Rafael could neither hear nor speak. The traditional healer tried to cure him with her medicines but was unsuccessful, ultimately declaring that his ancestors’ anger with his mother had caused the condition.
In 1998, when Rafael was 10 years old, the government of Mozambique made a commitment to formally educate children with hearing loss. After a trained social action worker assessed Rafael's hearing with pots, pans, keys, and clapping hands, he confirmed that Rafael could only hear very loud sounds and advised his parents about the new educational opportunities.
Rafael soon began attending primary school and learned to communicate with his teacher, Senhora DeoLinda, in sign language. He also met other children with hearing loss and made friends.
Then in 1999, a group of foreigners and workers from the local hospital came to the school. Within a few hours, Rafael and most of his classmates were tested with a machine and had a hearing “apparatus” placed in one of their ears.
Over the next 12 months, the medical technician from the local hospital would bring batteries for Rafael's hearing apparatus and check on him and his classmates. The group of foreigners came every year to assess the students, teach them new signs, and bring pencils and books with signs and words printed in Portuguese.
Today, Rafael is determined to be a teacher for other children who cannot hear.
The above anecdote is just one example of the great need for hearing healthcare services in under-resourced areas. About five percent of the world population—360 million people—are affected by disabling hearing loss (World Health Organizationhttp://www.who.int/mediacentre/factsheets/fs300/en/), with two-thirds living in developing countries.
A humanitarian audiologist responds to this need by promoting hearing health for the underserved and disenfranchised. This article is meant as a call to action for such professionals to provide well-planned and sustainable care.
When considering travel to provide hearing health services in another country, it's essential to learn about the region first, including travel advisories and recommendations, disease incidence and prevalence, peak seasons for infectious diseases like malaria and cholera, and morbidity and mortality weekly reports.
A local health department or the Centers for Disease Control and Prevention are good resources. Many local health departments offer vaccinations.
For malaria prevention, multiple medications are available. It is also necessary to sleep under mosquito netting, use insect repellant, and wear long-sleeved tops and long pants. Bottled water and careful cleaning and cooking of food reduce the risk of contracting cholera or typhoid.
The host country embassy or consulate grants a travel visa after the traveler has provided a reason for the visit, anticipated entry and departure dates, and proof of U.S. citizenship or green card status.
Some countries allow travelers to apply for visas at the airport of arrival. However, the visa desk there may be open only a few hours a day or every other day, forbid credit card payment, or only accept specific currency denominations, such as U.S. $20 bills—no coins, singles, or fives.
In terms of health and travel insurance, a number of companies provide short-term options for international and U.S. travelers. Some international insurance providers help minimize security risks for travelers by sending e-news and updates about the regions of travel, as well as 24-hour access to expert advice and emergency assistance.
For individuals looking to use an existing long-term health insurance plan, it's important to verify coverage areas, the protocol for accessing help, and whether deductibles are part of coverage.
A ROSE IS A ROSE
Many monikers are used throughout the world for professionals who study and treat hearing, balance, and related disorders, including speech and hearing therapist, phonoaudiologist, audiological physician, audiological scientist, and phono-acoustician.
Various programs, such as those in Mexico, China, and Russia, incorporate the discipline of audiology after an individual has completed medical training. So, while it might seem that there is an absence of “audiologists” throughout the world, it is important to recognize the different terminology.
There have been occasions when first-time humanitarian audiologists have excitedly shared their plans to introduce the profession to Brazil or Mexico. In fact, Brazil has about 30,000 phonoaudiologists—about double the number found in the United States—who minimally must hold a bachelor's degree in speech pathology and audiology. In Mexico, approximately 400 physicians consider themselves hearing healthcare providers, and are qualified to perform surgery and provide hearing aids.
By no means do such numbers imply that there are ample hearing healthcare services in those high-population-density countries. It is wise for humanitarians to discover the various terms so that they can partner with these professionals.
When preparing to provide hearing healthcare services in an under-resourced area, it makes good practice to respectfully meet, enlist, and partner with as many local professionals as possible. The first site visit can be dedicated to identifying local contacts and partners, resources, protocols, goals, and needs, which will build a strong foundation for the program.
In order to create a sustainable program, it is just as important to engage with the local, provincial, or national minister of health, as well as with policy makers and community workers, who can be trained to provide appropriate referrals to medical practitioners and ear health education for their neighbors. When children are involved in the humanitarian program, collaboration with the minister of education can help ensure the children have educational opportunities, like Rafael in the opening story did.
In the best of circumstances, that final leg of the two- to three-day journey to Chicuque, Mozambique, is mind (and body)-numbing. Much of the drive up the tropical coast is spent catnapping, singing songs, learning (or refreshing the memory of) Portuguese phrases, and taking in the never-ending sight of Mozambicans walking along the narrow and harrowing Highway 1, dotted on each side with small ancestral homes.
There is always some stress as night falls on those final hours of the drive because local drivers believe they save gasoline by forgoing headlights or defrosters.
