Part one of this article began with a light-hearted anecdote about Count Volta sticking electrodes in his ears. Part two takes a more serious tone. Here, we address the reasons why cochlear implants aren’t available to everyone, and why they are nearly inaccessible to those who need them most in the developing world.
The most pressing barriers that prevent adults and children in developing countries from accessing the benefits of cochlear implants are plain enough: (1) the high cost of cochlear implant components; (2) the complexity and skill level required to perform the surgery; and (3) the lack of local post-operative rehab services and expertise.
Fortunately, there’s a light at the end of the tunnel. In part two of this article, we look at the tremendous efforts of nonprofit groups to overcome these barriers to cochlear implants in developing countries. We also look at an experimental (yet controversial) approach to cochlear implants that could dramatically reduce the cost and complexity of implant components and surgeries.
Why Access to Cochlear Implants Is So Important for Children
Cochlear implants can offer life-transforming help to adults with hearing loss, but they are even more important for children. That’s because children with hearing loss have a limited period of time in which to develop speech and listening skills. If a hearing problem isn’t addressed with hearing aids or cochlear implants by the age of 3 (and preferably earlier), children with serious hearing conditions may not be able to develop auditory and speech skills naturally.
Without listening and spoken language skills, it is more difficult for children with deafness and profound hearing loss to attend mainstream school or fully participate in their hearing communities. Tragically, many of these children in developing nations are miscategorized as intellectually disabled – when in fact, there is a shining, beautiful mind hidden behind their inability to communicate.
Photo Courtesy of the Global Foundation For Children With Hearing Loss
According to Paige Stringer, Executive Director of the Global Foundation For Children With Hearing Loss (GFCHL): “It is essential that hearing loss be identified as early as possible in newborns and young children so they can get the hearing technology and early intervention support they need to learn to listen and speak. For a child to develop on par with typically hearing peers in the areas of speech, language, and audition, they must have access to the sounds of speech. Early access to hearing aids or cochlear implants is key for successful outcomes.”
A landmark 2010 study echoes Stringer’s perspective by confirming what most in the hearing and speech-language professions already knew. The study found that children who receive cochlear implants before the age of 18 months achieved a speaking ability closer to that of hearing children. In contrast, those who received cochlear implants after the age of 3 continued to exhibit certain gaps in speaking ability compared to children without hearing loss.
In developing countries, where access to cochlear implants and hearing aids is scarce, some deaf children may be able to attend schools where they can learn sign language and benefit from a specialized curriculum. But children in rural, undeveloped areas don’t tend to have this option. Without cochlear implants, access to affordable hearing aids, or proper schooling, these children may not be able to develop their language and communication skills in a mainstreamed environment. To say that these children face severe discrimination, social isolation, and extreme socio-economic challenges as a result of their hearing difficulties would be an understatement.
Image source: BBC
When children are born with hearing impairment and deafness in developed countries like the United States or the United Kingdom, technologies, therapies, and educational opportunities are more readily available and help to remove the barriers to living a normal life. These children have the potential to grow up without impediments as developing children typically do.
Why Are Cochlear Implants Difficult to Access in Developing Countries?
There are three main reasons why cochlear implants are difficult to access in developing countries: (1) the cost of the components and surgeries; (2) the complexity and surgical skill required to perform the procedures; and, (3) the need for post-operative rehabilitation services.
(1) The High Cost of Cochlear Implant Components
The cost of cochlear implant components and surgeries depends on a number of factors, but one thing is certain: The prices far exceed what the average person in a developing country can afford. In the United States, the components alone – without factoring in surgical costs – can exceed $25,000 per ear, and total costs with surgery can exceed $80,000 per ear. In developed nations, private or national insurance usually covers these costs, so access isn’t an issue.
In many Asian, African, and Latin American countries, the cost of cochlear implant components is less, but the prices are still prohibitively high. In the article, “The Challenges of Starting a Cochlear Implant Programme in a Developing Country,” Dr. Kumaresh Krishnamoorthy writes that Cochlear Implant components cost from $12,000 to $25,000 in India. With surgery, total costs come to $17,000 to $29,500. If you consider that the average Indian salary is $2,120 per year – and that these individuals are living paycheck to paycheck – it’s easy to see why cochlear implants are absolutely unaffordable for most Indians without any available government or insurance financial support.
According to Stringer: “There are also the ongoing costs associated with cochlear implants after surgery – which includes a lifelong commitment to paying for post-op rehabilitation, replacement parts, servicing, and upgrades. Many families focus on the cost of the initial device and surgery, but they don’t have the means to pay for these ongoing costs.”
