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Applying ethnography to digital health aims; challenges and opportunities – by Charlotte Hawkins

LauraHaapio-Kirk10 August 2019

Author: Charlotte Hawkins

Photo (CC BY) Charlotte Hawkins

How can a holistic ethnographic understanding of ageing experiences, particularly related to health mobile phone engagement, contribute to an mHealth initiative and improve the accessibility of health services and information through mobile phones? This applied challenge in the ASSA project has initiated partnerships with digital health practitioners in most of our fieldsites – in particular, with collaborators working within existing phone practices. This aligned with our early finding across the fieldsites, that mobile phones are commonly used for health purposes, but through communication on apps evidently most popularly used, such as calls, Facebook and WhatsApp. In Kampala, I worked with The Medical Concierge Group (TMCG), a medical call centre founded by Ugandan medics to improve the accessibility, affordability and quality of healthcare. They offer a 24-hour toll-free phone line, SMS, WhatsApp and Facebook access to a team of doctors and pharmacists and have 50,000 interactions each month. At the time of fieldwork, they were in the process of researching the development a psychiatric call line, or ‘telepsychiatry’. This early stage of service development meant that TMCG were interested in and able to accommodate holistic ethnographic insight in their considerations.

Ethnographic insights included systematic information on 50 low income research participants’ existing mobile phone and mobile health practices as relevant to accessing TMCG services. For example, access to airtime and data is intermittent, with a tendency towards regular low-cost subscriptions. This suggests that calling or using the internet could be inaccessible to users at least once a day. Furthermore, 54% of participants had made health-related calls in the last month, and 27% of their previous three remittances were for health purposes, which confirmed an existing propensity to use mobile phones to support family health – but only across their own network of friends and relatives. Interviews with 50 respondents encountered during the wider ethnography also offered TMCG feedback on mental health perceptions, experiences and help-seeking preferences. These interviews were predominantly with older people, mostly older women, who would not typically opt to engage with research on mental health, and yet who represent an advisory position within their family or community. This also included interviews with health workers, including psychiatric clinicians at the local government hospital, and private health clinicians within the fieldsite. Research showed that treatment for mental illness was perceived to be unavailable, costly, or stigmatised. Often respondents said they prefer to handle mental health problems through prayer or counselling within their community, with hospital treatment sought only once problems become severe. This suggested that optional, confidential, accessible or community-based mental health services could be useful for low-income people in Kampala, if advertised accordingly.

Initially, the wide-reaching interview responses were considered thematically, from causality to treatment seeking, and condensed into representative quotes for presentation back to the team. More recently, alongside the team, these themes have been expanded to inform a draft publication in psychiatric journals, which TMCG hope to use seek further funding. We also hope to further disseminate findings in accessible formats amongst other digital and mental health service providers in Kampala. As familiar to many applied medical anthropologists, translating interpretive, subjective and relativist ethnographic information within positivist, objective and universalist medical paradigms brings challenges, such as risking that complex human experiences and perceptions are reduced into ‘practical’ or digestible concepts (Kleinman, 1982; Scheper-Hughes, 1990). However, this assumes that the health practitioners and their discipline are not open to understanding their patient’s everyday realities, which has not been the case in this instance, perhaps reflecting a particular affinity between anthropology of digital health – appropriation of phone based health services is entirely dependent on their relevance and usefulness for their target populations.

The on-going collaborative process has also highlighted what anthropology might learn from the research and writing processes of health disciplines, for example: ensuring findings are widely disseminated and thus accessibly written; avoiding anecdotal, emotive or biased claims; and ensuring that quantitative statements, “many people said xxx”, are qualified and backed-up. The collaboration has  also confirmed that the flexibility of anthropological research and richness of qualitative insight potentially has much to offer health programmes, to ensure their contextual relevance. In ethnographic research, we have the privilege of time, which comes with in-depth insight, and familiarity with the community – time and understanding which we can offer usefully to other audiences. The data provided can perhaps confirm a hunch of a practitioner from the area but can also surprise them. When documented and publicised, the data encourages practitioners to both tailor their approach, but also allows them to share the specific requirements of their target population, encouraging others to do the same – or hopefully even to offer funding to support them.

 

REFERENCES

Scheper-Hughes, N. Three Propositions for a Critically Applied Medical Anthropology. (1990) Social Science & Medicine 30 (2): 189-97.

