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Exploring international perspectives in hearing health care.

Dr. Dolores E. Battle is a professor of speech-language pathology and senior advisor to the president for equity and campus diversity at Buffalo State College. She is a former president of the American Speech-Language-Hearing Association (in 2005) and a very active member of international organizations of both individuals and organizations committed to global speech-language and hearing concerns. She served as president of the International Association of Logopedics and Phoniatrics from 2005 to 2007. I have admired Dr. Battle's professional and volunteer work for many years, including her publications on critical multicultural themes. This interview was conducted after she shared important information on this topic at key conventions in both Copenhagen, Denmark, and Boston, Massachusetts. I think you will find that the global projects she describes in this personal interview reflect the challenges outlined in the articles in this special issue of Communication Disorders Quarterly.

Q: Some readers may not be cognizant of the international organizations you have been working with for several years. I know that some are primarily health related, some focus on education, and others represent the professionals in speech-language and hearing disabilities in a global perspective. Would you please name, describe, and explain the involvement that you have had with these groups recently?

A: Living in Buffalo, New York, across the river from Fort Erie, Canada, and 60 km from Toronto, international issues have been a part of my awareness for many years. We have had many Canadian students who have made us aware of international issues in health care and education in our professions for many years. In my position at Buffalo State, I have the pleasure of working with many international students who come to us for an education. It is always informative to me on how little experience they have had with students with disabilities in their elementary and secondary education or their previous life experiences. I was a mentor for an international student from South Africa who came to Buffalo during the apartheid era for a master's degree in special education. When she completed her degree, she returned home to Durban and participated in the first elections in the postapartheid era. I think it was my involvement with her that sparked a genuine interest in understanding education and health care around the world.

My formal involvement with international issues has come from involvement with the International Association of Logopedics and Phoniatrics [IALP], a worldwide organization for professionals interested in speech, language, voice, hearing, and swallowing. This organization has been in existence for nearly 80 years. It has 55 affiliated societies and individual members in 55 countries on 6 continents. Through the IALP I have worked in developing standards for the education of logopedics in both developed and developing nations. Through the IALP and its 14 committees I have been involved in a wide range of topics such as bilingual or multilingual education and intervention for persons living in countries where it is usual for people to speak as many as 6 languages. For example, there are 12 official languages in South Africa. In Zimbabwe, the children learn English in addition to their 3 or 4 native languages. I have looked into the recent mandatory ninth-grade education in China and identification of hearing impairment in remote geographical locations where there is no electricity or clean drinking water. I also have become aware that depending on the country and its political and economic situation, the focus on special education communication disorders varies.

Last summer I took a group of speech-language pathologists, audiologists, and educators in a People-to-People tour of China. We visited audiology clinics and schools for the deaf in Beijing, Shanghai, and Xian. China has a recent mandatory infant-hearing screening program; however, the level of screening differs from the major cities such as Beijing to the remote areas such as Gui Guang. Although state-of-the art facilities were available in Beijing for hearing and vestibular assessment and they had wonderful facilities to do cochlear implants, it was remarkable how little rehabilitation was available. Children with implants were mainstreamed into general education classes in the local region, where the teacher may have had a 2- to 3-week course in rehabilitation. Children and families often had to travel from remote parts of China for testing. The limited rehabilitation was available only in the major cities. Although the education is at no cost, the cost of boarding is prohibitive to most families who are not able to relocate to the cities.

In China and much of the world, for example, special education and speech-language pathology as we know them are in their infancy. In other parts of the world, even in more developed countries, special education and related services are provided but use different models of service delivery and different levels of training for service providers. The lessons learned are that as the world is getting smaller and smaller, as we are able to communication and travel with relative ease, and as more and more people from other parts of the world come to this country, it is important for all professionals to understand disability services, not just from our point of view but from the point of view of the consumers of our services with consideration of their backgrounds, their life experiences, and their understanding of disabilities. It is wonderful that the American Speech-Language-Hearing Association has taken an interest in international issues and has established an International Issues Board.

Q: As president of IALE you saw the interrelationships between these organizations. How did you and your board members convince others of the importance?

A: When I was president-elect of the American Speech-Language-Heating Association, ASHA established a strategic plan for 2005-2008 that included a focus on international issues. I recall the discussion among the ASHA leaders at the time, felt that it was important not to appear to want to overpower international organizations but that the ASHA members should know and understand international issues as they impact on our professions and our association.