As Krishnamoorthy points out: “Cochlear implants are a proven auditory rehabilitative option for individuals with severe to profound sensorineural hearing loss, who otherwise do not benefit from hearing aids. Nevertheless, only a small percentage of these individuals receive cochlear implants, and cost remains a leading prohibitive factor, particularly in developing countries […] the technology is virtually unavailable to the masses.”
Unfortunately, even though many developing countries have government-sponsored cochlear implant programs, most do not have enough surgeons or facilities – or rehabilitation support post-surgery – to service all of the people who need them.
(2) The Complexity and Skill Level Required to Perform Cochlear Implant Surgeries
Once fully trained, a neurotologist can safely perform a cochlear implant procedure, but the surgical training is long, involved, and expensive – and it’s only available in developed countries. As a result, there are not enough surgeons in developing countries who can safely perform cochlear implant procedures.
Image Source: Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.
When you see the steps involved, it’s easy to understand the complexity of the procedure:
Administer general anesthesia: General anesthesia is required during the two- to four-hour procedure.
Make an incision behind the ear: The surgeon makes an incision behind the ear to expose the mastoid bone.
Identify the facial nerves: The surgeon finds the facial nerves and drills an opening between them through the mastoid bone to expose the cochlea.
Place the electrode array: The surgeon opens the cochlea and threads the electrode array into the cochlea.
Place the receiver: The surgeon makes a shallow indentation into the skull behind the ear and fixes the round, flat receiver into the bone just beneath the ear.
Close the incisions: The surgeon closes the incisions and the procedure is complete.
Considering these steps, the cochlear implant procedure is neither “simple” nor “easy” to perform. It requires general anesthesia, drilling through the mastoid bone, and the removal of a portion of the skull. There is also the risk of facial nerve damage. While the use of surgical robots for cochlear implant procedures could reduce the skill requirement, this technology is still largely inaccessible in developing countries.
As we will discuss in further detail below, there is the possibility that an experimental cochlear implant design could one day reduce the cost and surgical complexity associated with this technology.
(3) The Need for Post-Operative Rehabilitation and Training
Beyond the cost and complexity of cochlear implant surgeries, implant recipients need several months – or years in the case of infants and young children – of training as they learn to recognize sounds and understand speech. For children, speech-language therapy is particularly important. This training requirement often prevents those living in rural areas from getting cochlear implants – simply because they cannot access an in-person therapist for post-op rehab and speech-language training.
Stringer from GFCHL offered the following perspectives on this: “Cochlear implant technology is not a stand-alone solution. It is an intensive medical device that needs a lot of support. CIs are not like glasses where you put them on and instantly see better. A CI is just a tool to enable access to the sounds of speech. There is a great deal of rehabilitation involved after the CI surgery, particularly in young children, to fully benefit from it.”
Getting cochlear implants to those who need them isn’t just a question of funding and sourcing surgeons. To make this technology available to more people in developing countries, national governments also need to conquer the serious logistical challenge of building a medical infrastructure that (1) has enough skilled surgeons and surgical facilities to serve everyone; and (2) has enough local training facilities where cochlear implant recipients can receive post-operative rehab and speech-language therapy.
(4) The Lack of Awareness Surrounding the Benefits of Cochlear Implants
There is also a lack of awareness surrounding (1) the need to screen babies and young children for signs of deafness, and (2) the benefits of cochlear implants and hearing aids when treating deafness and other hearing conditions. Without a general understanding of these issues, children born with hearing loss may never be identified – and even if they are identified, parents may not be aware that treatments and therapies are available.
As for adults with hearing loss, they also might not realize that they are suffering from hearing loss – and if they do realize it, they might not know that a pair of hearing aids or cochlear implants can dramatically improve their lives. Incidentally, this lack of awareness is also a problem in the developed world, but adults – no matter where they are – can quickly assess their level of hearing loss by taking a free online hearing test. If you’re curious to check your hearing, here’s a free, 5-minute hearing test from MDHearingAid.
Overcoming the Challenges of Cochlear Implant Access
The most common approach to overcoming the lack of access to cochlear implants is to increase nonprofit support and international aid for government cochlear implant programs. This involves helping developing nations overcome the logistical challenges of sourcing surgeons, establishing surgical and post-operative facilities, and educating the public on hearing loss treatment options.
A second approach to increasing access involves a radical rethinking of the technology and its surgical techniques. By redesigning cochlear implants to be more affordable – and making surgeries simpler and less invasive – overcoming the cost and logistical challenges of cochlear implants becomes a great deal easier.
(1) Nonprofit Efforts to Boost Cochlear Implant Access in Developing Countries
There aren’t many organizations expressly dedicated to increasing access to cochlear implants to children in developing countries. However, the Global Foundation for Children with Hearing Loss (GFCHL) is one such organization that’s passionately engaged with achieving this goal. Led by its Founder and Executive Director Page Stringer – a public health specialist and cochlear implant recipient herself – GFCHL has a mission to bring direct and lasting change for babies and young children who are deaf or hard of hearing and living in developing countries. Watch this video from Stringer to get a sense for the organization.
