Screening without a cure (revised)
I spent yesterday (Wednesday) at Black Lion Hospital, attending the resident's morning report and a guest lecture by an ENT physician from Phoenix, Arizona. The purpose of his talk was to introduce a neonatal hearing screening program that is being started at Black Lion and to explain its importance. The doctor donated a machine that detects otoacoustic emissions from the inner ear that are absent in people with hearing loss. (For extra credit: Does anyone have any theories as to why such a phenomenon even exists? It seems counterintuitive for the ear to produce its own sound).
In the US, children who are identified with hearing loss are enrolled in early intervention programs that educate the parents in various forms of communication, such as sign language, beginning at six months; many children who experience this early intervention end up in normal school classrooms and communicate at a level on par with their normal-hearing peers. In the US, children with very severe hearing loss are often given cochlear implants before the age of 2. But should the same standards and interventions apply in a resource-poor country such as Ethiopia? (Important side note: the hearing test requires minimal training to administer, less than 5 minutes, and is as invasive as taking a baby's temperature in their ear)
These are the questions that were repeatedly raised by the physicians and residents after the doctor's presentation: Sure, it's great to screen for hearing loss, but should we screen if there's nothing we can do about it? In a society that already has limited opportunities for healthy, normal-hearing individuals, what extra efforts are going to be made to support the education of the hearing impaired?
In America, partially/completely deaf children are taught alternative modes of communication at an early enough age to be normalized into functioning society without significant developmental delays. There is also the option of a cochlear implant. In Ethiopia, cochlear implants are still at least 5-10 years away (conservative estimate) and infrastructure for this type of early educational intervention simply does not yet exist. Which brings us back to the question, should we test for a disease/condition that we can't treat?
The lecturer's host, an Ethiopian physician who works for the World Wide Orphans organization, made the interesting comparison of this screening test to the HIV testing that was available in 1987, before effective anti-retroviral treatments were available in 1995-6. Her argument was that it is important to assess the size of the problem, normalize testing, and have a protocol in place for when treatments are eventually available. From a purely public health standpoint, not considering any outside factors, I think she is correct. However, providing medical care in a facility/country with limited resources forces prioritizing (rationing?) certain medical conditions above others.
The physicians and residents are keenly aware of their predicament, starting off most questions with "Since we can't do cochlear implants here in Ethiopia..." I can't blame them for questioning the value of this screening test. But the other point, about normalizing testing before a cure exists, is also a valid point in favor of capacity building. I tentatively side with the skeptical Ethiopian physicians, questioning the value of doing this test at this time in this country. Unlike HIV, there are myriad potential causes - multiple infectious agents or congenital diseases - of neonatal deafness with few, if any, cures available. Unlike HIV, the possibility of a "cure" is remote and the palliative measures available in the US are not available here. Until the government builds a social welfare infrastructure to help care for its neediest citizens or Black Lion starts offering cochlear implants, I think there are more important medical issues that need to be addressed first.
On the other hand, the screening test requires only 5 minutes and minimal training. If even one child is identified and goes on to become a highly-functioning member of society as a result of different education/communication strategies used for the hearing-impaired, then one could argue the test is worth the additional investment. This type of issue is a daily occurrence in Ethiopia and always warrants a debate on the best use of resources and personnel.
(On a totally separate note, at the Mission today I saw a patient with typhoid fever, a woman who allegedly suffered a hyena attack, and a patient with "lockjaw," which may or may not have been tetanus.)
In the US, children who are identified with hearing loss are enrolled in early intervention programs that educate the parents in various forms of communication, such as sign language, beginning at six months; many children who experience this early intervention end up in normal school classrooms and communicate at a level on par with their normal-hearing peers. In the US, children with very severe hearing loss are often given cochlear implants before the age of 2. But should the same standards and interventions apply in a resource-poor country such as Ethiopia? (Important side note: the hearing test requires minimal training to administer, less than 5 minutes, and is as invasive as taking a baby's temperature in their ear)
These are the questions that were repeatedly raised by the physicians and residents after the doctor's presentation: Sure, it's great to screen for hearing loss, but should we screen if there's nothing we can do about it? In a society that already has limited opportunities for healthy, normal-hearing individuals, what extra efforts are going to be made to support the education of the hearing impaired?
In America, partially/completely deaf children are taught alternative modes of communication at an early enough age to be normalized into functioning society without significant developmental delays. There is also the option of a cochlear implant. In Ethiopia, cochlear implants are still at least 5-10 years away (conservative estimate) and infrastructure for this type of early educational intervention simply does not yet exist. Which brings us back to the question, should we test for a disease/condition that we can't treat?
The lecturer's host, an Ethiopian physician who works for the World Wide Orphans organization, made the interesting comparison of this screening test to the HIV testing that was available in 1987, before effective anti-retroviral treatments were available in 1995-6. Her argument was that it is important to assess the size of the problem, normalize testing, and have a protocol in place for when treatments are eventually available. From a purely public health standpoint, not considering any outside factors, I think she is correct. However, providing medical care in a facility/country with limited resources forces prioritizing (rationing?) certain medical conditions above others.
The physicians and residents are keenly aware of their predicament, starting off most questions with "Since we can't do cochlear implants here in Ethiopia..." I can't blame them for questioning the value of this screening test. But the other point, about normalizing testing before a cure exists, is also a valid point in favor of capacity building. I tentatively side with the skeptical Ethiopian physicians, questioning the value of doing this test at this time in this country. Unlike HIV, there are myriad potential causes - multiple infectious agents or congenital diseases - of neonatal deafness with few, if any, cures available. Unlike HIV, the possibility of a "cure" is remote and the palliative measures available in the US are not available here. Until the government builds a social welfare infrastructure to help care for its neediest citizens or Black Lion starts offering cochlear implants, I think there are more important medical issues that need to be addressed first.
On the other hand, the screening test requires only 5 minutes and minimal training. If even one child is identified and goes on to become a highly-functioning member of society as a result of different education/communication strategies used for the hearing-impaired, then one could argue the test is worth the additional investment. This type of issue is a daily occurrence in Ethiopia and always warrants a debate on the best use of resources and personnel.
(On a totally separate note, at the Mission today I saw a patient with typhoid fever, a woman who allegedly suffered a hyena attack, and a patient with "lockjaw," which may or may not have been tetanus.)
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