The Dominican Republic shares with Haiti the island of Hispaniola, which is between the Caribbean Sea and the Atlantic Ocean. It is the home to approximately 10.6 million people. The Dominican Republic is known for its exportation of sugar, coffee, and tobacco (Central Intelligence Agency, 2017). The Dominican Republic is also known to be the originating place of bachata and merengue, popular styles of Latin America music and dance.
In this touristic destination and low-income country, quality audiology services and education seem unlikely. Yet, nonprofit organizations have been working diligently to provide best practices in hearing health care.
Ear and hearing services are difficult to access in the Dominican Republic, especially in areas outside of Santo Domingo and Santiago, the two largest cities. The main barriers are lack of trained professionals, lack of surgical tools, and access difficulty due to distance and cost.
The Dominican Republic only has approximately 60 to 65 ear, nose, and throat physicians (ENTs), who are heavily concentrated in the capitol city, Santo Domingo. The only residency otolaryngology training program in the country produces two to three new ENTs a year. With the exception of one U.S.-trained ENT, the ENTs are not trained to perform microscopic ear surgeries because of lack of microscopes. Patients depend heavily on visiting surgeons from overseas to perform these surgeries.
Audiologists are a rarity in the Dominican Republic. One nonprofit hospital system, eight private hearing centers, and some private practice ENT offices are responsible for serving the whole country. As most of them are clustered in Santo Domingo and one in Santiago, the rest of the country is mostly underserved (Carkeet et al, 2014).
Close to one-third of the population in the Dominican Republic live under the poverty line and millions live in slums. Many Dominicans cannot afford medical care due to the lack of access or the high cost of medical care (Carkeet et al, 2014). The rural populations in the Dominican Republic tend to have high infant-mortality rates, greater malnutrition among children, and are less likely to receive vaccinations (Caban-Martinez et al, 2012). This is largely due to the lack of health professionals and facilities in the rural areas, requiring people to travel twice the distance to access public health-care facilities compared to their urban peers. Also, because of low pay, health-care professionals who work in the rural areas typically are interns or entry-level professionals without much experience (Caban-Martinez et al, 2012).
Many people in the Dominican Republic depend on nonprofit hospitals and mission trips to obtain hearing health care. One of the largest audiology service providers in the country is Centro Cristiano de Servicios Médicos, Inc. (CCSM), which focuses on providing affordable medical care to those with low social-economic status. CCSM has one main hospital in Santo Domingo, several newborn hearing screening (NBHS) clinics in the city, and two satellite clinics in the southwestern and eastern parts of the island (Hunter-Diaz, 2018). The audiological services provided in the hospital include audiometry, tympanometry, otoacoustic emissions (OAEs), auditory brainstem responses (ABRs), and hearing aid fittings and services. The southwestern and eastern satellite clinics provide limited diagnostic services and refer patients to the main hospital as needed. CCSM also has two ENTs who see patients two days a week (Troncoso and Hunter-Diaz, 2017).
The Dominican Republic has socialized health care. Previously, the government health insurance covered hearing aids, but rarely do now. There is no government program to provide amplification or early intervention for children; it appears to be random whether the government health insurance decides to cover amplification for a specific child (Troncoso and Hunter-Diaz, 2017). Cochlear implants are available but are often unattainable due to high costs (Carkeet et al, 2014).
CCSM is the largest hearing aid service provider in the Dominican Republic. Its staff fits hearing aids using real-ear measurements and the National Acoustics Laboratory hearing aid fitting prescriptions (Carkeet et al, 2014). CCSM receives 50 to 100 donated digital hearing aids per year through the Hear the World Foundation and is a distributor for Unitron hearing aids to help keep the hearing aid retail price low (Troncoso and Hunter-Diaz, 2017). CCSM charges for services using a sliding scale for different income levels and sometimes fits refurbished hearing aids. The patients pay the fee for accountability of the hearing aids and for the staff’s time (Carkeet, 2014). Everyone fitted at CCSM must attend follow-up appointments 15 and 30 days after the initial fit (Troncoso and Hunter-Diaz, 2017).
