James was rather surprised and also amused as he pointed out a guy hitting himself with a wooden hammer at the neighboring table where we had lunch. We had gone hiking in the Western Hills outside of Kunming. Stalls offered all sorts of souvenirs ranging from mechanical birds chirping monotonously to little massage devices such as this one. “Hitting” yourself with what looks like a wooden hammer, taking a foot bath before going to bed, or massaging relevant acupressure points to maintain a balanced health are just some of the countless activities people do to feel “shufu”, meaning comfortable and relaxed.

Having lived in China many years myself, I have observed how my perception of my own health changes while I am in China. When I get a sore throat in Germany or the US, I reach for herbal teas, apple vinegar or an Advil. In China, my behaviors change: I stop drinking green tea and switch to hot water, I try to figure out whether I am having a "heat-induced" or a "cold-induced" cold, I go for suction cup treatments on my back and Chinese acupressure massages. To what extent does the language I am thinking in determine how I go about maintaining my health? Or is it the interactions with my Chinese friends who give me much free advice on what to do when I feel under the weather?
More on hot and cold colds and the binary health mental model later.

 

 When we did a project on pediatric dosage forms in the US, one of the strong push-backs against pediatric-friendly looking or tasting medication was the argument that kids might find it too appealing, think it's candy and overdose while their parents aren't looking. While the pushback seem to be stronger from our client rather the parents themselves who often had great experiences with child-friendly vitamins. These caused no daily struggles and at the end of the day, most parents want to keep vitamines and meds in a difficult to reach place for their kids anyways. Others even took on the stance, explaining that it was more important for parents to teach their kids to respect meds rather than just hide them away. Of course, the age group matters in this respect. On a trip to a pharmacy in Kunming, I was surprised to find the following aisle for pediatric medications. First of all, the packaging struck me as incredibly appealing to children. While all of these where OTC meds mostly for colds, their visual language was all about making it cute looking and appealing to kids.

One dosage form struck me in particular. Chewables like Tums Antacid but in this interesting shape. It reminded me of sugar decoration for cakes in Germany. When I asked the pharmacist about the shape, her candid reply was very pragmatic. Kids only like to put things in their mouths that look appealing in shape and color, this one here is very successful.

 With pirated DVDs, fake luxury brand goods, and many fraudulent business practices, counterfeit drugs pose another daily challenge in people's lives. Sellers often talk openly about the level of sophistication of pirated goods. For example, a grade A fake Louis Vuitton bag used to cost half the price of a real one when I lived in Shanghai. Some piraters of luxury goods would even praise their skills by telling stories about placing a fake bag into a real store for a day to see whether the sales staff or customers would discover it. Fake medication is of a different matter. Here the sellers always claim that these are real – of course, which customer in her right mind would purchase bad meds for herself or someone she cares about? This leaves customers confused and with the only option: to stay away from small pharmacies as people don't know whether they will get the real drugs or something mixed up in someone's underground lab but professionally packaged. Common stories I’ve heard tell of people taking what they thought was an Aspirin but instead of helping with their headaches they got tunnel vision for half a day. So, large chains and established pharmacy brands such as Tong Ren Tang in Beijing become the trusted retailers.

The pharmacy chain Jian Zhi Jia, meaning Excellent Health in Chinese, has tried to create trust by installing high-tech touch screen-enabled information kiosks in their stores. In theory, you can scan the barcode of OTC medication packages and be reassured that the drug manufacturer is in the pharmacies database and so a trustworthy source. The terminal also offers information in terms of directions of usage, side effects and contraindications. Only some drugs have that barcode, yet, leaving me rather confused. I also wonder to what extent a system like this actually makes me feel less reassured, as the barcode could be slapped on any drugs, with some fake story of a reliable pharmaceutical company somewhere.

From the pharmacist I learn that this is already the third version installed, but people don't like using it. Not even for conditions that might have a stigma associated, e.g. mental and sexual health. (GI health is something people talk openly about in China). People rather talk with a pharmacist or doctor, the personal connection matters much more in terms of building trust, she tells me. Most Chinese pharmacies have a small clinic attached where a doctor for Chinese and Western medicine is available to do check-ups and write prescriptions – another great business strategy. Despite not being used, she claims that the information kiosk does play an important role in the building of trust: it shows to customers that the pharmacy is wealthy enough to afford this piece of technology giving the chain stores an air of trustworthiness. Is this really the case? Unfortunately, I didn’t get to sneak an interview in with a real customer. It was a cold day in Kunming where everyone rather stays at home.

Kunming has changed much over the past 14 years. While in 1997 the retail highlight for us foreigners was a Japanese supermarket and no foreign fast food chain had yet opened a restaurant, today Kunming's growing middle class is foreign brand hungry. Grocery shopping at Carrefour, a snack at KFC, meeting friends at Ginko shopping mall to shop at Louis Vuitton and Dunhill. Despite this shopping behavior, the advertisements speak of a health obsessed Kunming. Wherever you look, there are hospital advertisements: pediatrics, proctology, gynecology and a hospital specializing on men's health. Is Kunming the health hub for the entire population of Yunnan Province? Is it that he repeated health scandals have given business opportunities to private hospitals, given that people don't trust the government hospitals anymore? Recently, government campaigns urged parents to get their children vaccinated. The vaccinations weren't handled well and resulted in many children getting sick and some even died, causing stronger mistrust in the government health system.

