SPECIFIC HEARING HEALTH ISSUES AFFECTING INDIGENOUS COMMUNITIES
I believe that hearing loss is a missing piece of the puzzle
of Indigenous disadvantage, and while it remains a missing piece of the puzzle
viable solutions are not easy to come by.
Dr Damien Howard, Committee Hansard, 16 February 2010, p. 100.
The committee has heard evidence from a wide range of individuals and
organisations about the particular hearing health issues affecting Indigenous
Australians. Of great significance is the fact that a higher proportion of Indigenous
Australians experience hearing problems than non-Indigenous Australians across
nearly all age groups, in remote, rural and metropolitan areas.
The causes and consequences of large scale hearing impairment for
Indigenous Australians are not yet fully understood. Evidence presented to the
committee strongly suggests that its roots lie in poverty and disadvantage,
that it impacts on education and employment outcomes, and that it has a strong
association with Indigenous engagement with the criminal justice system.
The large body of evidence before the committee in regard to Indigenous
hearing health largely falls under three broad categories, which will form the
framework of this chapter:
the causes and dimensions of high levels of Indigenous hearing
the specific implications of hearing impairment for Indigenous education
engagement with the criminal justice system.
Hearing loss among Indigenous Australians
Indigenous Australians experience ear disease and associated hearing
loss at up to ten times the rate of non-Indigenous Australians.
In 2004-05, 10 per cent of Indigenous children aged zero to 14 years were
reported as having ear or hearing problems, compared to three per cent of
The Department of Health and Ageing (DOHA) noted that: 'It is important to note
that the survey is not a measure of the national prevalence of otitis media. In
fact there is [no] national data collection for this purpose.'
The committee heard evidence that these figures may under represent the
actual rates of hearing problems in Indigenous children.
It has been estimated that some form of hearing loss may affect up to 70 per
cent of Indigenous adult people.
DOHA noted in a question on notice that:
The Menzies School of Health Research recently reported that
in a recent survey of 29 communities throughout the Northern Territory, 25% of
young Aboriginal children had either chronic suppurative otitis media (CSOM) or
acute otitis media with perforation; 31% had bilateral otitis media with
effusion; and only 7% of children had bilaterally normal middle ears.
The major factor behind such high rates of hearing loss amongst
Indigenous Australians is a higher prevalence of conductive hearing loss caused
by otitis media.
Otitis media is the term used to describe an infection in the middle ear.
Other terms commonly used include 'glue ear' or 'runny ear', both references to
the fluid discharge that can sometimes be a symptom of otitis media.
Middle ear infections cause a fluid build up in the middle ear. This
build up creates pressure on the ear drum, sometimes to the point where it
bursts. It is the presence of fluid, and in some cases the resulting perforation
of the ear drum, which inhibits the conduct of sound through the middle ear.
Types of Otitis Media
Acute otitis media (AOM) without perforation: acute inflammation of
the middle ear and eardrum (tympanic membrane), usually with signs or
symptoms of infection. AOM is characterised by the presence of fluid behind
the eardrum, combined with one or more of the following: bulging eardrum, red
eardrum, recent discharge of pus, fever, ear pain, and irritability.
Acute otitis media with perforation: discharge of pus through a perforation (hole) in
the eardrum within the previous 6 weeks.
Recurrent acute otitis media (RAOM): more than three attacks of AOM within six months,
or more than four in 12 months.
Chronic otitis media: a persistent inflammation of the middle ear – it
can occur with or without perforation, either as chronic suppurative otitis
media, or as otitis media with effusion (respectively).
Chronic suppurative otitis media (CSOM): recurrent or persistent bacterial infection of the
middle ear, with discharge and perforation of the ear drum (CSOM is
distinguished from acute perforation with discharge in that the discharge
persists). Symptoms include hearing loss – pain is not a feature. CSOM has
been identified on the basis of discharge persisting for 6 weeks or more, but
an expert panel convened by the World Health Organization defined it recently
as discharge for at least 2 weeks.
Otitis media with effusion (OME): an inflammation of the middle ear
characterised by fluid behind the eardrum, without signs or symptoms of acute
otitis media; also sometimes referred to as serous otitis media, secretory
otitis media, or (more colloquially) 'glue ear'.
Dry perforation: perforation of the eardrum, without any signs of discharge or fluid
behind the eardrum.
viewed 23 March 2010, http://archive.healthinfonet.ecu.edu.au/html/html_community/ear_health_community/reviews/ear_background.htm
Otitis media is a common, short-term childhood ailment amongst Australian
children. It is usually self-limiting, and resolved by the time children start
school. However for Indigenous children in Australia, Canada and the Americas,
as well as Pacific Island and Maori children, otitis media is more persistent.
Of these, evidence before the committee stated that Indigenous Australian
children have the highest rates:
High levels of middle ear disease and related hearing loss
are observed in a number of indigenous populations around the world, however
those of indigenous children in remote Australia are consistently higher than
Another witness testified in a similar vein:
In most populations in developed countries now it is very
unusual to get chronic suppurative otitis media unless you have some form of
immunodeficiency, yet we see it in about 20 per cent of Aboriginal children
[between 6 months and two and a half years of age].