In 2017, CCSM started the country’s only newborn hearing screening program in the three largest tertiary maternity public hospitals in Santo Domingo to screen high-risk newborns. Infants are screened with OAEs before being discharged. If an infant fails OAEs, they are referred for automated auditory brainstem response (AABR) testing at a CCSM clinic. If the infant fails the AABR, he or she is referred for a full diagnostic ABR at the CCSM hospital.
There is no national school hearing screening in the Dominican Republic. School hearing screenings are mostly conducted by nonprofit organizations. CCSM provides school screenings, community support, and basic education on hearing-related topics to spread the awareness of hearing health (Troncoso and Hunter-Diaz, 2017). Many stores have radios on full blast, and the doors of their houses are often open allowing street noise in. Therefore, education on noise exposure is important for hearing preservation (Troncoso and Hunter-Diaz, 2017).
Besides CCSM, Institute for Latin America Concern (ILAC) is a Jesuit mission post near Santiago that receives audiology volunteers annually to provide hearing services to people in the surrounding areas.
In 2001, David Pither, president of Australia-based EARS, Inc., trained the first two local audiology technicians and established the only earmold lab in the country in CCSM. After teaching several short-term courses, Donna Carkeet, a pediatric audiologist with EARS Inc., established a two-year training program in 2005 based on audiology program curriculum in developed countries (Carkeet, 2013). Carkeet ran the diploma program through EARs, Inc., from 2005 to 2013. Miguel Angel Evangelista of CCSM is now the program director, who completed the training program in 2009. Currently, Hear the World Foundation partially funds the training program and provides partial tuition waivers for students.
The two-year diploma program mainly focuses on diagnostics and hearing aid services. Students work alongside the audiology technicians at CCSM during the day and take college courses in the evenings at the Universidad Federico Henriquez y Carvajal. The students are trained to perform various audiological tests and services (Troncoso and Hunter-Diaz, 2017). They observe hearing aid fittings in their first year and learn to fit hearing aids under supervision in their second year. Students also are trained to troubleshoot/repair earmolds and hearing aids. If the hearing aids are unsalvageable, they are taught how to save hearing aid parts for other repairs, (Carkeet et al, 2014; Troncoso and Hunter-Diaz, 2017).
The program requires students to take basic academic courses and 12 audiology classes (Troncoso and Hunter-Diaz, 2017). The CCSM program graduates approximately eight people per year. If students are interested in providing hearing aid services to infants and young children, they must graduate from the two-year diploma program and then take additional classes to ensure they are trained properly before fitting hearing aids for children (Carkeet et al, 2014).
Heart of the Hearing Trip
Seven students and faculty from Northern Illinois University traveled to the Dominican Republic twice on the Fathom cruise line. The majority of the testing time in the first trip was spent on providing hearing services to people who came to three neighborhood government primary care clinics at Puerto Plata: Centro de Primer Nivel El Javillar Clinic, Centro de Primer Nivel San Marcos Clinic, and Centro de Primer Nivel Padre Las Casas Clinic. The screening protocol included otoscopy, tympanometry, and distortion product OAEs at 1.5, 2, 3, 4, 5, and 6 kHz. Patients with excessive cerumen were sent for onsite cerumen management and were tested immediately after. Patients who did not yield OAEs with signal-to-noise ratios of ≥ 6 dB at four of the six test frequencies were tested with air-conduction pure-tone audiometry. The same protocol was used during the second trip.
After the testing in the first trip, the faculty discussed the results with the patients using an interpreter:
- Thirty-one patients with cerumen that could not be removed were instructed to come back during the second trip.
- Patients with middle-ear conditions were referred to see the clinic doctors.
- Patients with hearing loss who would benefit from amplification were recommended to seek hearing aids.
