Although treatment is what gets the emphasis, prevention of hearing loss is what is needed to curtail the epidemic in the United States. On June 2, 2016 the Institute of Medicine’s (IOM*) Committee on Accessible and Affordable Hearing Health Care for Adults will publish its long-awaited report. Although its focus is on accessibility and affordability of care, including hearing aids, the report has the potential to change the national discussion about how to prevent hearing loss and make treatment of hearing loss more effective. To do so it must go beyond evaluation and treatment strategies. It must address the root causes of hearing loss, consider prevention strategies, and recommend environmental modifications to allow those with existing hearing loss to understand speech. Get the facts.
A recent report from the President’s Council of Advisors on Science and Technology (PCAST; Aging America and Hearing Loss: The Imperative of Improved Hearing Technologies, October 2015)  acknowledged the high prevalence of hearing loss in older Americans [2, 3], but considered only technological solutions to the problem. The PCAST report appeared to assume that hearing loss is a natural consequence of aging without consideration of root causes:
“Age-related hearing loss is a substantial national problem. Age-related hearing loss affects many Americans, with older adults particularly at risk—a quarter of adults between 60 and 69 years, over half in the range 70-79 years, and almost 80 percent of those older than age 80 have difficulty hearing. The absolute number of those affected, already almost 30 million, is expected to grow as the population ages .”
Perhaps I shouldn’t have been surprised, but I was. The nation’s technology leaders wrote a report to the president about “age-related hearing loss”, which it deems a substantial national problem, without addressing why hearing loss occurs, what can be done to prevent it, or what else needs to be done to help those with hearing loss.
Noise Prevention and Hearing
Noise is a well-established cause of hearing loss. As noted in a special report published recently by Harvard Medical School, “More often than not…the noise that causes sensorineural hearing loss is not one deafening bang but decades’ worth of exposure to the high-decibel accessories of daily life: leaf blowers, car horns, highway traffic, movie theater sounds, hair dryers, vacuum cleaners, loud music…” . Reducing people’s exposure to environmental noise is a logical and cost-effective alternative, but one not addressed in the PCAST report.
UnfortunateIy, I learned too late of the IOM Committee deliberations to attend its public meetings. Instead, I submitted a detailed comment letter in which I discussed the epidemic of hearing loss in America and the importance of prevention, drawing this analogy to the polio epidemic in the 20th century:
“Polio, which fortunately has been eliminated in the United States, illustrates the importance of both prevention and environmental modification for a disease and those affected by it. Discussing hearing health care for adults today without discussing prevention of hearing loss would be like convening an expert panel in 1950 to discuss better health care for polio victims, as they were called, including physical therapy and better and more affordable braces and crutches and wheelchairs, without mention of a vaccine to prevent polio. And without including environmental modifications in the discussions, even with the best assistive devices polio victims would be unable to have full mobility in society. It took architectural modifications mandated by the Americans with Disabilities Act- wheelchair ramps, curb cuts, wider doors, and other design modifications- to help those with polio gain full access to places others could enter.
Modifications made to help the physically disabled also helped others- parents wheeling a baby carriage, delivery workers, or repair workers with wheeled carts. Similarly, a quieter environment, in addition to preventing hearing loss, will help parents trying to listen to a toddler, young lovers whispering sweet nothings to each other, or grandparents trying to hear their grandchildren at a family dinner in a restaurant.”
My main point is that significant hearing loss in older Americans is not a natural consequence of aging. It can be prevented by reducing exposure to noise. Merely putting a better technological Band-Aid on a preventable problem is not a strategy that is in the public’s best interest.
Recommendations to the IOM
My hope is that the IOM Committee will take a more comprehensive look at the broader issues of hearing loss in older Americans. To that end, I suggested that the following ten statements and recommendations be included in its report.
- A statement that, based on sound scientific evidence, noise is not just a nuisance but is a major health hazard, causing both auditory damage (hearing loss, tinnitus, and hyperacusis) and non-auditory health impacts.
- A statement recognizing that there is a hearing loss epidemic in the United States and that noise exposure is the most likely cause of this epidemic.
- A statement acknowledging that significant hearing loss in older Americans is not an inevitable consequence of aging, but rather most likely due to the cumulative lifelong impact of environmental noise exposure. The terms “noise-induced hearing loss” and “sociocusis” should replace the terms “age-related hearing loss” and “presbycusis.”