It did not take a lot of convincing at all. Through a planning retreat we simply looked at the issues, the involvements of ASHA with international organizations such as International Association of Augmentative and Alternative Communication, International Cleft Palate Society, International Fluency Organization, International Audiology Society, and the list goes on, to bring to an awareness level that the profession was already looking across the world and that ASHA was being left behind in this regard. Fortunately, in the year I was president [2005], a lot of the international activity in the strategic plan began to take place. Although ASHA has long been a supporter of the IALP as one of the larger affiliated societies, there was more involvement with the organization by members of ASHA.

Q: The World Health Organization [WHO] has massive global projects under way at all times. How or why did they focus on heating health care at this time?

A: The World Health Organization is a unit of the United Nations that focuses on world health. A major sector of the WHO is the sector on chronic diseases. Among the major diseases it tracks are stroke, heart disease, cancer, and sensory impairment. The person in charge of sensory impairment became interested in the prevention of blindness and hearing impairments as a worldwide health concern. A series of pilot projects to identify the scope of hearing impairments worldwide has estimated that 278 million people worldwide have a significant hearing impairment that could benefit from the use of a hearing aid. The surveys indicated that 80% of those living with hearing impairment live in middle- and low-income countries. The WHO established a program for prevention of deafness and hearing impairment to assist member states in reducing and eventually eliminating avoidable hearing impairment and disability through appropriate preventive and rehabilitative measures. Its strategic target is to eliminate 50% of the burden of avoidable hearing loss by the year 2010.

In 2006, the WHO established a goal to provide affordable hearing aids and services to people in developing nations by 2010. However, it needed financial support to reach this goal. They worked with a consortium of governmental agencies, nongovernmental agencies, manufacturers, and charitable organizations to establish an entity called WWHearing [World Wide Hearing Care for Developing Countries]. This entity has now joined forces with WHO to raise awareness and the necessary funds to provide affordable hearing aids and services on a massive scale to developing countries to reduce the burden of heating impairment in developing countries by 2020. Not only must the cost of the heating aid be affordable to developing countries, but the cost of batteries must also be affordable and accessible. [Information about the WHO/WWHearing project can be found at]

Q: Please share some of the data on hearing health that you have gathered this year.

A: The most interesting information I have learned this year is the various levels of service delivery that have been found to be effective in the delivery of hearing aids and services in developing countries. First, and I guess the most important, is that no one really knows the extent of heating impairment or other disabilities in the world, because it is not among the highest priority of health concerns in much of the world. The estimates are that 278 million persons have a moderate to severe hearing impairment. This does not include the many millions more with mild hearing loss.

Clean drinking water, HIV, AIDS, tuberculosis, maternal health, infant mortality, emergency medical care are all more important to much of the world than hearing. The different levels of health care available in primary, secondary, and tertiary health care centers in different parts of the world and the training of the health care providers have been an education for me. In some developing countries, providing hearing care is more cost-effective at the tertiary care level because of the reduced cost of training workers and reduced cost of equipment. Satisfaction ratings also indicate cost-effectiveness because the tertiary care workers are more likely to be aware of cultural issues and families are more likely to receive follow-up care at the tertiary or local care center than at the primary care centers, which may require travel of hundreds or even thousands of miles to major cities or centers.

The issues in the identification of hearing loss where there is no electricity for audiometers; no trained health care workers for basic health needs, including hearing screening; economic issues that make the cost of replacing batteries out of reach, let alone the cost of the hearing aid itself; the cultural issues with wearing a sign of impairment such as a hearing aid; and the unavailability of aural rehabilitation for hearing aid wearers are just the beginning of the many issues involved in hearing care that have been addressed at the WHO meetings.

Q: What is currently being planned or under way to change these conditions?

A: The plans are to investigate and educate on how best to meet the needs. WWHearing is supporting special projects to investigate ways to meet the need. Projects are under way in China, Indonesia, India, Pakistan, Nigeria, and Brazil. The WHO has developed training materials for persons providing hearing services at primary, secondary, and tertiary care centers. Primary care centers are closest to what people in developing countries consider to be appropriate levels of care. But since audiology is a new or nonexistent profession in much of the developing world, hearing services are often provided by physicians or nurses. WHO has special training programs for persons who provide hearing care at each of the levels. The WHO projects are trying to provide training for health care workers in the secondary and tertiary care centers and providing affordable hearing aids and solar-powered battery rechargers to help with accessibility. They are attempting to partner with manufacturers to provide the affordable hearing aids and batteries at no cost to see how effective the services can be provided in a cost-effective way.

Speech pathology and special education are also new professions, with most education being provided by psychologists or teachers who have little or no special training in disabilities. Children with special education needs may not go to school at all or are mainstreamed into primary classes. The few specially trained teachers or clinicians are usually in major cities or are able to reach only a few of those in need.

Q: Why should our readers take action in regard to these findings? What can be done to help? Would increased membership in IALP help these causes?

