammed with phone covers. A woman sat among them as if, obviously, we had been on the way and due to arrive at some point, whenever.  Inexplicably, she had only one type of tablet cover, in one size, and it was a size that fit our efficient little mini-tablets.

“We’ll take five,” I said.

We packed them up, shoved them in our now very full backpacks, and set off on the last part of our expedition through Bishal Bazaar and Ason, butter lamps burning what seemed like everywhere in the lively chill.

“Muna,” I said over the phone a little later, “I’ve secured our tablets. We can cancel the online order.”

“Where did you find them?” she asked.

…You know…streets?

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