- Fifteen patients with ear conditions that potentially would be improved by surgery were referred to Dr. Ivan Tavarez, an otolaryngology surgeon at Centro Medico Bournigal. Dr. Tavarez agreed to offer free otologic evaluations to determine patients’ suitability for surgeries. Bournigal agreed to donate pre-surgery check-ups, pre-surgery holding rooms, and post-surgery recovery rooms for the surgeries performed by surgeons from our collaborating nonprofit organization, Global ENT Outreach.
The goals of the second trip were as follows:
- To assess the patients with cerumen we could not remove during the first trip.
- To complete audiological evaluations of the potential surgery patients.
Among the 273 patients served during the two trips (546 ears, aged between 5 months and 103 years), 92 ears (16.8 percent) needed cerumen management. We removed the cerumen of most people but could not for 31 patients. Two weeks before the second trip, we sent some individually boxed cerumen softeners to the doctors at the government clinics. We asked them to administer to the 32 patients and asked the patients to come when we visited Puerto Plata. During the second trip, we found that some patients’ wax was drained out already, and we removed the softened cerumen of the all the returning patients, except 8 ears of 5 patients who were referred to an ENT for cerumen management.
Among the 546 ears we tested, 125 had abnormal tympanometry results, which included Type As, Ad, B, or C. Many people had abnormal otoscopy conditions such as infections, red tympanic membranes, perforations, mold, fugus, white spots on the tympanic membrane, bulging tympanic membrane, masses, and drainage. Others had white tympanic membranes or scarring on their tympanic membranes that suggest previous otitis media. Hearing loss was found in 357 ears (65.4 percent).
For the potential surgical patients, we brought an audiometer with bone-conduction capability and tested them at the Laboratorio Clinico Puerto Plata, the owner of which allowed us to use their audiology area and equipment. We performed otoscopy, tympanometry, distortion product OAEs, and air- and bone-conduction pure-tone audiometry. Nine of the original 15 patients returned. Their test results were later passed to Dr. Tavarez. Two of our patients with otosclerosis and cholesteotoma received free surgeries by Drs. Michael Alexiou and Richard Wagner of our partnering organization, Global ENT Outreach. They taught two otology surgeons from Centro Medico Bournigal to operate on a total of 12 patients with similar conditions.
In addition to testing people in the Dominican Republic, we volunteered our services to other cruise travelers aboard the Fathom Adonia during the “at sea” days. A total of 85 people aged between 13 and 93 years came for free hearing tests, and we used the same protocol as in the Dominican Republic, except cerumen management, which was not performed due to the swaying of the ship. Of the 170 ears screened, 76 (44.7 percent) had some type of hearing loss, and 22 ears (12.9 percent) needed cerumen management. The faculty explained the test results to the patients at the end of the testing, and if warranted, recommended further actions.
Compared to the cruise travelers, the Dominicans who came for our free services had a higher incidence of hearing loss (HL and HL+1=45.9 percent of Americans vs. 55 percent of Dominicans). They also had higher incidences of middle-ear problems (none of Americans vs. 10 percent of Dominicans). Surprisingly, the number of people with wax warranting professional cleaning were comparable (e.g., ~18 percent), indicating the need for ear care education for both populations (see FIGURE 1).
The Dominican Republic is a beautiful country, and the people were very friendly despite having less resources compared to people in the United States. The need for hearing services is great due to a lack of trained professionals, a lack of surgical tools, and the difficulty accessing services. Many Dominicans would benefit from humanitarian missions to give them immediate relief. It is also important to build infrastructure and expand services to cities and rural areas to provide year-round care to improve the quality of life of people with ear and hearing disorders.
We would like to thank students at Northern Illinois University, Florida State University, Naperville North High School, and Stuart Country Day School, who were troopers during the two humanitarian trips. We also want to thank the Fathom Cruise line team led by Katie Dow and Ambra Attus who helped us with logistics and ground transportation. Special thanks to Drs. Richard Wagner and Michael Alexiou of Global ENT Outreach to travel to the Dominican Republic to provide surgical training, and Drs. Jose and Roberto Redondo, Ivan Tavarez, and Daniella Meyer for donating the hospital resources and their time to provide ear care to our patients.
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