Audiology in Iraq

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GENERAL INFORMATION

Iraq Map
Table 1: Country Information [Source: Wikipedia]

Country Name IRAQ
Current Population 38,433,600 (2018)
Geographic Area 437,072 km2
Gross Domestic Product (GDP) 733.926 billion$ (2019)
Currency Iraqi dinar
Official Language Arabic and Kurdish

History of Iraq

The historical period of Iraq truly began during the Uruk period, 4000 BC to 3100 BC, with the founding of a number of Sumerian cities, the drawing of pictographs, the carving of cylinder seals, and the producing of mass-produced goods.

The "Cradle of Civilization" is thus, a common term for the area comprising modern Iraq as it was home to the earliest known civilization, the Sumerian civilization, which arose in the fertile Tigris-Euphrates river valley of southern Iraq in the Chalcolithic (Ubaid period).

Babylon was the capital city of Babylonia, a kingdom in ancient Mesopotamia, between the 18th and 6th centuries BC. It was built along the left and right banks of the Euphrates river with steep embankments to contain the river's seasonal floods.

In the late 4th millennium BC, the world's first writing system and recorded history was born. The Sumerians were also the first to harness the wheel and create City States and whose writings record the first evidence of mathematics, astronomy, astrology, written law, medicine and organized religion.

The Arab Islamic conquest in the mid-7th century AD established Islam in Iraq thus saw a large influx of Arabs. Under the Rashidun Caliphate, the prophet Muhammad's cousin and son-in-law, Ali, moved his capital to Kufa when he became the fourth caliph.

The Abbasid Caliphate built the city of Baghdad along the Tigris river in the 8th century as its capital, and the city became the leading metropolis of the Arab and Muslim world for five centuries. Baghdad was the largest multicultural city of the Middle Ages and the center of learning during the Islamic Golden Age.

Baghdad was destroyed by Mongols in the 13th century, who invaded Iraqi land and destroyed all libraries. Up until the 20th century, Iraq was a victim for invasion by the Safavids, Ottoman, Mamluk dynasty, and British. Iraq gained independence on October 3, 1932 (“History of Iraq,” 2020).

HISTORY OF AUDIOLOGY

Audiology is a recent and young field in Iraq that needs to be improved. In 1975, a few physicians returned to Iraq with a degree in audiology. These physicians started treating hearing problems and training ENT residents, doctors, and technicians (who usually had a degree in some type of physics).The government supported these teams by providing large quantities of hearing aids to be distributed free of charge to the patients in governmental hospital.

There were only three audiology centers in the country: the first one was located in the center of the country - the capital city of Baghdad, the second located in the major city of the north in Mosul, and the third located in the largest city of the south in Basrah.

In the 80’s and 90’s, each of the 18 major cities in Iraq had a basic pure tone audiometric unit in the government hospitals managed by a technician that was trained locally (usually in the medical city hospital of Baghdad). These technicians were supervised by ENT specialists. Meanwhile, the audiology center in the medical city implemented the first auditory brainstem response potential studies in the country in the late 90’s.

During the 21st century, the audiometric units in each city started to upgrade to basic audiology units. In the last ten years, the major audiology units in the cities Baghdad, Mosul, Karbala, and Basrah started to offer more advanced services, such as ear molds, shells for completely-in-canal (CIC) hearing aids, and other photo-plastic works. These units also started to provide more advanced auditory tests, such as otoacoustic emissions (OAEs) and auditory steady-state response (ASSR).

In the last 5 years, a basic vestibular assessment unit was added to the audiology unit in the medical city hospital in Baghdad and some private clinics to serve patients in major Iraqi cities as well.

INCIDENCE AND PREVALENCE OF HEARING LOSS

Due to the lack of neonatal screening, national audiologist surveys, and researchers, the exact incidence and prevalence records are unknown (Kadhim et al., 2017). But as a general idea of the clinicians working in this field, the incidence and prevalence of hearing loss is higher than the international averages due to higher incidence to noise trauma during the wars (1980-1991), missile exposure (2003), and also unprotected exposure to industrial and other work related noises.

INFORMATION ABOUT AUDIOLOGY

Educational Institutions

There was one program for a diploma in audiology (one-year study) for the graduated physicians from the college of medicine at Baghdad University. The program was open for 4 years until it closed in 2012. Another program of MSC Audiology (2-year study) for graduated physicians from the college of medicine at Sulaimani University was closed in 2014.

Training of the technicians for audiometry and ear mold/shell techniques is usually done by an intensive short period course in one of the major hospitals, mainly the medical city hospital in Baghdad.

Audiology Practice: Private & Public

Audiological services are provided free of charge in the governmental hospitals. The quality and degree of services are usually dependent on the hospital. Hospitals with limited audiological services can refer the patient to another hospital to complete the required tasks. Free audiological services range from a hearing assessment up to a hearing aid prescription (if the patient needs 2 devices, the government can supply one for free). This is due to the governmental tenders for hearing aids that run on a regular basis.

The private clinics offer paid services to the patients that can afford to pay. Recently there are highly specialized centers that can provide up to date full range of services.

In Iraq, an audiometry test is usually free in the governmental hospitals and costs about $10 to $20 in the private clinics. Hearing aids vary in price depending on brands and providers. Access to hearing aids is limited to the few specialists in the country. In addition, the level of the devices is linked to the "affordable costs" that society can accept; accordingly, the device selection is usually dependent on the patient budget.

