Hearing aid and medications. (Credit: Bigstock)
The maddening fall of the lira, arbitrary banking restrictions and gradual lifting of subsidies for several imported drugs has made life difficult for Lebanese patients who cannot afford to buy needed medicines or travel for surgeries unavailable in the country.
Those with impaired hearing are no exception. This specific condition has received little attention from the media despite its serious social implications for patients.
“The stats have not been updated since the outbreak of COVID-19; but in Lebanon, around 1 in 1,000 people suffer from severe bilateral congenital hearing loss,” Dr. Jad Nehme, chief of ENT service at Bellevue Medical Center in Metn, told L’Orient-Le Jour.
According to Nehme, the crisis has impacted screening, treatment and surgeries. “It’s a health aspect that is neglected, often for social reasons [the shame of having to wear a hearing aid or of being hearing impaired], and for financial reasons, given the treatment costs of this type of disorder,” said a patient on condition of anonymity.
Multiple factors
Hearing loss can be acquired or congenital. According to the medical consensus, what qualifies as mild hearing loss lies between 20 and 39 decibels (where the patient will have some difficulty hearing). Moderate deafness lies between 40 to 69 decibels (the patient understands only if the interlocutor speaks loudly), and with severe deafness, a person only detects sounds between 70 and 89 decibels (the patient suffers major, daily discomfort).Profound hearing loss is anything greater than 90 decibels (the patient can no longer hear speech) with several levels, depending on the frequencies picked up.
“Intensity is just one of the characteristics to be taken into account in the provision of care,” added Nehme.
The type of hearing loss — whether it is one-sided one (unilateral) or two-sided (bilateral) — as well as the patient’s age and the type of illness affecting their hearing, are the three other decisive factors to be considered.
All these factors can affect the nature of the treatment and its cost. “For instance, we tend to be more aggressive in procedures designed to detect and treat hearing losses in children, because at this stage there is a risk that the child will not be able to learn to express himself,” said Nehme.
“The sooner the treatment, the more reversible the after-effects. After a maximum of four years, the child may not be able to speak if the hearing loss is severe, due to maturation deficit of the audio-phonatory loop,” he added.
Lebanon has the necessary equipment to carry out screening campaigns for congenital hearing impairment, and every child born is supposed to be screened for hearing loss. “There are many genetic cases of deafness, which reinforces the need for early detection,” said Nehme.
Screening and treatment
The problem is that many Lebanese won’t have their children tested because of the cost, especially in rural areas where the standard of living is lower and the medical infrastructure is limited. As a result, “many children come to us deaf at the age of three or four,” he said.
While the tests carried out at birth to detect whether a newborn has hearing problems (oto-acoustic emission measurements) only cost around $20, those required for a child, before the age of four, with symptoms, to establish a complete diagnosis are much more expensive. A basic diagnosis costs $200, but the bill can rise to $3,000 if additional tests are added to refine the diagnosis.
This phenomenon increased with the crisis, amid a currency devaluation and tens of thousands of Lebanese being illegally denied access to their bank dollar deposits and forced to withdraw them at a lower value. Furthermore, these tests are never covered by insurance. Generally speaking, insurance companies do not cover the cost of treating congenital hearing disorders.
The crisis also affected prices and availability of medicines and treatments for hearing disorders and illnesses. In 2021, subsidies on medicines, medical equipment and raw materials for the pharmaceutical industry have been almost totally lifted, which has pushed up their prices in Lebanese lira.
Since January, these prices have been updated daily to keep pace with the sometimes-erratic changes in the market rate (plus or minus LL94,000 to the dollar since the end of April).
“Today, only a handful of items are still subsidized, and they are about the treatments for chronic illnesses, cancer, dialysis equipment and raw materials for the pharmaceutical industry,” said Salma Assi, head of the medical equipment importers' syndicate.
According to several physicians contacted, many decongestant antibiotics and other key products, even the most basic ones, are no longer on the market.
Speaking to L’Orient-Le Jour, Joe Ghorayeb, president of the Pharmaceutical Importers’ Association, stated that some antibiotics used in the treatment of a number of diseases, including those causing hearing disorders, “were or are unavailable due to a global shortage of amoxicillin,” caused by a number of factors affecting the pharmaceutical industry and global supply chains.
He added, however, that there is always an equivalent to the missing items from other brands distributed on the market.
According to several pharmacists L’Orient-Le Jour contacted, some products may be unavailable during some periods due to restocking delays, which became longer with the crisis.
Non-reimbursed costs
The problem, argued Nehme, is that not all medicines are equal in terms of quality, (those manufactured in Europe or the United States remain the most reliable ) it is that some antibiotics may be less effective in treating the diseases at the root of hearing problems, be they recurrent ear infections or more serious disorders.
“In the latter cases, the doctor is sometimes obliged to extend the patient’s hospital stay because the treatment given is less effective, which leads to additional healthcare costs,” he added.
Finally, those with severe to profound hearing problems have paid the heaviest price since the start of the crisis. The price of equipment and interventions can quickly rocket, and insurance coverage depends on the policy chosen.
The public insurance schemes and mutual insurance funds that cover categories of civil servants no longer cover this type of expenses, while they initially reimbursed only a small proportion of the costs incurred, in lira.
As a result, patients and their families have to pay more than $1,000 per ear for quality hearing aids, between $600 and $800 for prostheses for surgical ossicular reconstruction, and between $16,000 and $25,000 for cochlear implants, a miniaturized electronic inner ear prosthetic device that gives people with severe hearing loss better access to speech sounds.
“An operation to place such an implant currently costs between $22,000 and $30,000, including a day in hospital,” said Nehme.
He pointed out that the operations require equipment that is as sophisticated as it is expensive. “The surgeon intervenes in a very delicate part of the human body — the cochlea — which is located close to the brain and nerve structures,” he said.
Product availability
Before the crisis, the financial burden of such an operation was considerably mitigated by a state subsidy mechanism in place since the late 1990s, which covered between 80 percent and 90 percent of the implant price, as an anonymous source at the Beirut-based Learning Center for the Deaf told L’Orient-Le Jour.
“The last requests were approved at the beginning of 2019, and since then, nothing,” the source recalled.
The bottom line is that, faced with these numerous obstacles, some patients would rather postpone operations that are nonetheless crucial.
Some NGOs and private charitable institutions sometimes offer financial assistance, but only sporadically.
The only consolation for the hearing impaired is that, despite the crisis and the lifting of subsidies, the country has not run out of specialized medical equipment.
“The sector has continued to import what it needs, despite major delays in payments by Banque du Liban, which manages subsidy payments,” said Assi.
However, she called on patients to be vigilant in the face of the increase in counterfeit and poor-quality products on the local market as a result of lax control by the authorities.
Youssef Bakhach, the head of the Lebanese Order of Physicians, did not answer our calls for comment.
This article was originally published in French in L'Orient-Le Jour. Translation by Joelle El Khoury.