I felt insecure about accepting an offer of website hosting from Dudu Balochini, who suggested we host the two websites we had developed together on his server at no cost. I asked him: “But what if you die?”. I was referring to my access to the servers, but he thought it was about his age since he was almost twenty years older them me (I’m 42). He then challenged me: “What if you die?” And that was how we laughed together and moved on. The first site we published together answered a need from the Center of Ageing Studies located at UNIFESP Medical School. Their researchers monitor the elderly population of a neighbourhood in Sao Paulo, and their studies include investigating the impact of physical activity on ageing. One of the interventions they made was to map out opportunities within walking distance for older people to exercise. This mapping was manually adapted to the address of each patient – a herculean task. But an informal survey showed that 70% of program-assisted seniors have smartphones. I had this information in mind when I met Dudu for a coffee. “Do you think we could make these activities accessible through Google Maps based on people’s location?”, I asked him. And he just said “I already know how to do that. I need two hours”. Twenty-four hours later, he produced the site we called Get Up and Go: nearby activities for the 60+. “I used the Store Location feature in WordPress, but it took me a while because it was blocked for developers from Brazil”, he apologised as though I thought he was late.

The second site is part of my delivery for the applied side of the ASSA Project – Anthropology of Smartphones, Smart Ageing and mHealth. With an ethnographic approach, I observed how WhatsApp was used for health purposes in Sao Paulo. I mapped the best practices and organised them into a set of protocols for communication within hospitals and clinics. I also developed a second set of protocols addressing nutritionists (obesity and being underweight are both health issues among older people in Brazil). Both materials are open-access and should be available for download. That is why I needed a website to publish them. This time, Dudu didn’t develop the website for me. “You’re going to become a SeniorGeek”, he told me. SeniorGeek is an initiative for digital inclusion of seniors created by him. At presentation events addressing older people, Dudu tried to demystify technological themes like Artificial Intelligence, Blockchain and Chatbots. He believed older people should know about those things or they would be cut off from conversation with children and grandchildren and, moreover, with society. Dudu also believed he could enable seniors to become digital entrepreneurs through courses that teach how to build a website, or an e-commerce or a blog. This is how I became his student. By myself, with the autonomy he wanted all seniors to achieve, I developed and published my WhatsApp manuals at http://www.saudeeenvelhecimento.com.br. In my field site, entrepreneurship gains strength among older people as a means of reintegration into the labor market. This is a consequence of the desire of many to remain productive but it is also their way to respond to corporate ageism. Dudu himself used to say he lived in a limbo: too old for the market, but not a “legal” senior yet.

Dudu was also a public figure. He was often in the media, giving interviews about the relevance of digital inclusion for seniors. At 58, he used to say, “If you are old, you invented the Internet. The problem is that people accommodated and forgot about it”. And he has a point. We just have to remember that Bob Kahn and Vint Cerf, creators of the TCP / IP protocol that enabled the Internet, are now aged 81 and 76 years old. However, ethnography showed me that this detachment from technology was also linked to retirement, when access to technology and needs in daily life change (Selwyn, 2004). Even so, Dudu’s speeches were inspiring and older people felt more confident because of him. Dudu died one week after I left my field site. An abrupt heart attack. On the one hand, he has achieved the death my informants desire the most: a death without illness or disease. I have written before about how my informants do not fear death. On the contrary, they see death as natural and even desire it when they think of the prospect of a future lived with physical, mental or financial limitations. On the other hand, it was an early death. Dudu was gone when he began to experience the purpose of life. I say experience because, among my informants, there is a feeling that the meaning of life is not something that can be explained by past achievements or by spiritual convictions. Therefore, they abandon philosophical reflections on the subject to focus on the present: they live today with purpose, filling daily life with pleasurable activities and, if possible, positively impacting the lives of those around them. Dudu brought these two accomplishments together in an intense agenda of events and courses.

And it was precisely the technology Dudu was so enthusiastic about that mediated his farewell. The news of his death spread via WhatsApp and was shared from group to group, giving rise to dozens of messages. Information about his funeral was also shared throughout the night, as well as information about the seventh day mass. For this last meeting, friends used WhatsApp again to prepare a last tribute. They have the idea to reproduce the “uniform” worn by Dudu, a black T-shirt, with the SeniorGeek logo. And during the days leading up to the mass, they spoke about how this production was made feasible all through their smartphones, as Dudu would like. The mobilisation was properly registered. And the pictures dominated social media again, now accompanied by the text “We are all senior geeks”. Dudu’s original WhatsApp group for his SeniorGeek initiatives was deactivated. A new one named “Senior Geek Connected” was created instead. It’s still a place where older people can find information about technology and new learning opportunities, keeping Dudu’s original idea alive. For him, above all, SeniorGeek was a manifesto against the invisibility of older people, something he believed only technology could solve.

Selwyn, N. (2004). The information aged: A qualitative study of older adults’ use of information and communications technology, Journal of Aging Studies, 18, 369–384

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.