A: All speech-language pathologists and special educators should become aware of the issues involved in providing education and health care around the world. This is especially important because so many people from different countries are coming to the United States or relocating to places other than their country of origin. The focus over the past several years has been on bilingual language issues. But the focus on international issues is much more broad. Language issues, cultural issues, life experiences, concepts of health care and education, role of the family and family members, as well as providers in service delivery and education, are as important. For example, among the largest immigrant groups in Buffalo, New York, in recent years are people from Yemen and Kenya. The people from Kenya were actually from Somalia and Sudan who came to this country after spending time in refugee camps in Kenya. In the camps, they had no education and minimal health care for survival only. They come to this country, and according to our laws, they must go to school and be taught by teachers who do not speak their language and who do not understand their culture. We talk about special education, but in their minds all education is special. In the schools of New York City, 56% of the children are living in homes where English is not the first language. While the most common of these is Spanish, an important question is, What is the country of origin of the speakers of Spanish? The more we know about people from other countries, the more we know we don't know. It should be our professional responsibility to recognize what we know and what we don't know and to be involved in becoming internationally culturally competent clinicians and educators. The easiest way to be prepared for the new world order of service delivery is to commit oneself to become more informed about international issues. Attend a conference in another country. Join an international organization such as the IALP [www.ialp .info], and get involved with members of an international community in your local area.

Q: Your work on these projects has taken you to many interesting international locations this year. Where have you gone, and who have you met in the pursuit of these goals?

A: In March I traveled to Sao Paulo, Brazil, for a conference on communication and violence that was attended by more than 700 speech--language pathologists. The conference's main theme was that violence can be prevented through better education and communication. In August I traveled to Copenhagen, Denmark, for the congress of the International Association of Logopedics and Phoniatrics, which was attended by nearly 900 persons from 55 countries on 6 continents. In September I represented the IALP at a conference on disability and rehabilitation at the World Health Organization in Geneva, Switzerland. In November I returned to Geneva for the fifth meeting of the WHO project on hearing aids and services for developing countries. The WHO meetings have been attended by a variety of professionals from 26 different countries. Within the past 2 to 3 years I have also been to Torino, Italy; Beijing, Shanghai, and Xian, China; Brisbane and Sidney, Australia; and Groningen, the Netherlands. At each location, I have met with a variety of professionals who are providing services to persons with communication disorders. What I have learned is that, depending on the country and geographic region, the identification of persons with communication disorders and the rehabilitation options available are largely determined by the economic development of the country. For example, at the WHO disability and rehabilitation meeting, it was very clear that while in the United States we are concerned with education for all children with disabilities, in many developing countries, education for children without disabilities is still a challenge. Education for children with disabilities is not an option for most other than the very wealthy who can afford private education in the major cities.

I have also learned that even though we think about some countries as technological leaders in the world, health care and special education are not universally provided throughout the country. China may be considered a developed country, but most of the country is quite remote, with limited training and resources. The 56 ethnic groups is the country make the provision of services less than uniform. While in economically developed areas of some "developing" countries, cochlear implants with rehabilitation are becoming common for children with severe hearing impairment, in developing areas of these same countries, the primary health concern is clean drinking water and prevention of disease. If implants are provided, rehabilitation is most often not. For example, in Lagos, Nigeria, hearing care is provided. But 20 miles outside of the city, hearing care is only a peripheral concern. In China, primary care is provided in Beijing and Shanghai, secondary care in Nanning, and tertiary care in Gui Guang and most other parts of the country.

Who were the most fascinating persons I have met in my travels? I would have to say the minister of education in Beijing, who was extremely interested in the causes of stuttering. Also a young deaf Palestinian man with a cochlear implant who engaged me and others from Indonesia, Nigeria, and Pakistan in a discussion of U.S. politics, including education and the upcoming presidential elections. The world is watching us. We owe it to them and to ourselves to turn the mirror toward other parts and other peoples in the world.

Editor's Note: From the Field connects readers with clinicians and practitioners in speech-language pathology. Each issue will present a professional selected for an in-depth interview on a highly practical topic. The interviews are conducted by the editor of From the Field, Judy K. Montgomery, PhD, CCC-SLP. Please address suggestions for future interviews and correspondence to Judy K. Montgomery, Special Education, Chapman University, 1 University Drive, Orange, CA 92866; e-mail:

Judy K. Montgomery

Chapman University

Judy K. Montgomery, PhD, CCC-SLP, is a professor of special education and literacy at Chapman University in California and a board-recognized specialist in child language.
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Title Annotation:From the Field
Author:Montgomery, Judy K.
Publication:Communication Disorders Quarterly
Date:Sep 22, 2007
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