Many submitters noted that the World Health Organisation
considers rates of chronic otitis media above four per cent in children to be '...a massive public health problem...which needs urgent
attention in targeted populations'.
Indigenous children in Australia experience an average of 32 weeks of
middle ear infections between the ages of two and 20 years, compared to just
two weeks for non-Indigenous children.
The committee heard a lot of evidence about the very high levels of hearing
impairment among children in remote communities:
Another Menzies [School of Health Research] study revealed
that in remote communities in the Northern Territory only one per cent of
Indigenous kids had normal appearing eardrums at three years of age, which
would be indicative of repeated bouts of otitis media and/or long-term otitis
media. Although the Indigenous adult data is less certain, it is estimated that
up to 60 per cent of Indigenous adults have hearing loss—in many cases due to
the effects of otitis media in childhood.
Evidence presented to the committee suggests that the prevalence of
otitis media in Indigenous communities ranges between 10 per cent and 54 per
Some witnesses testified that even these rates, based on state and territory
surveys, understate the prevalence of the problem:
Otitis media affects 90 per cent of Indigenous babies [in the
Case Study: Onset of
Otitis Media in Indigenous Children
in a Remote Northern Territory
A recent longitudinal study
of 41 Aboriginal infants from a northern tropical island community off the
coast of the Northern Territory revealed the endemic nature of OM in some
The study examined infants
shortly after birth and monthly thereafter.
By 8 weeks of age, 21 of 22
Aboriginal infants had clinical or audiological signs of effusion or acute
inflammation, while only three of 10 non-Aboriginal infants had signs of OME
and none had signs of AOM.
By 3 months of age, otitis
media was present in the entire Aboriginal cohort, with acute inflammation
identified in 28 per cent of infants and effusion in 72 per cent.
All Aboriginal infants
experienced repeated or persistent infections throughout their first year of
Overall, Aboriginal infants
were four times more likely than a comparison group of non-Aboriginal infants
to develop AOM and three times more likely to develop OME. Over the course of
the study, 37 per cent of all Aboriginal infants experienced a perforation at
least once, with the mean age of first perforation being 5.6 months. Of those
infants who had reached 6 months of age or more by the end of the study, 33
per cent had experienced perforation of the eardrum within their first 6
months. Among those infants who experienced perforation, one-third had
perforations that persisted for more than 60 days.
Australian Indigenous HealthInfoNet, Review of ear health and hearing
among Indigenous peoples, retrieved 23 March 2010 from
The study referred to is Boswell JB, Nienhuys TG, Rickards FW, Mathews JD
(1993) 'Onset of otitis media in Australian Aboriginal infants in a
longitudinal study from birth' Australian Journal of Otolaryngology; 1:
The causes of high rates of otitis media
among Indigenous Australians
Whilst otitis media is common amongst all children, it is the
early onset, severity and persistence of infections in Indigenous children that
can lead to longer term hearing loss.
The reasons for this are complex, and tied to environmental and social factors
that may impact on the lives of Indigenous Australians. These factors are usually more pronounced in remote
areas, and may include poor housing, overcrowding, limited access to nutritious
food and exposure to passive smoking.
As one audiologist based in a remote area commented:
I am often asked, ‘Why is the rate of otitis media and
hearing loss so high in Indigenous people?’...speculation that I hear...[is that]
there must be some genetic predisposition to otitis media in Indigenous people.
But there is no proof of this. The more likely causes of otitis media and
hearing loss among Indigenous Australians would be related to the myriad social
determinants of health, some of which are housing overcrowding, nutrition,
sanitation, education, marginalisation and so on.
Another witness summed up his view of the causes of otitis media:
...severe otitis media—and by that I mean otitis media
associated with perforation of the eardrum—is a complex medical condition
caused by poverty and poor living conditions.
Resolving these underlying, environmental causes of otitis media will be
the solution for Indigenous Australians in the long term. Taking the long view,
Professor Peter Morris believed that when environmental factors are addressed
the situation would improve for remote areas as it has for other parts of the
In the poorer areas of, say, Melbourne—the Fitzroy slums and
that sort of thing—in the prewar years we saw a very similar pattern of
respiratory disease: kids with discharging noses, discharging ears and a
chronic wet cough. That does not happen much now in [mainstream] Australia,
which gives us the belief that you can see dramatic improvements in remote
communities. We believe that what remote community children experience is
similar to what we saw in poor communities 100 years ago.
Other factors can act to compound the impact of such environmental and
social influences. These often include inadequate primary health care services,
poor access to specialist services, poor compliance with medical interventions
and a poor understanding among medical staff of the role of social and
environmental conditions on hearing loss.
One witness commented that clinical staff in remote areas are not always
aware of the importance of addressing hearing health:
Ear disease is one of many conditions competing for the
attention of health staff and it perhaps lacks the consideration it deserves to
manage acute infections aggressively because the association with longer term
ear disease and risk of permanent hearing loss is not always made by the health
Another view presented to the committee was that clinical staff in
remote communities are all too aware of ear health issues, and in fact may be
so overwhelmed by the volume of health issues they face each day that they are
unable to respond effectively.