Kleinman A. The teaching of clinically applied medical anthropology on a psychiatric consultation-laison service. In Clinically Applied Anthropo1ogy: Anthropologists in Health Science Settings (Edited by Crisman N. and Maretzki T.) Reidel. Dordrecht, 1982.

 

Health and Ethics – by Pauline Garvey

LauraHaapio-Kirk1 August 2019

Author: Pauline Garvey

The current advertising slogan for Gaelic Sports Clubs is ‘Where We All Belong’. The girl is shown holding a hurl for the sport called camogie. Gaelic sports including camogie for women and hurling for men have a huge national following, all-Ireland finals easily fill the national stadium with 80,000 spectators.

 

Why is it important to be active, or is it important to be active in specific ways? In recent years there has been mounting focus on health and wellbeing, as evident in the launch of the ‘Healthy Ireland Framework’ (2013-2025) a Government-led initiative that aims to enhance the population’s health. In this initiative health is presented as a public good, of individual and social concern. In the face of troubling temptations that arise with modern lifestyles the launch of this framework explicitly carries an ethical imperative: individual health, it asserts, affects the quality of everybody’s life experience. It is for the collective good to maintain one’s health. The approach recommends that the way to enhance wellbeing is less by focussing on the negative and more by highlighting what one can do to stay well. It recommends, in other words, a focus on the positive instead of the retribution of a poor quality of life that comes with bad behaviour.[i]

Often such initiatives focus on activities. From my fieldwork with middle-class Dubliners I have learned that staying well and being healthy is often talked about as routinised and collective in nature. People gather to walk, run or do yoga and the group aspect is an essential ingredient in the diverse efforts to stay healthy. When people talk of ‘activities’ they are often referring to group activities rather than solitary ones. Lots of keep-fit activities like walking or running can be done alone, yet they seem to be more successful when done with others. Respondents who attend tai chi classes might attend with a friend, and even if they don’t join these groups to extend their social networks they seem to prefer them to following a YouTube course online. This is interesting because it implies there is an added feel-good factor to the demonstration of healthy living beyond the benefits that come with social interaction. It is not just about being healthy, I suggest, but pursuing health in the company of others carries an added benefit in a cultural context where consensus is highly valued.

Younger respondents who have children report emphasis on mindfulness in schools where the health and wellbeing of children and young adults is couched as a social and spiritual category as much as a physical one. The National Council for Curriculum for example states that in ‘health promotion, health is about more than physical health and wellbeing. It is also concerned with social, emotional and spiritual health and wellbeing.’[ii] What we are seeing therefore is an interesting blurring of health, ethics and even spirituality to the degree that it is difficult to discern their distinctions.

 

References:

[i] A Framework For Improved Health and Wellbeing 2013 – 2025, available online https://assets.gov.ie/7555/62842eef4b13413494b13340fff9077d.pdf)

[ii] The National Council for Curriculum and Assessment. https://curriculumonline.ie/getmedia/007175e5-7bb7-44c0-86cb-ba7cd54be53a/SCSEC_SPHE_Framework_English.pdf

The place of WhatsApp in the ecology of care

Marilia Duque E SPereira26 August 2018

Author: Marilia Duque

Dr. Gusso uses WhatsApp Business at Amparo Health Clinic (Photo: Marilia Duque)

In 2015 a PwC research report suggested that the Brazilian m-health market would reach $ 46.6 million while a GSMA report forecasted that 45.7 million Brazilians would benefit from mobile health projects (see here). In 2017 the scenario was even more optimistic. According to Statista, Brazil was expected to become the largest m-health market in Latin America with revenues of around $ 0.7 billion. These numbers explain the impressive amount of m-Heath startups and startup Incubators I’ve seen in Sao Paulo (see Eretz.bio, for example). But they don’t explain why after 7 months of fieldwork I still couldn’t find the people who are actually using these m-health apps. Instead, I found an intensive use of WhatsApp among my informants, filling the gaps in communication and making a huge impact on the ecology of care which we address in this project.