According to Stringer: “A sustainable cochlear implant program in a country requires LOCALLY based expertise and services in cochlear implant surgery, audiology, cochlear implant mapping, auditory-verbal therapy, and early intervention. Not only do parents and family members need access to professional expertise and support, but they also need ongoing servicing and equipment. In many developing countries, these elements are lacking. There is also the high cost of all the elements, which makes it challenging for many families to afford if there is no insurance or government subsidy to support it.”
Photo Courtesy of the Global Foundation For Children With Hearing Loss
Stringer says that bringing hearing technology to children in developing countries is a two-fold effort:
Raising awareness: Helping governments, local health administrations, caregivers, and the community at large understand that children with hearing loss can learn to listen and speak when they receive the proper support at an early enough stage. This is a process of educating and involving family members and caregivers while raising awareness among the general public.
Organization and Logistics: Offering training programs that help developing countries establish local services and professional expertise. This is a process of showing countries how to develop screening programs that support early identification, encouraging timely fitting of hearing aids and cochlear implants, and ensuring access to locally-based professionals – such as audiologists, cochlear implant specialists, and speech therapists.
With programs in Vietnam, Bhutan, and Mongolia, and previously in Ecuador, the efforts of GFCHL have made possible:
The screening of tens of thousands of infants
The training of hundreds of teachers, therapists, and medical professionals
Educational support about hearing loss in children for hundreds of families
The fitting of over 400 children with digital hearing aids with ongoing support from professionals trained by GFCHL
The GFCHL has also partnered with the global hearing care organization Hear the World Foundation (the charitable arm of Sonova that manufactures Advanced Bionics cochlear implants) to provide 10 Vietnamese children in need with cochlear implants along with 15 years of complimentary audiology support and technical upgrades. The children also receive complementary auditory-verbal therapy support by Vietnamese professionals trained by GFCHL for several years.
Other organizations are also involved in providing hearing aid assistance to those in need. For example, key leadership from the affordable hearing aid manufacturer MDHearingAid (CEO Doug Breaker and VP of Product Sourcing Paul Bryant) recently helped sponsor the AllHear Foundation’s 2020 mission to Belize. The AllHear Foundation completed 100 free hearing tests and provided 91 free hearing aids to those in need.
Image source: AllHear Foundation, Photos of Hearing Loss Patients in Belize, Photo Dr. Chip Goldsmith (Center Left) with Patient (Right)
The Belize mission with AllHear Foundation was MDHearingAid’s first participation in an overseas project. Locally, MDHearingAid also partnered with H.O.M.E. to give away $100,000 worth of hearing aids to Chicago seniors in need. MDHearingAid says it will participate in more overseas and local missions to provide further hearing assistance in the future. Doug Breaker, MDHearing CEO commented, “Giving back is very important to us. Our mission is to provide affordable, high-quality hearing aids to as many people as possible. As part of that, we give to those in need whenever we can, and hope to expand those efforts in the future.”
According to Stringer, overcoming the financial, organizational, and logistical challenges of providing hearing assistance to children in developing countries takes time. Nevertheless, the profound results of GFCHL’s efforts – and those of other organizations – can already be seen.
(2) An Experimental Technology that Could Make Cochlear Implants More Accessible
So far, we’ve discussed how nonprofit groups are working to bring cochlear implants to more people around the world. However, there could be another way to boost access to cochlear implants even more. This involves a fundamental redesign of cochlear implant technology to make the devices more affordable to buy and the surgical techniques easier and safer to perform.
We reached out to Dr. Chip Goldsmith, a neurotologist and cochlear implant surgeon who founded the nonprofit AllHear Foundation, to learn more about the latest in low-cost cochlear implant design. Goldsmith is working on an experimental – yet safer and more cost-effective – approach to cochlear implants. According to Goldsmith, the larger medical community views his approach with skepticism, but he believes that once fully developed and tested in patient trials, his design could dramatically improve access to cochlear implants for those living in low- to medium-income countries.
Goldsmith’s ideas center around the question of whether the long, multi-channel electrode arrays in modern cochlear implants are necessary. Neurotologists usually agree that a multi-channel cochlear implant is required to stimulate key areas of the cochlea. Without this specific stimulation, they believe that perceiving speech and other complex sounds isn’t possible (see part one of this article to understand how conventional cochlear implants work). Unfortunately, the multi-channel requirement makes cochlear implants expensive to manufacture, and the surgery is invasive and difficult to perform. Moreover, inserting the long, multi-channel electrode array into the cochlea usually destroys any natural hearing ability the patient still has.
