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Cultural Considerations for Hearing Care in the Nepalese Himalayas

Eisner, Sandra

doi: 10.1097/01.HJ.0000575384.89722.c9
Audiology Without Borders

Ms. Eisner completed her degree in speech and language therapy and audiology in Innsbruck, Austria. She has volunteered across the globe (Cambodia, El Salvador, and Nicaragua), and has been organizing ear and hearing care awareness programs in Nepal. She's also pursuing her master's degree in rehabilitative audiology at the Queen Margaret University of Edinburgh in the United Kingdom.

“Tomorrow we'll take a jeep for about eight hours, then we'll start walking the next day. We'll walk for two days up and down the mountains,” my husband said, shortly after we arrived in the Sankhuwasabha district of northeastern Nepal after 28 hours in a local bus racing across the country. Since 2015, I've worked with local groups to promote hearing care in Nepal, particularly with the Nepal Lhomi Society (NELHOS), a non-profit organized by a local indigenous community. Among the group's many projects is a small health post in Lingam, a village in Sankhuwasabha's Upper Arun Valley near the Tibetan border. Health workers have reported ear disease and hearing loss to be prevalent among the locals—the Singsa Lhomi, an ethnic group that left Tibet thousands of years ago and settled down in the southern part of the Himalaya. Their rich language, culture, and religion are of Tibetan origin and similar to those of other Himalayan groups such as Sherpa, Lowa, or Dolpo. However, their unique health beliefs and practices, which are firmly based on tradition and religion, also serve as barriers to seeking proper audiological care.

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Singsa Lhomis believe that diseases are caused by evil spirits, gods, or goddesses, and that a person gets sick if he or she is cursed by someone from the unseen world. For example, an old villager once shared a traditional story about ear disease and its possible causes:

“A long time ago, an old king had an ear infection and ear pain. He believed that a certain god was not satisfied with him, which was why he got this infection. However, there were ants inside his ear building a house. The king had no clue about the ants; in his mind, an angry god was responsible for problems. He wanted to satisfy this god by organizing a puja, and so he bought two sheep—a mother sheep and her lamb. The animals were brought into the palace. Among the people living in the palace was a young deaf boy, and even though he was deaf, he could understand animals. The sheep talked about the ants inside the king's ear and noted that the disease was not caused by an angry god. As the deaf boy understood their conversation, he offered to help them. The sheep gave the boy instructions: Go to the king, sprinkle water into his ear, and place a burning wood close to the outer ear. The deaf boy did as he was told, and the ants left the king's ear; they thought it was raining and a thunder storm was approaching so they left the ear. The king's ear problems then went away.”

Singsa Lhomis would first treat any disease with home remedies. If this doesn't help, they would invite a local priest, a “pujari,” to perform a certain ritual (“puja”). Their last resort is to seek help at a local health clinic. By this time, the person may already be seriously ill and suffering from irreversible consequences.

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In my first two years in Nepal, I worked in a hospital's audiology department and did retrospective analyses of medical charts collected by the International Nepal Fellowship (INF) during ear surgery outreach activities in western Nepal. This was when I realized just how much these remote communities are affected by ear disease and hearing loss. In 2017, my husband, a Singsa Lhomi, and I learned about NELHOS and their clinic in Lingam, and decided to start health education programs in the Upper Arun Valley to raise awareness about ear diseases, hearing loss, and the importance of having healthy ears and hearing.

But how and where do we start? Our goal was not only to talk about or treat ear disease, but also to change the people's health-related behavior regarding ear disease and hearing loss. We wanted the Singsa Lhomis to understand the severe consequences of untreated ear disease and experience the effects of treatment. Finally, we wanted to motivate the community to seek medical treatment and break down the barriers that hinder them from doing so.

We decided to start with field visits to conduct baseline surveys and interviews with members of local communities to know more about their knowledge level, health behaviors, and attitudes toward ear disease and hearing loss. We worked with a small team from NELHOS to know more about the patients who go to the health post and their disease patterns, as well as how the local health workers diagnose and treat ear disease and hearing loss. We also conducted awareness sessions in schools in the villages of Lingam, Chepuwa, and Rukuma.

We felt that we were on the right track: The students, teachers, and school administrators expressed much interest in what we shared. We talked about ear and hearing health care, conducted ear check-ups, and did ear syringing when needed. Students who were found to have ear/hearing problems, along with their teachers and parents, were counselled in ear care and given additional information about further treatment.

Noting the Singsa Lhomi's custom of passing knowledge by word of mounth, other villagers heard about our activities, attended our sessions, watched us clean students’ ears, and asked for advice about their ear problems. Some parents even visited the NELHOS health post with their children who were not examined during our school visits. It didn't take long for the word to spread, and families approached us for help and support.

In 2018, we organized health education programs in seven local schools. Altogether, 358 children (including non-students) attended these programs and were screened for ear disease. About 33 percent were diagnosed with an ear condition; of these, 90 percent (120 students) got one or both ears cleaned. Those with other ear pathologies were advised to see a specialist. We also took on special cases and financially supported the surgical treatment of two girls, Datik and Phinsum, who had severe chronic ear infections and bilateral moderate to severe hearing loss. They both received treatment at INF's Ear Center, which is part of the Green Pastures Hospital in Pokhara in Central Nepal.

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While overwhelmed and encouraged by the community's response, we faced several challenges. Traveling to remote areas in the Upper Arun Valley and transporting equipment proved to be expensive, time-consuming, and exhausting. Another challenge was dealing with patients with ear disease and hearing loss who were not interested in getting a hearing test, treatment, or hearing aids.

Singsa Lhomis are not used to going to hospitals or medical clinics. They work hard in the fields, and some would only consider visiting the health post for an emergency. Otherwise, ear disease and hearing loss are seen as “minor” problems not worth treating. Some would just live with it, while others prefer consulting a local shaman about ear problems. Finally, our services are limited to counseling patients to seek further treatment. However, specialized clinics and hospitals are too far and expensive, and hearing aids—along with its regular follow-up and maintenance—are very expensive and difficult to obtain. All of these contribute to the small number of people who go to the health post.

Despite these challenges, our mission continues to expand. Today, we are working closely with local health care workers in improving their skills in diagnosing ear and hearing conditions and identifying those who need further treatment. We are also developing telemedicine and smartphone options to aid diagnosis and referral with an ear center in Pokhara. Ultimately, our hope is for more patients to seek proper hearing care as we continue to promote awareness about hearing care and disease prevention.

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