For example, every day early in the morning, Ms. M (54) sends a good morning message through WhatsApp to four lady-friends older than her. “It is like volunteer work because I know they are lonely and that message will make them happy and socially connected”, she explained. Ms. D (66) also starts her day sending a WhatsApp message. But in her case, the message is sent to her only daughter who lives in France, as a sign that she spent the night well. She is supposed to send this message every day before 10am otherwise her daughter will call a friend to check on her. “Some people say my daughter abandoned me, but the truth is that she is closer than many of my friends’ children who just live nearby”.

That is the same in the case of Dr. J., a physician who works in Sao Paulo and uses WhatsApp to take care of his 93 year-old father. After having a stroke, his father moved to Dr. J. brother’s house located two hours away.  Dr. J. created a WhatsApp group to talk to his brother and to his father’s caregiver. He gives her all the instructions she needs, and she updates him with information such as what his father ate, how he slept, how much water he drank, how much he exercised and how he was feeling. After a few months, he could tell how improved his father was and he explained how WhatsApp helped him and his family to feel safe and engaged.

Dr. K. also uses WhatsApp to provide care at distance. He works in my field site as a generalist providing ambulatory care to old people. WhatsApp allows him to give orientation about what to do when patients don’t feel well, and he can also ask them to go to his office if necessary. In many cases, he said, he can solve problems providing only care at distance. Dr. K. believes that the simple fact that the patients know they can use WhatsApp to contact him makes them feel safe and comfortable.

WhatsApp is also helping clinics to manage people’s health. Amparo Health, for example, is a clinic that uses WhatsApp Business to connect patients to doctors. The patient pays a monthly fee to have access to low-cost exams and to specialists like ophthalmologists, gynecologists, dermatologists, nutritionists and psychologists. What is new here is that all procedures and exams are coordinated by a generalist, who is available on WhatsApp. Dr. Gusso, the head physician at Amparo Health, explains that because the clinic business model is based on membership, they have no interest in demanding unnecessary exams or appointments. Doctors are paid by the hour and not by performance and that includes time to answer WhatsApp messages during the morning and afternoon. At the end of the day, he said, they are using WhatsApp to provide care at a distance, helping people to stay healthy, to feel safe and to save money. Prevent Senior, a health insurance company, also uses WhatsApp to make patients’ lives easier. In cases where treatments require on-going medication, patients can use WhatsApp to ask for new prescriptions. They can receive their prescriptions at home or they can go to the doctor office to get them, but with no need to schedule an appointment.

WhatsApp is the primary method of communication for 96% of Brazilians with access to smartphones. And among my informants older than 60 years old, that is also the app they use the most. Now imagine what can be achieved if WhatsApp features are explored to make the communication between health insurance companies, doctors, patients, caregivers, family and friends healthier too.

Infrastructures of Care

LauraHaapio-Kirk19 April 2018

Photo (CC BY) Laura Haapio-Kirk

Someone recently told me about how he encourages his 86-year-old mother, whom he lives with, to use her home blood pressure monitor every day and record her readings in a notebook. He said that doctors had prescribed her medication to lower her blood pressure, which she did not like to take. His solution was to turn to traditional Japanese medicine which he explained is tailored to the individual’s body, rather than western medicine which relies on a universal concept of the body. He was able to track the success of this approach through the home monitoring kit, and now her blood pressure is back to normal. This story reveals how infrastructures of care are made up of various integrated systems – that blockages in the form of non-adherence may reveal alternative routes by which people navigate care and self-care.

I am part of a reading group at Osaka University hosted by Gergely Mohacsi and Atsuro Morita. A few weeks ago we discussed Morita’s recent co-edited volume called ‘Infrastructure and Social Complexity’ (Harvey, Bruun, Morita 2017). He explained that a recent focus on infrastructure in social sciences, indeed an ‘infrastrucutural turn’ in anthropology, is a result of infrastructures becoming increasingly precarious and therefore more visible. Ageing infrastructures are becoming more and more tangible as we bump up against cracks in roads and other markers of decay. Infrastructures are systems that should enable things to flow, whether that’s water, electricity, goods, or people. But what happens when people are disconnected from infrastructures, or for whatever reason the flow is blocked?

Photo (CC BY) Laura Haapio-Kirk

I began to think about how smartphones are integral to navigating many of the infrastructures that enmesh us, for example through maps that visually place you within an infrastructure of roads, or health apps that extend the infrastructure of a national health service towards more individualised care. However, as digital technology becomes more integral to health services will people with limited access (through lack of digital literacy, or affordability for example) face increased marginalisation from infrastructures of care? And how are health professionals to identify blockages in the flow of care before it’s too late for individual patients? In such cases where care is not received, it is not only the infrastructure which is revealed to be vulnerable, but individuals themselves.

