I have just returned from spending 3 weeks in Vietnam working with the Global Foundation for Children with Hearing Loss. This was my second visit with this group. We visited a teacher training university, a children’s hospital and an early intervention center. Let me start by saying that things are very different in Vietnam, as they are in many places in South East Asia.
What is an audiologist in South East Asia?
In the United States, an audiologist is a person with a Master’s or Doctoral Degree in Audiology. When I started in Audiology (in the age of the dinosaurs), you could work as an audiologist with a Bachelor’s Degree, but that changed early on in my career. Last summer I spoke in Singapore and Bangkok and met many people working in audiology from many countries. Some had graduate degrees, others undergraduate degrees, and some had no degrees but on-the-job training.
What services are provided in Vietnam?
Newborn hearing screening is not being conducted in Vietnam. Kids with hearing loss are identified as they get older and parents notice that they are not speaking. This happens somewhere between ages one and three, just as it did in the US before we had newborn hearing screening. Families will likely go to the local hospital for evaluation, and likely end up at one of the major children’s hospitals such as the ones in Hanoi and Ho Chi Minh City. They will first see an ENT and then an audiology technician. On this trip, I spent a week at a Children’s Hospital in Ho Chi Minh. We saw children whose families had traveled 17 hours (on motorbikes) to have us evaluate their children. They were desperate for assistance and willing to do what ever they could do to get assistance for their children.
Audiology in Vietnam
In Vietnam there is no audiology training. People who do audiology testing are called audiology technicians. Many have no degree and learned from the people around them. This is a complicated problem. Getting education is difficult. Textbooks in audiology are, for the most part, published in English. They are certainly NOT published in Vietnamese, so training people is difficult. Unless someone can read English well, getting information is difficult. I have brought copies of my pediatric audiology textbook (Madell and Flexer, Pediatric Audiology: Diagnosis, Technology, and Management, Thieme, NY) and left copies in all the places I have visited, but this is clearly a drop in the bucket.
What was our job?
At the children’s hospital, the two audiologists from the Global Foundation, (me and Elizabeth Preston from the University of Utah, Logan) were providing audiology training to ENT physicians and audiology technicians, about 30 people in all. ( Two colleagues who are auditory-verbal therapists were there at the same time working to train clinicians who are doing therapy with children with hearing loss about how to listen and talk.)
We asked in advance what the groups wanted to learn. The people there for audiology training said they wanted to know about ABR and about masking. Being me, considering what I think is important and my previous experience doing training in Asia, I decided that we should also talk about behavioral testing, assessing speech perception and determining when to move from hearing aids to cochlear implants.
We spent the first day lecturing. We talked about the different types of behavioral hearing tests with videos, electrophysiological tests, and selecting technology. I asked if people felt comfortable doing behavioral testing. The answer was silence. I asked how many people had ever done VRA? One person raised his hand and said he had tried but was not successful. It was clear to me that they really needed to know about behavioral testing, even if they were not interested in it.
When children of any age come for evaluation they are scheduled for an ABR. When we asked why everyone was scheduled for ABR, we were told that this was the way things are done in Vietnam. At the start of the week, the ENT physicians were clear that they were not interested in behavioral testing. They told us that they did not believe that behavioral testing was reliable, and used that old “we don’t have enough time” excuse. We tried to convince them that behavioral testing took less time than ABR, but they did not believe us.
Elizabeth and I were determined to change their minds. One of the first children we saw for evaluation was a 10-year-old who was sent for an ABR. She was a cooperative, intact child and we made the decision to override the physician’s wishes (dangerous wherever you do that) and do behavioral testing. Everyone in the room was shocked. In 10 minutes we had a complete audiogram – air, bone, right, left. People’s eyes were opened.
In the US, behavioral testing is the gold standard. Behavioral testing is a measure of hearing; ABR is a measure of brainstem response. Infants are tested with ABR. In some centers (ones I work with), behavioral observation is also performed on infants, utilizing changes in sucking to determine a response. Once an infant reaches 6 months we proceed to do visual reinforcement testing, and once a child is 30-36 months conditioned play is the standard. We asked to have young children brought in for evaluation and tested newborns using sucking, and saw lots of kids testing with VRA.
Technology in Vietnam
Technology is not available in Vietnam through government or insurance. Families need to purchase hearing aids, cochlear implants, and FM systems for their children. This is a considerable burden for many families. We saw lots of children whose families earn the equivalent of $200 US a month. Hearing aids cost about the same as they do in the US and some cost more. (We had families tell us that they had paid the equivalent of $7000 US for a pair of hearing aids.)
Cochlear implants cost about $50,000US in Vietnam, so very few families can afford them. Getting technology repaired is another problem. It is difficult to get things mailed in and out of Vietnam so repairs have to be done in the country. Very few people have this skill. The Global Foundation for Children with Hearing Loss collects donated hearing aids, and purchases hearing aids when there is donated money, and gives them to families who cannot afford them.
Working in this part of the world can be heartbreaking. I have had families ask me if they should sell their land to get the money to pay for a cochlear implant. If I said yes, what would that family eat? Their land supports them. In the US, before cochlear implants, it used to make me very sad when I identified a child with hearing loss because I knew how difficult it would for that child with a profound hearing loss to learn to listen and talk. With cochlear implants it became much easier because I could honestly say to almost every family that the technology available would enable their child to hear. Compared to the US, Vietnam seems to have a higher percentage of children with profound hearing loss as opposed to mild and moderate losses. This may be because their kids still get diseases that have hearing loss as a component, such as rubella, that are rare in this country.
Is the technology working?
Not always. This may be because Vietnam has only been doing ABR testing. We tested lots of kids. Most were not hearing well with their hearing aids. We saw one child (10 years old) with bilateral cochlear implants who could hear nothing. He was easily conditioned to play using tactile and visual stimuli, but he still was not hearing. We saw other kids hearing at 50 dB with their technology. We checked lots of hearing aids, changed lots of hearing aid settings, taught lots of families how to check aids, and taught audiology technicians how to test and adjust hearing aid and cochlear implants settings. We think we accomplished a lot.
What is left to be done?
Here is my short list
- Get donations of audiometers, including soundfield speakers, to set up test rooms in schools and early intervention centers
- Maybe someone would even donate a test booth or two
- Get donations of hearing aids or get them at reasonable prices so we could get hearing aids for the kids who need them
- Get someone to donate cochlear implants so the kids with profound hearing losses can hear
- Get some money to train people in Vietnam to be audiology technicians and to send some people out of the country to get audiology degrees and degrees in speech-language pathology with a Listening and Spoken Language emphasis so they can do in-country training.
- Set up early intervention centers throughout the country
- In other words, let’s save the world – one little piece at a time.