- A recommendation that public health authorities take steps to deal with the burgeoning hearing loss epidemic, including raising awareness of the public health impact of environmental noise and means to reduce those impacts.
- A recommendation that the federal government develop and implement a safe environmental noise exposure level for the public to prevent permanent hearing loss. A maximum 24-hour average exposure of 70 decibels (unweighted) is supported by scientific evidence . A recommendation that physicians and audiologists (including members of the IOM Committee and other professional societies and organizations), educate the public, regulators, and legislators about the dangers of environmental noise for auditory health (as well as non-auditory health) and promote the benefits of a quieter environment..
- A statement that hearing aids do not work well for many people, certainly not as well as desired in helping them understand speech. Studies show that 30%-40% of those who acquire hearing aids do not use them [6, 7].
- A statement that a quiet environment is needed so those with partial hearing loss (with or without hearing aids) can understand speech.
- A recommendation that legal protection be afforded to those with partial hearing loss, tinnitus, and hyperacusis under the provisions of the Americans with Disabilities Act (ADA) , specifically recommending indoor noise limits in places of public accommodation as defined in ADA Title III. People with auditory disabilities meet the legal definition of being disabled under law and qualify for legal protection to allow them to fully enjoy places of public accommodation.
- A recommendation for a vigorous federal effort to control noise with the goal of making noise levels “As Low As Reasonably Achievable” (ALARA), as used for radiation and chemical exposure thresholds. This effort should include mandatory noise rating labels on all consumer products, noise warning labels on products which cannot be made quieter, and warning signs posted in public places about the risk of hearing loss from noise.
This IOM Committee has a chance to make as important a contribution to America’s auditory health and safety as the IOM Committee on Quality of Health Care in America made with its report on patient safety (To Err is Human, 1999) . Limiting its recommendations to hearing aids and insurance coverage is an incomplete response to a larger problem.
* The Institute of Medicine changed its name to the National Academy of Medicine (NAM) on March 15, 2016. The report writing function has been delegated to the Health and Medicine Division of the NAM. Since the committee writing the report has been called “the IOM Committee” for several years, the older term is used for ease of reference and to avoid confusion.
- President’s Commission of Advisors on Science and Technology, Aging America and Hearing Loss: Imperative of Improved Hearing Technologies. Washington, DC: October 2015 Available at https://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_hearing_letter_report_oct_meeting.pdf Accessed May 13, 2016
- Cassel C, Penhoet R, Saunders R. Policy solutions for better hearing, JAMA 2016;315(6):553-554. Available at http://jama.jamanetwork.com/article.aspx?articleid=2484352 Accessed May 10, 2016
- Lin FR, Niparko JK. Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med. 2011;171(20):1851‐ 1853. Available at http://archinte.jamanetwork.com/article.aspx?articleid=1106004. Last accessed September 2015.
- Hearing Loss: A Guide to Prevention and Treatment. A Harvard Medical School Special Health Report. DM Vernick, A Gentili-Stockwell (eds). Norwalk, CT: Harvard Medical School and Belvoir Media Group, 2016.
- Environmental Protection Agency, Office of Noise Abatement and Control. Information on Levels of Environmental Noise Requisite to Protect Public Health and Welfare with an Adequate Margin of Safety,March 1974. Available at http://www.nonoise.org/library/levels74/levels74.htm Accessed May 13, 2016
- McCormack A and Fortnum H, Why do people fitted with hearing aids not wear them. Int J Audiology 2013;52(5):360-368. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665209/ Accessed May 13, 2016
- Barker F, Mackenzie E, Elliott L, Jones S, de Lusignan S. Interventions to improve hearing aid use in adult auditory rehabilitation. Cochrane Collaboration, July 2014. Available at http://www.cochrane.org/CD010342/ENT_interventions-to-improve-hearing-aid-use-in-adult-auditory-rehabilitation
- Americans with Disabilities Act. Available at http://www.ada.gov/pubs/adastatute08.htm Accessed May 13, 2016
- Kohn LT, Corrigan JM, Donaldson, MS (eds), Institute of Medicine, Committee on Quality of Health Care in American. To Err is Human: Building a Safer Health System. Washington DC:National Academies Press, 2000.