In some cases ear infections in Indigenous children go unreported and
untreated, leading to damaged hearing. The committee heard evidence that
whereas many children experience pain associated with ear infections (thereby
prompting medical examination of their ears), recent studies found this was not
always the case among Indigenous children.
Whilst the reason for this is not known, there was some speculation that early
onset of otitis media may be a factor:
...a normal eardrum is like a very thin sheet of glass and you
can see through it, with a lot of nerve fibres running through it. When the
eardrum bulges we think that is what causes the pain. Because when you examine
these children they have red bulging drums.
Interestingly, we know that in non-Aboriginal children the
pain usually only lasts six to 12 hours, and the bulging does not resolve in
that time, so it seems that it is the stretching of the nerves that is painful.
It is the initial stretching that causes the pain. We think that in Aboriginal
children, who have already had the fluid there for a long time, the drum is
much thicker and the nerves just cannot be stretched as much.
The committee also heard that another reason for low reporting of ear
disease may be that due to its high prevalence, ear disease among Indigenous
Australians has become accepted as a normal and inevitable part of life.
Kacy Kohn, a remote hearing health practitioner, remarked to the committee that
...never had an adult Aboriginal client approach me complaining
of a hearing deficit, and I wonder if this is because they have normalised
their hearing loss or because of a lack an awareness of what assistance may be
available to them.
One witness commented that she had seen no improvement in Indigenous
hearing health outcomes in Central Australia:
I have been an audiologist for 15 years and [nearly] all of
that time has been spent working with Indigenous ear health. Unfortunately, I
have to say that I have not seen any improvements in hearing health or ear
health over that time.
The impact of hearing loss among Indigenous Australians on education
As noted above Indigenous children, especially those from remote areas,
suffer very high rates of ear disease and hearing impairment. The committee
heard a considerable amount of evidence which strongly suggests a link between
hearing impairment among Indigenous school children and poor educational
outcomes. This link has been made in the past,
though the problem appears to be still widely in evidence today.
The Northern Territory Department of Education and Training (NT DET) described
the issues of hearing impairment in classrooms as being threefold:
Looking at the implications of hearing impairment for
individuals and the community, as well as the large number of children
suffering from otitis media and having conductive hearing loss we also have the
added issue of the majority of them having English as a second language [ESL] or
developing English as a second language at a time when they may not have
already developed their first language because of the hearing issues. In
addition, a lot of our teachers, if not most, come from interstate and are
therefore dealing with the situation of teaching perhaps the first time in a
cross-cultural situation. Those three things—the conductive hearing loss, the ESL issue and the cross-cultural issue—impact greatly on the provision of education.
NT DET's view was shared by another Northern Territory (NT) submitter,
who expanded on these difficulties:
Australia, most Indigenous children are taught in standard Australian English
by a non‐Indigenous teacher. In this
setting certain factors appear to compound the difficulties associated with
hearing loss for Indigenous children.
culturally unfamiliar and highly verbal teaching styles that require students
to learn from listening to teachers and peers in an artificial classroom
classrooms are often noisy and seldom have adequate acoustics or appropriate amplification for Indigenous
children with hearing loss.
These problems are not limited to the NT. Evidence was heard about
similar conditions in South Australia (SA), Western Australia (WA) and
The impacts of these factors on the children's engagement with their schooling
can include disengagement:
The main problems are language delay, schooling delay and
truancy—you just cannot keep up with what the teachers say, so you switch off.
And what do you do if you are switched off and you are bored? You start mucking
around with the kid next to you. When you muck around with the kid next to you,
you get a pattern of behaviour of being a bit of a rebel or you get into trouble.
You say, ‘I do not want to come to school,’ so you have truancy issues.
One researcher found that once the number of hearing impaired Indigenous
children in a classroom went above a certain level, the non-hearing impaired
children's education also suffered, as the teacher's time was taken up
providing individualised support and managing behaviour.
Some studies have shown that Indigenous children suffering from chronic
ear disease may become disengaged from their learning, sometimes with big consequences:
Learning within the school environment relies on language and
communication skills, and children who have experienced hearing loss in early
life are likely to struggle with most aspects of schooling. Children who have
difficulty performing tasks that require literacy and numeracy skills may
become disinterested in learning and attend school less regularly.
Consequently, they are less familiar with classroom routines and less able to
interpret and participate in classroom activities when they do attend school.
Ultimately, hearing loss may lead to school failure, absenteeism, early school
dropout, and reduced employment opportunities.
Early onset hearing loss can have a great impact on a child's ability to
acquire language as they grow older. This is a critical issue for children for
whom the language of instruction is different from their native language, as
was noted in one submission:
Children on the [Anangu Pitjantjatjara Yankunytjtatjara] Lands
learn English as a second language and this usually commences when they start
school. It is overwhelmingly the language of instruction in schools, yet the
primary language of use is Pitjantjatjara. Hearing impairment at the levels we
record will impact significantly on a child’s ability to learn, particularly
where a second language is the means of instruction, with global consequences
for the acquisition of basic literacy and numeracy. Hearing impairment thus
contributes to the cycle of poverty and disadvantage so common in remote
Indigenous children who experience hearing loss at a young age, and who
do not have English language skills will also have difficulty accessing and
using a sign language, such as Auslan, to communicate. The committee heard from
several witnesses that people often develop their own idiosyncratic sign
language to communicate with family and community groups, which is of little
use outside those groups:
[Hearing impaired Indigenous people from remote communities]
learn in their own communities not in the [English] language or Auslan; they
have their own sign in that particular community. Once they get out of that
community, if they do not speak English and they do not read, they do not know.