One particular year, we quickly unloaded our luggage after an exhausting 10-hour drive only to realize that one suitcase had accidentally been left in the hotel lobby in Maputo!
If our supplies had not been spread among all team members, this accident could have been catastrophic. Still, it was definitely challenging for the team member who owned the suitcase packed with personal belongings.
Such an oversight also could have dealt an irreparable blow to team engagement. It did exactly the opposite, resulting in a much more cohesive group mind-set that understood the value of building long-lasting relationships in Mozambique.
Distributing equipment and supplies among team members is always good practice in case a suitcase is left behind at a hotel, as in the above example; goes missing during travel; or is confiscated by customs agents. It is far better to have fewer supplies and equipment for a program than arrive at the destination without equipment that was packed into a single suitcase.
Some seasoned humanitarians suggest that bribery of government officials to get equipment through customs or allow passage through provinces is just part of the package.
During 16 years of travel to Africa, I have only experienced the need to initiate bribery to get the entire team and supplies through customs twice. We later discovered that by keeping our arrival specifics from our local host/translator (“friend”), the bribery demands never recurred.
Even though the humanitarian work site is often under resourced, the same standards for high-quality and ethical service that are expected in the United States should be followed.
The World Health Organization (WHO) has established guidelines for the provision of hearing aids in developing countries, training manuals for primary ear and hearing care, and strategies for the prevention of deafness and hearing impairment.
Even with the best of intentions and preparation, the program will not go as originally planned. Electricity may be inconsistent, and power surges may break audiometric equipment. During holidays, patients may be unavailable for weeks or months at a time. Providers must be patient and flexible.
HERE TO HELP
There are well-established philanthropic organizations that provide insightful guidance, support, and training in hearing healthcare, including the Christian Blind Mission, Skillshare International, United States Agency for International Development, World Health Organization, and World Wide Hearing.
The Coalition for Global Hearing Health is a newer charity focused on advocating, equipping, and empowering humanitarian hearing healthcare professionals. The organization was established to provide networking opportunities for multidisciplinary hearing health professionals, organizations, foundations, corporations, government agencies, and academic institutions through international conferences and an interactive website. Individuals can apply to receive used equipment for work in under-resourced regions.
A founding co-organizer of the Coalition for Global Hearing Health conferences is the Humanitarian Committee of the International Society of Audiology (ISA). ISA is the only audiological organization with a structured humanitarian committee.
The committee promotes best practices in humanitarian programs by making audiologists worldwide aware of existing guidelines and by providing networking opportunities through meetings at various conferences.
One of the documents devised by the ISA Humanitarian Committee is a request-for-donation form that travelers can submit independently to funding agencies or manufacturers of various supplies. The form was constructed to follow the WHO guidelines for provision of hearing services so that travelers can show sustainability and long-term strategies.
There are also published resources on providing hearing healthcare in developing countries. For example, The Hearing Journal's “Audiology Without Borders http://journals.lww.com/thehearingjournal/Pages/collectiondetails.aspx?TopicalCollectionId=14” column highlights the work of humanitarian hearing healthcare programs. I coedit the monthly feature with King Chung, PhD, associate professor of audiology at Northern Illinois University in DeKalb.
Another publication is Audiology in Developing Countries, which is coedited by Bradley McPherson and Ron Brouillette, and written by a number of authors from across the globe (New York: Nova Publishers; 2008).
CLOSE TO HOME
Domestic travel can be one-half to one-quarter the cost of international travel, with a much shorter time commitment. In fact, many of the locations can be reached inexpensively and relatively quickly by automobile, bus, or train.
Accommodations are held to certain local and state standards. If they are found unacceptable, the traveler is easily able to negotiate with the facility or make alternative arrangements on short notice.
Upon arrival, the ease of communication in a shared language reduces the volunteer's anxieties. Since most infectious diseases like malaria, cholera, yellow fever, rabies, and typhoid are extinct or stringently controlled in the United States, there are far fewer health risks and immunization concerns.
Humanitarian programs in the United States include community hearing screenings initiated by nonprofit clinics, such as the University of Texas at Dallas Callier Center for Communication Disorders or John Tracy Clinic in Los Angeles.
Through the Special Olympics Healthy Hearing program, established as part of the Healthy Athlete program, volunteer audiologists and audiology students provide free hearing screenings to athletes.
Travel in conjunction with national conferences or congressional lobbying also presents an opportunity to offer humanitarian services domestically.
There are privately established programs in the United States that reach out to the underserved populations in remote regions, such as in Appalachia and at American Indian reservations in New Mexico. The work is overwhelmingly difficult, and one can learn who the organizers are through word of mouth or within limited-release press.
Closer to home, or even at home, all an audiologist needs is Internet access to conduct a diagnostic audiometric test, fit and dispense a hearing aid, and counsel patients in developing countries. The TeleAudiology Network, established in 2009, connects volunteer audiologists to health clinics in remote regions, with no extra hardware required.
Near and far, there is a great need for hearing healthcare services in under-resourced areas. Humanitarian audiologists can help.