 

Here are a couple of impressions of health ads from a bus ride through Kunming. The writing on the bus outside reads along these lines: "Because we only focus on Men's Health, that's why we are more spezialized."

In Chinese restaurants one used to never know whether the chopsticks and dishes had been washed properly. When I used to study in Kunming from 1997-1998, we would just take some of the hot tea provided and rinse out the bowls, chopsticks and tea cups. In 2005 when I came back to visit, sterilizing cabinets where widely used in restaurants. Most eateries would show off their hygiene standards by putting the cabinets right by the entrance to reassure their guests. Now in 2011, hygiene has been taken even further: dishes are supplied by outside companies, sealed into little packages and the cost is rolled onto the customer. It's just RMB 1 but I am sure, every party involved adds on cost to get their share. From a traveller's perspective it's convenient, although the larger carbon footprint for clean dishes does make me feel bad. The restaurants now have all their utensiles shipped to a cleaning station and back again. Where are those stations? Are they in someone's backyard or actual little factories? I wish I had a choice between self-rinsing my dishes with hot tea and the neatly packaged hygiene deal.

On Sunday, James and I ran a half marathon in Hong Kong. (I know, at some point I said I'd never run a race in my life ... oh well, life transitions make even me more open to try out new experiences.) Unfortunately, I stubbed my toe and as we were flying out of Shenzhen (just across the boarder) the same day, I was limping through the airport. Luckily, they had a first aid station where I asked for an ice pack. The EMT gave me a frozen glucose IV pack. Fair enough, it does have the same features like an ice pack: sealed plastic with liquid inside. So beautifully pragmatic!

At the airport in the ladies restroom, I encountered the following situation: a toilet stall for mom and child to go to the bathroom together. This reminded me of a project where one of our concepts was to engage patient and caregiver to do the dosing of the daily medication together. This idea in the US died a fast and painless death as it was rejected by everyone. Now, in a different scenario here we have a culture that embraces the notion of doing it together. Obviously, there is a need for both of them but maybe this also shows an openness to ideas that wouldn't be successful in the West. Notice the child's toilet seat is even at an appropriate lower level - so perfectly pragmatic!

James forgot his toothbrush, so we ventured out to explore what we would find in Hong Kong.

Hand sanitizing stations are ubiquitous in Hong Kong. This one here is next to our hotel reception on Lantau Island. While I've seen them
everywhere, I hardly noticed any people using them, though. Maybe if I had hang around for a litte while, I would have been able to observe someone using them.

We visited my Hong Kong friend and his family in their new apartment. They just had a baby and instructed us that anybody who wants to hold or come close to their baby would need to wash their hands beforehand. Here our values of health clashed, as me and my husband believe that over-hygenic behaviors might result in allergies, while my Hong Kong friend prides himself as being a good father protecting his daughter from getting sick. What is the right level of daily hygiene?

When we got to his apartment, we took of our shoes, washed out hands and it reminded me of what I had seen in all Chinese homes I have been to in Mainland China, Taiwan and Hong Kong. The inside space is the clean space, while the outside is considered dirty. The floor in people's homes has no grain of dust, while littering on the streets often isn't considered a bad thing at all. This time, it also made me think of the Chinese notion of in-groups and out-groups. While the in-group consists of people you know, e.g. family and friends, these
relationships require to show respect and stick to strict social values, while the out-group consists of all the other people that one doesn't know and can treat without much effort. That's for example why elbowing on public transports isn't perceived as wrong. This is the "jianghu", the wild space where hardly any rules apply and everyone needs to look out for their own survival. This of course is exaggerated as a sense of community does exists. Now, if the same mindset is true for germs and germs being the out-group, then all of a sudden it makes sense to fight them with such fierce efforts and harsh chemicals, putting little consideration on the long term effects.

PS: I am emailing this to my blog since posterous.com seems to be blocked from China, so apologies if these pictures as not in order or upside-down. 

In my almost 5 years at IDEO, for the past 3 years I've focused on projects in the health and wellness space. As design researcher and project leader at IDEO, I have been fortunate to be given the opportunity to create complex innovation strategies for a wide range of design challenges, such as physicians' business and pharmaceutical sales reps, adherence and facilitated adherence, pediatric dosage forms, auto-injectors for large molecules, chronic disease self-management programs, knowledge sharing and organizational transformation at teaching hospitals, as well as IP generation in the connected health space enabling patients with chronic conditions to change their unhealthy behaviors. It's been a fascinating and insightful journey that allowed me to gain deep understandings of people and health in the US. In the upcoming months, I am excited to focus on places outside of the US.

What do people do to stay healthy around the world, across cultures and climates?
How do cultures shape people's perceptions of their bodies, health and disease?
What mental models fuel daily rituals and habits for being well?
What mental models apply when people get sick or struggle with staying well?
When is being healthy normal versus something that requires constant efforts to be achieved?

In the next six months, I'll be capturing my observations and stories here as my husband and I are traveling the world for our honeymoon.

My goal is to inspire you with stories about health and wellness from around the world.
Drop me a line at lucie(dot)richter(at)gmail(dot)com

Be well,
Lucie