The committee heard evidence that communication difficulty caused by
hearing loss can sometimes be misinterpreted as being caused by language or
cross-cultural communication issues. One witness, an audiologist, provided an
example of the consequences of this confusion in a classroom setting:
What I found in...one school was a young Indigenous girl. They
thought English was her second language and that therefore she could not
understand English, so her older sister was interpreting for this young girl.
When we did the hearing assessment, we found she needed hearing aids. So her
problem was not that English was her second language; it was simply that she
could not hear.
NT DET described to the committee how it employs a team of people which
works across the NT to help coordinate hearing services to schools, and support
teaching and school staff to teach hearing impaired children.
Nevertheless, the committee heard from an Aboriginal Health Worker who
specialises in hearing health who gave evidence that, in her experience, teachers
are not trained to understand the implications of hearing loss for individual
In Queensland the Deadly Ears program also emphasises the importance of
You have to teach the teachers who are going out to these
communities how to teach a classroom where they are all deaf. You do not talk
while you are writing on the blackboard. You have to sit down with individual
kids and say, ‘Did you take in what I just said to you?’
Good practice in the education of
hearing impaired Indigenous children
The committee heard from a wide range of individuals and organisations
engaged in addressing Indigenous hearing health issues. Witnesses testified to
the effectiveness of different approaches.
Sound field systems
A sound field system is a low power public address system with a
wireless microphone for the teacher to wear. The committee heard evidence that
the installation of a sound field system in classrooms where a significant
proportion of students are hearing impaired has been shown to provide
educational benefits. Teachers who have used the systems report they are
helpful because students are able to hear and follow instructions, they behave
better, and they are less distracted by outside noises.
Evidence was also presented that the sound field system is most
effective when the classroom has acoustic conditioning features.
Witnesses noted that whilst children are able to access hearing aids
under the Australian Government Hearing Services Program, the program does not
support the purchase of sound field systems.
This is despite the fact that Indigenous children do not always wear their
hearing aids: 'Hearing aids are often strongly disliked and cause acute
embarrassment and shame.'
The committee was unable to identify any systemic, centralised program
in any state or territory, for funding, installing and maintaining sound field
systems in classrooms.
It was suggested to the committee that providing funding for sound field
systems makes more economic and social sense than providing funding for
individual hearing aids. Sound field systems do not involve the stigma of
hearing aids, and they benefit all children in the class. In the words of an
Alice Springs-based audiologist:
We know for a fact that if you have got a classroom of children
with, say, four hearing aids in there, it would probably be more expensive than
having one sound field system that is going to help all of those kids.
Professor Harvey Coates was unequivocal about installing sound field
systems in classrooms:
Starting with every new school that is built, every classroom
should have a sound field system using the new infrared system so that you do
not have the problems we had in the Kimberley, where the rats would eat the
wiring to the speakers and so forth. I think that is the first step—no doubt whatsoever. The second step then is to retrofit those classrooms where there are children
identified as at risk.
Deadly Ears (Queensland)
As has been noted above, part of the reason for continuing high levels
of ear disease and hearing loss among Indigenous Australians is the poor access
to primary and specialist healthcare services in remote areas. The issues of
remote health delivery are summed up in Ear Science Institute Australia's
...a reliance on face-to-face contact with scarce specialists
to assess children [in remote areas] and manage ear conditions cannot be
sustained. Visits by these specialists to regional centres are infrequent,
whilst visits to towns and communities are very rare. Delays in receiving
treatment results in complications including permanent hearing loss,
cholesteatoma and even risk of death. Pre- and post-surgical assessments are
often difficult to arrange as well, and there are significant barriers for
children to travel to the regional centres for medical care.
In addition, the committee heard evidence that if Indigenous people from
remote areas have to travel for an hour or more for an operation or medical
services, only one in three will make the trip.
The Queensland Government has responded with the Deadly Ears initiative.
Deadly Ears provides a combination of fly-in fly-out Ear, Nose and Throat (ENT)
specialists conducting minor surgery on site, health promotion and education
programs, and health worker training all underpinned by community engagement
Dr Chris Perry, Clinical Director of Deadly Ears, told the committee
that one of the great strengths of the Deadly Ears approach is to engage with
community leadership about the type of services they need and the best approach
for delivery before sending teams of specialists in to a community.
The committee also heard evidence that technology is being employed to
address remote servicing issues.
Ear telehealth (sometimes called 'teleaudiology')
involves training local health workers to use specialised equipment to take
high quality images of the ear drum and ear canal. These images are then
assessed remotely by a specialist, who can provide health management advice for
the health worker.