According to Goldsmith, his late mentor, Dr. William F. House (who is credited as one of the inventors of cochlear implants), believed in a different approach to cochlear implant design. Dr. House maintained that a short, single-channel cochlear implant could serve as an affordable, less invasive solution to treat hearing loss. Goldsmith adds that “Dr. House was known as the Father of Neurotology, and he was not too often wrong with his theories.”
Image Source: Edited Image from Advanced Bionics
As a continuation of Dr. House’s ideas, Goldsmith argues that we can achieve similar treatment results using a tiny cochlear implant with a short, single-channel electrode array, instead of a long, multi-channel array. Goldsmith alleges that – even with a short, single-channel implant – the brain has the ability to interpret sounds with sufficient clarity to understand speech and experience a rich complexity of sounds. Putting he and Dr. House’s theories into practice, Goldsmith has designed an affordable, single-channel cochlear implant that – after human trials and development – could retail for about $1,800, representing a considerable savings over the cost of conventional implants.
The device is so tiny that the surgery for installing it is far less invasive and less complicated than traditional cochlear implant surgeries. Unlike conventional cochlear implants, installing the device would not pose a risk to the patient’s remaining hearing capabilities. Note the tiny size of Goldsmith’s single-channel implant compared to a multi-channel device:
Image source: AllHear Foundation
According to Goldsmith: “Our smaller and far less expensive cochlear implant system can be inserted through a simpler trans-canal surgical approach that goes through the ear canal and eardrum. This ‘transtympanic’ procedure is safer than conventional cochlear implant surgeries because it does not require drilling through the mastoid bone or skull. We have also demonstrated that this procedure can be performed under local anesthesia.”
Goldsmith also wanted to add the following: “I worked with Dr. House on his AllHear short electrode system for many years, and my AllHear Foundation is named after this implant. My transtympanic configuration is merely an offshoot of Dr. House’s fundamental theories.”
At this time, Goldsmith’s team has built a new sound processor for single-channel implant recipients. Researchers are currently retrofitting patients who received one of Dr. House’s single-channel implants with this sound processor. If they can improve the hearing of these patients, they will adapt the new sound processor to fit Dr. Goldsmith’s transtympanic configuration.
Goldsmith’s single-channel cochlear implant still requires extensive trials and testing – and the technology needs to gain acceptance and approval from the larger medical community. However, we spoke with Brandy Klann, MA, a cochlear implant audiologist at the Michigan Ear Institute who offered the following: "Dr. Goldsmith's ideas are intriguing. I look forward to seeing the clinical trial data on his single-channel cochlear implant."
It is encouraging to see that certain medical innovators are working to make cochlear implants more affordable and accessible to everyone – especially when efforts like these are often hindered by a lack of funding and support from governments and the industry at large.
To think that the road to overcoming deafness and hearing loss began with scientists like Allessandro Volta, Giuseppe Veratti, and Benjamin Wilson sticking electrodes in their ears over 200 years ago – and to see where we’re at today – is absolutely inspiring.
Considering what we've already achieved, the barriers to cochlear implant access in developing countries are not insurmountable. We have all the technology and organizational tools at our disposal to make this miraculous technology available to everyone – regardless of their economic status. All we need is the continued determination of organizations like the Global Foundation for Children with Hearing Loss, Hear the World Foundation, and AllHear Foundation, and innovative physicians like Dr. Chip Goldsmith, who are willing to think outside the box. Like a ripple effect, their efforts will bring transformative assistance to more children and adults with hearing loss, until eventually, no one is left behind.
This article was sponsored in full by MDHearingAid, a hearing aid manufacturer that offers high-quality, affordable, FDA-registered hearing aids for a fraction of the cost of traditional aids. By selling its medical-grade hearing aids directly to consumers for just $399.98 to $999.99 a pair, MDHearingAid cuts out the middleman – transferring thousands of dollars in cost savings to its customers. This has opened the door to effective hearing loss treatment for millions of people who couldn’t previously afford to purchase hearing aids.
If you’d like to support MDHearingAid in its mission to break the cost barriers associated with hearing loss treatment, tell your friends and family who need hearing aids about MDHearingAid and its affordable product line. Also, if you want to check your hearing to see if you could benefit from a pair of aids, click this link to take a free 5-minute hearing test from MDHearingAid now.
Fascinated by emerging science, Jeremy Hillpot’s background in consumer litigation and technology offers a unique perspective on the latest developments in medical science, agrotechnology, blockchain, data engineering, app development, and the law. Contact Jeremy at jhillpot@legalwritingFINRA.com or follow him on Quora.