A couple of days after the seminar I happened to read a newly published article titled ‘Thinking with care infrastructures: people, devices and the home in home blood pressure monitoring’ (Weiner and Will 2018) in which the authors use the concept of care infrastructure to look at the variety of people, things and spaces involved in self-monitoring using a blood pressure device. Their work reveals self-monitoring as a socio-material arrangement that expresses care for self and for others, as opposed to focusing only on the individual and the device: “Specifically, our analysis has drawn attention to the range of local actors and work involved in the practice of self-monitoring, even in the case of consumer technologies. Through this attention to work, monitoring may also come to be seen as involving not just data, but also care amongst kin, family and colleagues.” My intention for my research was always to look at smartphones as situated within wider practices and things including other technologies and people, but thinking specifically in terms of infrastructure expands my scope and gives rise to questions about how multi-layered flows are connected (or not), ranging from state level, to family based care.

References

Harvey, P., Jensen, C. B.Morita, A. (2017). Infrastructure and Social Complexity. Routledge

Weiner, K. and Will, C (2018) ‘Thinking with care infrastructures: people, devices and the home in home blood pressure monitoring’ in Sociology of Health and Illness 40: 270–282. doi:10.1111/1467-9566.12590.

Looking to the Future

Marilia Duque E SPereira3 March 2018

Author: Marilia Duque

By the year 2050, the Brazilian population over 60 years old is expected to grow from 24 million to 66 million[1]. Fortunately, my first impression of the District of Vila Mariana, in São Paulo city, where I have been conducting ethnography since January, is that there are already innumerable initiatives for the elderly, both public and private.

In addition to public health units, there is the AME-IDOSO for example, a centre dedicated exclusively to the care of people over 60, taking referrals from other health units in the city of São Paulo. It provides examinations, medical appointments and treatments, as well as activities such as dance classes. Just a few blocks away, you can find the Elderly Coexistence Centre (NCI), also subsidised by São Paulo City Hall. If you are 60+ and live in the Vila Mariana District you can join a large number of activities such as knitting and crocheting, fitness, circular dancing, senior dance, manual work, pilates, painting on canvas, chanting, memory games and rhythm dancing. I went there the week before the carnival. When I arrived, it was snack time. While one group were doing a dance class in the lounge integrated into a beautiful garden, another group were chatting and eating, all dressed up in traditional carnival ornaments. The worker told me that the menu takes into account the food restrictions and needs of the participants.

(CC BY) Marilia Duque

During this first month, I have already mapped five squares in the neighbourhood, all of them with gymnastics equipment, in another São Paulo City Hall initiative for people over 60 called “Longevity Playground: Happiness is Ageless”.

(CC BY) Marilia Duque

But if you keep walking you will also see many gyms offering activities for the elderly with special prices, not to mention Aqui Fitness, which has a program of physical activities developed by a geriatrician. And just a few minutes away, you can also exercise your mind and improve yourself; the Nossa Senhora da Saúde Parish offers an adult literacy course (20.4% of the population of Brazil over 60 is illiterate[2]), language classes and a Whatsapp course, especially for people over 60.

(CC BY) Marilia Duque

One of my ethnographic challenges is to investigate how the ageing population in the neighbourhood perceives these initiatives. Do they really work? Do they work for everyone? Could appearances be deceptive? This is an important point because Vila Mariana District is far from being a utopia. You can choose to see just the modern buildings that are rising everywhere among the two storey houses. But you will have some difficulty ignoring the Mario Cardin Community, a favela where more than 500 families live in precarious conditions, or the homeless people living on the streets.

(CC BY) Marilia Duque

But for the moment let us take this apparent wealth of amenities at face value. Actually, this raises a rather different question. Do Brazilian people have to get old before they experience something approaching the support and solidarity of an egalitarian state?