Dr Chris Perry remarked on the advantages of using ear telehealth:
[the local health worker] takes pictures and he sends them
back to us. You can see 27 kids in about an hour and a half that way. You
cannot see them in remote communities but you can with telehealth.
Ear telehealth can be more sophisticated than just reviewing images,
with advanced diagnostic assessments being undertaken by specialists in
Queensland remotely via computer.
In his evidence to the committee, Professor Harvey Dillon of NAL was supportive
of the ear telehealth approach,
as was Professor Harvey Coates in WA.
The Ear Science Institute Australia has estimated that the economic
benefits of a large scale rollout of ear telehealth to remote Australia could
be around one billion dollars over 25 years.
However it was pointed out to the committee that under existing arrangements,
ENT specialists are unable to access funding through Medicare for telehealth
Taking an holistic approach to
The committee heard from a range of witnesses that treating ear health
in isolation from the other realities of people's lives may inhibit the effectiveness
of treatments. It was suggested that Indigenous people's cultural, social,
environmental, and economic circumstances should be part of the solution. In
the words of one witness:
You cannot necessarily target hearing health or optical
health or oral health as in the [Northern Territory Emergency Response] because
they have the same underlying causes anyway [i.e. poverty and overcrowding and
much more general health issues]. These programs really need to involve and
empower Indigenous people to long-term strategies.
The evidence suggests that a large part of a successful solution lies in
educating and engaging families:
In dealing with and treating otitis media and hearing damage,
across the board everybody has said that working with and engaging directly
with the families of kids is the approach that will make a difference in the
long term. It means educating the carers and the parents, the people who are
around those kids, the young mums.
A number of witnesses referred the committee to the work of the
Aboriginal Resource and Development Services (ARDS), an organisation based in
Arnhem Land which has worked for many years with Yolngu people of the area on
health issues. According to one witness:
The interesting thing about [about ARDS] is because they are
working only in [Indigenous] language they have to restrict themselves to the
words that are already known by the community and to the concepts that are
already known by the community. They find out what is known about whatever the
health topic is and then they build onto that in language, using concepts that
are already understood. So if they are trying to teach about bacteria, they
look around and see what is similar in concept and build onto that. In that
way, community members get a greater understanding about what is underpinning
all these health problems, and with that knowledge are better able to manage
their own environment and to manage their own health.
Ms Ann Jacobs provided evidence about the effectiveness of the primary
healthcare model in addressing Indigenous hearing health. She explained that:
The primary healthcare model has a community focus. It looks
at prevention, identification, control of the transmission of the disease and
management from prenatal to adults. It has got a community focus and it
recognises that you do not have individual children with conductive children;
you have families and communities—because it is so infectious.
The committee heard evidence from Ms Jacobs about her experience of harnessing
strong Indigenous family ties to make a difference in addressing children's
One man I worked with recently was a single parent who had recently been released from jail. He was illiterate and he had three children. All had
middle ear disease, and unfortunately the middle ear disease of the middle [child]
was so bad that he was mute; he could not speak at all. He was five. I
explained the whole thing to [the father], and the next week he brought me five
additional children. He collected up all the little kids and brought them all
in. He was a wonderful dad. Each week I would teach him something new and each
week he would bring these kids back...So there is a level of community and family
that exists within Aboriginal families that we can really use, and we need to
build capacity and knowledge. To me, that is the way forward...
The Goldfields Ear Health
The committee heard evidence that the Goldfields Ear Health Conference,
held biennially in Kalgoorlie since 2005, is the 'only Australian conference
that brings together leaders in the field of [ear health] research and service
provision from both health and education [perspectives].'
The conference is focused on improving ear health for Indigenous Australians in
Australian Hearing gave evidence about the value of the conference,
especially for people who work in isolated communities:
I think it does play a valuable role. I think any
opportunity to get together and talk about strategies and experiences is
valuable. Outreach audiologists, whether they work for Australian Hearing or
for NT Hearing, often work in isolation. It is good to bring them together.
One Alice Springs-based audiologist was enthusiastic about the
conference, and noted that the Ear Health Infonet is an outcome of that
For us it is all about having hearing people together to talk
about these issues and to find out what others are doing and to let them know
what we are doing, what has worked for us and what has not. The one great thing
that has come out of it is the ear Infonet.
Whilst many witnesses similarly testified about the great value of this
conference to educators and ear health professionals, its future is in doubt as
it is run by volunteers and has no secure funding. In the opinion of Dr Damian
Howard 'unless it gets national support I think it is
going to fall over.' 
Ear Health Infonet
The Ear Health Infonet is a web-based resource which:
...aims to increase evidence-based prevention and management of
Indigenous ear health and hearing problems by improving access to relevant
evidence-based information and educational resources and increasing national
collaboration and communication in this area.
As with the Goldfields Ear Health Conference, the Ear Health Infonet
links practitioners and researchers with quality, evidence-based information
and resources. Menzies School of Health Research, a key partner of Ear Health
Infonet, testified that whilst the site has been around for over three years it
is based on a need that has existed longer than that.