Audiological Services

According to the guidelines published recently by the Iraqi Society of Otolaryngology (Iraqi Medical Association, n.d.), the possible services that can be offered by the otolaryngologist/otologist and audiologist as below:

  1. Full hearing evaluation by different hearing tests for all age groups, such as pure tone audiometry, auditory brain-steam responses and oto-acoustic emissions.
  2. Speech therapy
  3. Vestibular evaluation
  4. Vestibular rehabilitation
  5. Hearing aids fitting and service
  6. Photo-plastic laboratory services for ear impressions, ear molds, and other techniques

Services Offered by Otolaryngologists & Neuro-otologists

Services offered by the otolaryngologists (in field of audiology):

  1. Basic hearing evaluation for adults (audiometry and tympanometry)
  2. Vestibular evaluation
  3. Intra-tympanic injections
  4. Myrengotomy and insertion of ventilation tubes
  5. Surgeries for myringoplasty and tympanoplasty
  6. Surgery of cochlear implantation

Services offered by neuro-otologist:

  1. Full hearing evaluation by different hearing tests for all age groups, such as pure tone audiometry, auditory brain-steam responses and oto-acoustic emissions
  2. Vestibular evaluation
  3. Vestibular rehabilitation
  4. Hearing aids fitting and service
  5. Photo-plastic laboratory services for ear impressions, ear molds, and other techniques
  6. Intra-tympanic injections
  7. Myrengotomy and insertion of ventilation tubes
  8. Surgeries for myringoplasty and tympanoplasty
  9. Surgery of cochlear implantation

Professionals

People working in the field of audiology are usually physicians (otolaryngologist, otologist and audiologists) that supervise the team that are working with them (technicians, physics specialists, and other trained persons who works under the responsibilities of the physician).

Unfortunately, the growth of the professionals in the field of audiology in Iraq is very slow because all the educational programs that offer a degree in audiology was no longer offered. Very few otolaryngologists continue their education to become neuro-otologists and a limited number of otolaryngologists are interested in audiology.

Research in Audiology

Research in audiology is poor in quantity in Iraq. This is because most of the audiologists are clinicians rather than academics. Some research was conducted by neurotologists and otolaryngologists, but studies are few in numbers and lack any governmental or institutional support.

SCOPE OF PRACTICE AND LICENSING

With a limited number of hearing healthcare professionals, information about licensing and scope of practice are not available.

PROFESSIONAL AND REGULATORY BODIES

All the governmental audiology centers and their staff are regulated by the Ministry of Health.

The private clinics are regulated by the Iraqi Medical Association (Iraqi Society of Otolaryngology, Head, and Neck Surgery, n.d.).

AUDIOLOGY CHARITIES

There are no specific audiology charities in Iraq; however, there are many nonprofit institutions offering charity support to the patients that cannot afford for medical specialties, including audiology. An example of these institutions is Alhawza in Najaf city.

CHALLENGES, OPPORTUNITIES & NOTES

The greatest challenge for audiology in Iraq is the practice by untrained, unpracticed, and unauthorized persons.

Sellers of hearing aids try to do hearing evaluation!

Sellers of medical equipment usually sell hearing aids without proper fitting! 

Lack of continual training and educational programs for the audiologists, audiology assistants, and ear lab technicians.

Lack of real speech therapists.

Lack of an educational program for the physiotherapists.

USEFUL LINKS

  1. History of Iraq - https://en.wikipedia.org/wiki/History_of_Iraq
  2. Ministry of health of IRAQ – moh.gov.iq
  3. almaalomah.com
  4. Iraqi society of otolaryngology - entiraq.com
  5. Iraqi medical association - https://www.ima.org.iq/ar
  6. Alkhawza - https://alhawza-noor.com/

REFERENCES

History of Iraq. (2020). In Wikipedia. https://en.wikipedia.org/w/index.php?title=History_of_Iraq&oldid=990735892

Kadhim, S., Deen, L. D. A., & Al-Sarhan, H. W. (2017). Early detection of hearing defects among newborn in Baghdad city. Iraqi Journal of Community Medicine30(4). https://www.iasj.net/iasj/article/151377

Iraqi Medical Association. (n.d.) Law of the Iraqi medical association. Law no 81 of 1984.

Iraqi Society of Otolaryngology, Head, and Neck Surgery. (n.d.) Regulations of duties, the message of the Iraqi society of otolaryngology, head and neck surgery to the Iraqi medical association, subject: regulations.

AUTHOR INFORMATION

Haider Wahab Alsarhan Dr. Haider Wahab Alsarhan is a fellow of the Iraqi Board of Medical Specialization – FIBMS-ENT and an assistant professor of neuro-otology in the college of medicine – Almustansiriyah University – Baghdad IRAQ. He is also a consultant neuro-otologist in Alyarmouk teaching hospital – Baghdad and head of the otolaryngology department at college of medicine/Almustansiriyah University since 2016. Certifications include certified trainer of vestibular assessment at audio-vestibular unit - UMC+ - Maastricht university since 2017 and a certified specialist in vestibular assessment and rehabilitation by the American institute of Balance AIB since 2018. Dr. Haider Wahab Alsarhan is an author of more than 10 articles published local and international journals and a guest lecturer of neuro-otology in many national and international conferences.

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