Bridging the hearing divide: A CGH alumna’s path to ending preventable hearing loss
Nina Martin | The Johns Hopkins Center for Global Health
“Anuk is a three-year-old boy I treated in Alaska. Ear infections started when he was barely four months old. His parents brought him into clinic, worried he didn't say much compared to his brothers. Sure enough, many rounds of infections had resulted in hearing loss,” began Susan Emmett, speaking into the darkness of the theatre. “Without treatment, Anuk's speech will continue to lag behind. He's more likely to do worse in school, have worse job prospects and experience social isolation...” Presenting at TEDGlobal 2017 in Arusha, Tanzania, Emmett - an otolaryngologist and former Paul S. Lietman grant awardee – shared one of the many reasons why she has dedicated her career to ending preventable hearing loss.
While this talk was given almost a year ago, the critical issue has not changed. It is estimated that 360 million people today worldwide suffer from disabling hearing loss (defined in adults as difficulty hearing above 40 decibels, and above 30 decibels in children – meaning hearing whispering would be a challenge, and normal indoor conversation extremely difficult). Thirty two million are children who, like Anuk, are at risk of poorer social, physical, and economic development compared to their peers without appropriate treatment. Over half of these cases are believed to be preventable (usually caused by infections or birth complications), and roughly 80% of individuals with hearing loss live in low- or middle-income countries.
For Emmett, this represents a fundamental question of equity – why should children like Anuk face a potential lifetime of not being able to engage with the sounds of his world, when his counterpart in richer, higher resource settings have access to technologies that can identify and correct these disabilities at an early age? It’s a question she started asking early in her training, as a resident in the Johns Hopkins Otolaryngology Residency Program. As a Spring 2013 Paul S. Lietman awardee, a grant which supports Johns Hopkins housestaff and fellows to pursue global health electives during their training, Emmett worked with Dr. Keith West’s group in Sarlahi, Nepal to better understand the connections between early childhood undernutrition and hearing loss. From her work there, Emmett has dug into her passion to not only understand why children in low-resource settings disproportionately experience hearing loss, but also how to flip the odds in their favor.
As she explains in her talk, standard tests for hearing loss typically involve expensive equipment in a fixed place, and treatment may require seeing a specialist – which are challenging to access in rural Alaska, where 75% of communities are not connected to a hospital by road. Enter innovation from afar: South Africa – a country nearly the geographical size of Alaska – recently rolled out hearScreen, a smartphone-based hearing screening tool developed at the University of Pretoria in 2015. The tool is designed for laypeople to screen children and adults for hearing loss outside the clinical setting. In South Africa, where over 80% of households have access to a cell phone, this technology is a perfect avenue to reach those who might not otherwise have access to an audiologist or ear surgeon. Emmett and her team recognized the opportunity to adapt this streamlined, low-cost concept and link it with Alaska’s sophisticated telemedicine system. Now, a child can be screened in a community center or school by a teacher or community health worker using a cell phone and referred quickly to specialists to receive treatment.
In Emmett’s words, “hearing loss affects over a billion children and adults globally, and the impact is lifelong. Innovative, evidence-based solutions to address this neglected public health problem have tremendous potential to change lives around the world.” Technologies like these novel screening tools could mean children like Anuk no longer have to live in silence and have an equal chance at reaching their fullest potential.
Dr. Susan Emmett completed her residency in Otolaryngology at Johns Hopkins University School of Medicine in 2016, and received a Masters of Public Health from the Johns Hopkins Bloomberg School of Public Health in 2014. She now serves as Assistant Professor of Surgery and Global Health at Duke University.
See below for an expanded version of our Q&A. Note the contents have been edited for clarity and length.
NM: Hearing loss presents many difficulties to young children and adults as they progress –you mentioned social isolation, poor educational and job prospects, etc. – and the numbers behind the burden of disease are staggering. Why is hearing loss personally meaningful to you?
SE: The impact of hearing loss is tremendous. Children experience speech and language delays and perform worse in school. Adolescents are more likely to drop out of school early, and as they grow into adulthood, they face limited job prospects and lower incomes. This health disparity is keeping children from reaching their full potential. Yet the World Health Organization estimates that up to 60% of childhood hearing loss can be prevented. Knowing that this is a preventable health disparity drives me to make a difference.
NM: There is a lot of talk now about “resilient innovation” – learning from ideas and best practices for health and wellbeing from around the world and adapting them to the US context – and your group’s mobile hearing screening could be considered a great example about that. What inspired this idea?
SE: Often innovations developed for low resource settings abroad are equally applicable for extending access to care in the US, and mHealth hearing screening technology is no exception. Similarly, Alaska has developed one of the best telemedicine networks in the world to address barriers to care that result from the state’s tremendous size (586,000 square miles) and 75% of communities not being connected to a hospital by road. This technology, which enables access to specialty care in even the most remote communities, has tremendous implications for expanding access to hearing care in other remote and rural environments both in the US and abroad. We see our work in Alaska has having implications in both directions – bringing South African mHealth technology to the US and setting the stage to expand Alaska telemedicine technology to other environments.
NM: Can you share more about the trajectory of your work in Sarlahi to your current work in Norton Sound with Native nations? Specifically, how did you get into mobile technology?
SE: The work I’m doing now is a natural extension of the undernutrition and hearing loss research in Nepal. Our overarching goal is to address disparities in hearing loss globally. One essential aspect of this is to understand why the global burden of hearing loss is disproportionately skewed toward low resource settings. If we uncover etiologies that are unique to these environments, we will be better equipped to prevent hearing loss from happening in the first place. This is what the work in Sarlahi is all about.
Simultaneous to developing new pathways for prevention, we urgently need innovative solutions to extend access to hearing care. In rural Alaska, we’re testing the concept of mHealth screening and telemedicine referral as a new paradigm to identify and treat children with undiagnosed hearing loss in remote communities.
Mobile technology underlies all work on hearing loss in remote environments, whether to develop new pathways for prevention or extend access to care. The traditional model of permanent audiologic equipment in a soundproof room doesn’t work in these communities, where the nearest audiologist is often hundreds of miles away. Evolution of mobile technology allows us to bring hearing assessment to the people who need it, regardless of how remote the community.
NM: What is your favorite place you’ve lived/worked/travelled to? Favorite meal? Always good to have a fun question!
SE: One of the most meaningful places I’ve lived and worked is Moshi, a town in northern Tanzania at the base of Mt. Kilimanjaro. I did a research year there on a Howard Hughes fellowship during medical school. The experience was transformational, solidifying my commitment to a career in global health.
My favorite meals in Moshi were from El Rancho, a restaurant down the road from where I lived that had planned to be Mexican but could only find a chef for Indian fare!