According to Miss Felicity Ward of Menzies School of Health Research:
[Ear Health Infonet] was about providing research evidence
online for all people working in the area. We have a yarning space as well,
which is a forum for people working in the area. So ENTs, speech pathologists,
audiologists, teachers and everyone can communicate across the country about
issues that come up working in the area of ear health and hearing. It is guided
by a national reference group that has Judith Boswell, Harvey Coates and a few
other people. They guide the process of how it works, what it looks like and
the way they would like to see it. They inform us of different ways that we can
make it more accessible to people out there at the level of working in the
communities, working in ear health and hearing. I think there are about 360
members on the yarning board. 
One witness, an audiologist based in Alice Springs, commented on the
value of Ear Health Infonet to her work:
It is absolutely fantastic. I have that on my desktop because
it is just such a valuable resource. I am constantly going there and making
sure that people are aware of it because it is a great thing. In this day and
age, realistically, it is very hard logistically for us all to get together so
when we have that kind of resource available it is really important that we use
it and that it is supported by the government, both Territory and federal.
Telethon Speech and Hearing run the Earbus initiative in WA. Earbuses
are mobile children's ear clinics which provide hearing assessment and
management for school children in Perth and South-West WA. The Earbus model not
only provides hearing assessments, it also refers children to a GP and, if
necessary, an ENT specialist for follow up.
Telethon Speech and Hearing noted in their submission the major success
factors for the Earbus project. These factors may be of broader application for
all service providers working in Indigenous hearing health, and therefore are
reproduced in the box below.
Ten 'indispensable elements' of a WA hearing
services delivery model
- Middle ear screening via
Earbus using a range of instruments – otoscopy, tympanometry, Pure tone
audiometry screening, otoacoustic emissions and acoustic refelctometry.
- School or district-based
Aboriginal Liaison Officers to work with Aboriginal families to elicit
their cooperation, support and consent for the screening program.
- Professional Development
for school staff to increase their understanding of the impact and
causes of middle ear disease; support for staff to develop intervention
- Community Development
(Education and Awareness) for families, health workers and allied health
professionals to engage them as informed supporters and participants.
- Infrastructure investment
and support advice for communities that can invest in value adding such
as soundfield amplification, swimming pools, personal FM systems etc.
- GP services delivered
directly into the schools wherever possible based on close liaison and
collaboration with existing Aboriginal Medical Services and GP
- ENT liaison and local
hospital support to expedite surgery for children in urgent need.
- School nurses as key
support personnel in administering medication, following up GP treatment
regimes and liaising with families.
- Follow up audiology
services where required using community resources (eg UWA Masters of
Clinical Audiology students), Australian Hearing and local area health
- Data capture for research
purposes to evaluate the success of the program in reducing the
incidence of middle ear disease in Aboriginal children and of primary
Telethon Speech and Hearing,
Submission 11, [p. 6].
A number of witnesses expressed the belief that swimming pools in remote
communities are likely to reduce the incidence of ear disease among children.
Specifically, people argued that a regular swim in a properly maintained pool
helps to keep the ear canal and outer ear clean, and may even wash away biofilm
and prevent damaging infections taking hold.
The committee notes the release of a recent report which tested, among
other things, the effects of swimming pools in remote Indigenous communities on
and found that:
...swimming pools have not had an impact on the ear health at this stage.
However the initiation of a further study funded through the Department [of Health
and Ageing] that commenced in March 2009 provides an opportunity to monitor
changes over the longer term.
Indigenous hearing health and the criminal justice system
The link between hearing impairment
and criminal activity
It has been noted at chapter four of this report that the committee
heard evidence of a link between early onset hearing impairment and increased
engagement with the criminal justice system. The committee further heard that
there are several factors which exacerbate this connection as it applies to
Indigenous people, particularly Indigenous people from remote areas who do not
speak English as their first language.
Evidence was heard that the factor between linking impairment with criminal
activity is poor educational outcomes. In its submission, the Northern
Australian Aboriginal Justice Association (NAAJA) cited research which shows
that Indigenous people who have completed school at Year Nine level or below
are twice as likely to be charged with an offence, and three times more likely
to be imprisoned than Indigenous people who have completed Year 12.
Language development is often impaired among people with a hearing
impairment, especially if hearing impairment is early onset and undiagnosed.
One witness testified that there is evidence showing a correlation between
language development and criminal activity:
It is...interesting that the Early years study 2 report
has shown that language skills at six, 18 and 24 months strongly correlate with
criminal charges in adolescence.
Other witnesses emphasise that there is a demonstrable link between
hearing impairment and criminal activity:
We believe that hearing impairment is a significant
contributor to the causal pathway that represents a failure basically of
education and health to deal with those issues and they get picked up by the
Hearing loss may not cause criminal activity, but when
considering the stigmatising effects of hearing impairment on self-concept,
educational attainment and social skills, there is a causal link to criminal
The extent of hearing impairment
among Indigenous prisoners
The committee heard evidence that there have been no large scale, formal
studies undertaken into the question of prevalence of hearing impairment among
Indigenous prisoners. Dr Damian Howard, who has been actively engaged in this
issue, gave evidence to the committee that:
There have never been any formal studies into [the extent of
hearing loss among Indigenous people engaged with the justice system], despite
the attempts on numerous occasions to get some going, particularly by me and a
number of other people. When trying to attempt to get these studies going, the
response has generally been people from the criminal justice system saying that
it is a health issue and people from the health system saying that it is a
criminal justice issue...when a problem is everyone’s issue, it very easily
becomes no-one’s issue.