 

 

[1] http://www2.camara.leg.br/a-camara/estruturaadm/altosestudos/pdf/brasil-2050-os-desafios-de-uma-nacao-que-envelhece/view

[2] https://agenciadenoticias.ibge.gov.br/agencia-noticias/2013-agencia-de-noticias/releases/18992-pnad-continua-2016-51-da-populacao-com-25-anos-ou-mais-do-brasil-possuiam-apenas-o-ensino-fundamental-completo.html

Individualised Japan

LauraHaapio-Kirk22 February 2018

(CC By) Laura Haapio-Kirk

Yesterday I met a woman who told me about her grandmother who lived until the age of 99 years and 11 months. She told me how she lived alone in the countryside yet was busy every day up until the end of her life. In her later years she took it upon herself to care for the mountain behind her house, focusing especially on ridding it of weeds. Her granddaughter claimed this daily (and apparently endless) work was one of the main reasons why she maintained her health up until the end. Such stories have been told repeatedly to me in the three weeks since arriving in Japan. Stories of elderly people maintaining their health by cultivating vegetables, teaching traditional arts, or indeed weeding mountains, abound.

(CC By) Laura Haapio-Kirk

From the conversations I have had, there appears to be a social expectation for an individual to maintain an active life for as long as possible and to continue to contribute to society in old age. This can also involve minimising the appearance of frailty and dependence. Another woman told me of how her grandmother, who also lives alone, makes use of a local health facility which picks her up in a minibus twice a week. However, she does not let the minibus collect her from outside her house, preferring to walk around the block so that her dependence on institutional support will not be visible to the neighbours. For this elderly woman, the fact that she lives alone and not with her family gives rise to sense of shame. She continually puts pressure on her children and grandchildren, asking when they will move closer to take care of her.

What is fascinating to me is the tension between an individual’s responsibility for self-care and the social motivations for maintaining one’s health. As Japan undergoes a shift towards a more individualised society (Allison, 2013), consequences such as loneliness and isolation are felt particularly by the elderly, especially if they are used to living in traditional multigenerational households (known as ie). However, my project focuses on the middle-aged who are caught in the middle of these tensions. They both desire the privacy and independence of living apart from parents, while wanting to fulfil their sense of filial piety. The couple with whom I am staying are both in their 60s and close to retirement. Their house is attached to that of the husband’s parents who are in their 90s and mostly independent. The elderly parents shop and cook for themselves and I have witnessed only rare interaction between the two households. The main mode of communication is an interphone system which buzzes sometimes in the evening, for example when the grandmother wants to share gifts of food she has received from the temple, or simply to let her son know that she is going to bed. While the elderly parents do not own a telephone, the interphone allows them to maintain a separation while facilitating daily communication. As monitoring and smart home technology becomes more commonplace, it will be interesting to see if this technology accelerates the trend towards an individualised society by facilitating care at a distance.

 

References

Allison, A. (2013) Precarious Japan. Duke University Press

 

‘Healthy Ireland’ by Pauline Garvey

LauraHaapio-Kirk16 February 2018

From the Healthy Ireland website: http://www.healthyireland.ie/

Author: Pauline Garvey

 

Just last month the Irish government launched the latest national initiative to promote health and wellbeing across the country. The Healthy Ireland campaign 2018 was launched on the 6th January and aims to encourage people to ‘get active, eat well and mind their mental wellbeing’ (www.healthyIreland.ie).  Many of the planned initiatives run through local libraries and are advertised by pictures of families cycling through wooded glades or groups of friends exercising outdoors.

On the day of the launch in Dublin’s sporting venue Croke Park, Taoiseach (Prime Minster) Leo Varadkar said:

The message of the Government’s Healthy Ireland 2018 campaign is simple; I’m encouraging everyone to get involved, by making the small changes needed to improve your health and your family’s health. That could mean including a walk in your daily routine, making healthier choice at meal times or taking a break from your phone to give your mental health a boost. These positive and sustainable changes can help us all build a healthy Ireland (MerrionStreet 06/01/18).

The webpage dedicated to HealthyIreland acknowledges that social factors such as levels of education and income, or housing and work conditions may adversely affect health, and are determined by social, environmental and economic policies beyond the direct responsibility or remit of the health sector. Therefore the campaign asserts the ‘health sector alone cannot address these problems – we must collectively change our approach.’