The committee heard preliminary results from one study which found high
levels of hearing loss and unhealed ear perforations among female Indigenous
inmates. The preliminary results of that study indicate that 46 per cent of the
women had a significant hearing loss, and that of those failing a hearing
screening, 30 per cent had perforations of one or both eardrums.
Notwithstanding the lack of hard data, anecdotal evidence from the NT seems
to indicate that in that jurisdiction at least the prevalence may be very high
Limited research work suggests that 85 to 90% of Indigenous
prisoners have hearing loss.
We know for a fact that out at the jail here [i.e. in Alice
Springs] out of the 90 per cent of the Indigenous people who would be out
there, 99 per cent of those would have a hearing loss. It is quite scary.
Researchers in other jurisdictions that have large populations of remote
Indigenous people have also given evidence about the high prevalence of hearing
impairment among Indigenous prisoners, and in one case their attempts to
quantify its extent.
Dr Stuart Miller, President of the Australian Society of Otolaryngology
Head and Neck Surgeons (ASOHNS), offered his opinion that the extent of hearing
impairment amongst Indigenous prisoners is likely to be the same as it is for
Indigenous people who are not in prison.
Communication difficulties between
police and Indigenous people
The committee heard that:
...hearing difficulties often lead to difficulties similar to
those that arise from cultural and linguistic barriers. This means that issues
of understanding and miscommunication are attributed to linguistic
difficulties, while the hearing impairments, which may really cause this, are
Dr Damien Howard explained further in Phoenix Consulting's
with inter‐cultural communication processes,
the perceptions and responses of non‐Indigenous staff and background
noise levels, in combination with Conductive Hearing Loss, can and do lead to
significant communication problems.
Linguistic and cultural differences are frequently presumed
to be the reason why an Indigenous witness may misinterpret a question, give an
inexplicable answer, remain silent in response to a question or ask for a
question to be repeated. The potential contribution of hearing loss to a break
down of communication is generally not considered. However, it is probable that
the distinctive demeanour of many Indigenous people in court is related to their
hearing loss. Where this is the case there is a very real danger that the
courtroom demeanour of Indigenous people (not answering questions, avoiding eye
contact, turning away from people who try to communicate with them) may be
being interpreted as indicative of guilt, defiance or contempt.
One witness testified about the potential consequences of poor
communication caused by hearing loss:
One audiologist talked to me about dealing with a client who
had recently been convicted of first-degree murder and had been through the
whole criminal justice process. That had happened and then she was able to
diagnose him as clinically deaf. He had been through the whole process saying,
‘Good’ and ‘Yes’—those were his two words—and that process had not picked him
up. Given the very high rates of hearing loss, you have to wonder about
people’s participation in the criminal justice system as being fair and just if
in cases like that people simply are not hearing or understanding what is going
The committee notes that there is legal precedent which suggests that
undiagnosed hearing impairment in a convicted person could, in some
circumstances, render that conviction unsafe on the grounds that it is an
essential principle of the criminal law that accused persons not only be present
at trial, but that they be able to understand what is going on and make
decisions about the conduct of proceedings.
Evidence was also presented to the committee that prison life for people
with a hearing impairment, including Indigenous people, can be harder than it
is for people with normal hearing ability. NAAJA noted in their submission
It is unquestionably the case that the experience of jail is
significantly more severe on people with hearing impairments. Prisons operate
with a heavy reliance on prisoners hearing commands, and responding as
required. This includes the use of bells and sirens and following oral
One witness supported NAAJA's view when he reported on his conversations
with hearing impaired prisoners at Alice Springs Correctional Centre:
Several of the guys...told me that, because of their hearing
loss, they often did not understand what guards wanted them to do, so they were
in constant strife with the guards in the prison. We had a program to provide
hearing aids to these guys, because they did not qualify for hearing aids from
any other sources. Thank goodness, the Office of Hearing Services would donate
returned hearing aids. We used those, and it made quite a difference in a lot
of individual guys’ lives now that they could hear and understand things. Their
perception by guards and their perceived behaviour improved because they knew
what was expected of them. So it all has to do with proper and clear
Ms Amarjit Anand, NT Government Principal Audiologist, testified that
arrangements have been in place in the past to conduct hearing assessments and
provide follow up services for prisoners in the NT, though she was uncertain as
to the present arrangements. Ms Anand also noted that the Northern Territory
Correctional Services had requested professional development for their officers
to help them work more effectively with hearing impaired prisoners.
Assistance and support
The committee heard from several witnesses that the use of technologies
and assistive devices can be of great assistance in police station and
courtroom environments. NAAJA submitted that whilst currently used
...amplifiers have an immediate positive impact on both the
ability of Aboriginal defendants to communicate and the demeanour of clients.