Excessive mobile-phone use has now been added to nutrition and exercise as a health risk. And while this is interesting, it is perhaps not surprising. Frequent associations between an unhealthy attachment or addictive behaviour and mobile-phone use have been profiled in the national media recently. For example in December 2017 new research from Deloitte, found that 90% of 18-75-year-olds in Ireland now own or have access to a smartphone – putting Ireland among the top users of smartphones in Europe. By comparison 88% of people own, or have access to a smartphone in Europe. Richard Howard, head of technology, media and telecommunications at Deloitte greeted this figure with some caution: “Mobile devices are a relatively new ‘addiction’ to our social fabric and they form an important part of our daily activities and interactions’ (Quann 2017).

There are lots of unknowns in smart-phone use, which is why we are currently investigating this topic, and why we try to understand the smartphone in actual life situations. For example while the Deloitte study found that half of Irish people thought they used their phone too much, 60% thought their partner used it too much! What does this tell us of the place of the phone in negotiating relationships? Are people neglecting their loved ones, forging new friendships or engaging with existing friends and family in novel ways?

Meanwhile the government’s response in the Healthy Ireland Campaign is clear:  “Take the stairs rather than the lift, Eat more fruit and veg, Take a 30-minute break from your phone”. And Varadkar describes his own practice of turning off the phone during meals – “it not only makes the meal more pleasant and your interaction with people more pleasant, it is actually good for your headspace.”  (O’Connor 07/01/18)

 

References:

HealthyIreland 2018, www.healthyireland.ie

MerrionStreet Irish Government News Service 06/01/18, available online at https://merrionstreet.ie/en/Issues/Taoiseach_Leo_Varadkar_launches_Healthy_Ireland_2018_campaign.html (http://www.healthyireland.ie/about/)

O’Connor, Wayne 07/01/18 ‘Healthy Ireland 2018 aims to get us all fitter and more mindful’ Irish Independent, available online at https://www.independent.ie/irish-news/health/healthy-ireland-2018-aims-to-get-us-all-fitter-and-more-mindful-36464484.html.

Quann, Jack 05/12/17 ‘Three million Irish people now own or have access to a smartphone’, available online at http://www.newstalk.com/Mobile-phone-habits-of-Irish-people-revealed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start-up Nation for Whom?

MayaDe Vries Kedem23 January 2018

Israel is perceived as a start-up nation; in 2016, alone 1,200 hi-tech companies were founded. Israelis have established several global start-up companies such as “mobileye”, “waze”, “gettaxi” and “wework”. There is also an Israeli presence in the field of mobile health and medicine. One of the criticisms within Israeli society is that the wealth created by these companies fails to trickle down, which is evident in that 2.4 million Israelis are considered poor. Nevertheless, in Israel there is a relatively good and largely public health system, which serves both citizens and non-citizens.

The term “non-citizens” refers to Palestinians living in East Jerusalem holding the legal status of “permanent residency”. They are eligible for some rights, including medical services, but are not considered citizens of the Israeli state.  East Jerusalem, an area of 70sqkm with 66,000 Arab inhabitants, was annexed/occupied by Israel from Jordan immediately after the 67’ war.

Today, in East Jerusalem there are 300,000 Palestinians, of which 78% are considered poor, and state welfare services are relatively inactive, Their ‘gray’ status has led to a different situation which includes the creation of private medical services clinics that are financially supported by the state. Last November, I met Mr. Fuad Abu-Hamed, an owner of two semi-private clinics in Beit Safafa and Sur Baher, two Palestinians neighborhoods/villages located in East Jerusalem. These clinics are linked to a major state public clinic, and have managed to provide better services, for example access to doctors without queues. They also have improved their online services including a website and an app in Arabic.

When I asked Mr Fuad if his 9,000 clients use the Clalit app, he replied “so-so, people here are not use to being online when it comes to health matters.” He then asked an intern, a young nutritionist, who graduated from Bir Zeit University in the West Bank, if she knew any popular health apps. She mentioned several apps in the field of fitness, wellbeing and diabetes. Mr. Fuad confirmed that diabetes is a serious condition within the Arab population. I am therefore expecting to include diabetes and associated digital applications in my research, but first, I need to know a good deal more about the general condition of health amongst the Palestinians of East Jerusalem; the way they access health services, and how this relates to their ambiguous status. I wonder, if perhaps eventually the ASSA project might encourage a startup that focuses upon this and other disadvantaged populations?

– Maya de Vries