Phoenix Consulting provided a case study to the committee which
highlights the benefits of assistive technologies for one Indigenous man:
Case study: Barry, a rehabilitation success story
was in his forties and suffered from persistent middle ear disease in both
ears which caused severe hearing loss which continued to as he got older. He
also had a long history of involvement with the criminal justice system, had
been to jail a number of times, and had a very negative relationship with
who had pulled Barry over in his car would tend to raise their voices when it
was clear Barry had trouble understanding them. However, this often provoked
anger and aggression from Barry who felt they were shouting at him. On a
number of occasions this resulted in his arrest.
was often excluded from family conversations, sitting with family members but
rarely included in the discussion. He had found it too stressful to join in [Community
Development Employment Program] (‘work for the dole’) activities, because of
the communication difficulties he experienced in working in teams.
had been trying to get a hearing‐aid for 20 years without
success. When his hearing loss was first identified as an adult, he was too
young to qualify for a free hearing‐aid and too poor to afford to
buy one. When Barry finally became eligible to receive a free hearing‐aid, the
complex bureaucratic processes involved were a major obstacle, because it
required literacy and phone communication skills that Barry did not have.
Barry was given a personal amplification device while he waited hopefully for
a hearing‐aid, which a
year later had yet to happen.
Barry had used the relatively inexpensive hand held or ‘pocket
talker’amplification device for a month, he and his wife described the
changes that the device had made in Barry’s life.
was generally much less stressed.
was able to participate in family discussions, and was now much more engaged
in family life.
was able to establish a more positive relationship with local police, as he
could now have a conversation with them.
was able to participate more easily in culturally important hunting and
fishing activities because he could hear people when they called out in the
Barry was finally fitted with hearing‐aids he was a changed man. He
found the hearing aid even better than the portable amplification device. He
was successful in gaining a supervisory position in his workplace. He
described how both he and his family experienced much less stress and
frustration now he had a hearing‐aid.
Source: Phoenix Consulting, Submission 112, pp
NAAJA noted the absence of hearing loops in police stations and
courtrooms. Having argued that there are links between hearing loss and
criminal activity, they conclude that assistive technologies such as hearing
loops in these places should be 'compulsory'.
The committee also heard evidence about the use of legal interpreters
for people with a hearing impairment. The use of interpreters is complicated by
three factors. Firstly, as has been noted elsewhere, Indigenous people from
remote areas, especially among those who suffered hearing loss at a young age,
often have low levels of English language and literacy skills. This limits the
capacity of many deaf interpreters to assist. Secondly, even if deaf interpreters
can be found with Indigenous language skills, they would need to understand the
particular language of the person they have been called to assist, which is not
always the case. And thirdly there are very few interpreters available in the NT,
arguably the jurisdiction with the greatest need.
The case study in the box below was provided to the committee by NAAJA.
This case illustrates the complexity of the challenges facing hearing impaired
Indigenous people engaged with the criminal justices system.
Case Study – N
N is charged with several serious driving offences,
including driving under suspension. He is deaf, and does not know sign
language. N has significant difficulties explaining himself and will often
nod during conversations, which leads to people to believe he is replying
‘yes’, when, in fact, he does not understand. He has a very limited and
idiosyncratic form of sign language. Every now and then he does something
that resembles signing.
N is not able to communicate with his lawyer. An AUSLAN
interpreter has been utilised, but because N cannot sign, he is not able to
convey instructions to his lawyer of any complexity. N’s lawyer sought to
arrange a Warlpiri finger talker through the Aboriginal Interpreter Service,
but the interpreter concerned was not willing or able to come to court. It
was also not known if N would even be able to communicate using Warlpiri
The witness statements
disclosed to defence included a statement from a police officer describing
how she came upon a group of men in a park drinking. She ran a check on N, to
discover he had warrants for his arrest, at which time she arrested him. Her
statement reads: "It is my belief that he understood as he looked at me
and became quite distressed. I asked (N) verbally if he understood and he
nodded and turned his head away from me while raising his arms in the
N is currently on bail, but has spent significant
periods on remand at Darwin Correctional Centre. His charges are yet to be
finally determined, and an application for a stay of proceedings is pending.
N is effectively trapped in the criminal justice system. He cannot plead
guilty or not guilty because he is not able to communicate with his lawyer
and provide instructions.
He had previously been granted bail, but after
failing to attend court as required, his bail was revoked. Significantly, his
inability to convey information (or to understand what his lawyer was trying
to tell him) in relation to his charges has also been highly problematic in relation
to bail. For example, when he was explaining to his lawyer with the
assistance of the AUSLAN interpreter where he was to reside, both the
interpreter and lawyer understood N to be referring to a particular
community. It was only when the interpreter was driving N home, with N giving
directions on how to get there, that it was discovered that he was actually
referring to a different community altogether.
It has arguably been the case that N was not able to
comply with his bail because he did not understand what his bail conditions
were. N has subsequently spent a lengthy period of time remanded in custody
as a result.
Whilst in custody, N is not provided appropriate
services or assistance. He relies heavily on relatives who are also in
custody. He is unable to hear bells, officers’ directions and other essential
sounds in the prison context. At one point, it was alleged that N was
suicidal and he was moved to a psychiatric facility as a result. N denied the
allegation but was unable to properly explain himself to resist his transfer.
Case study included in NAAJA, Submission 170, p.
The committee notes that the 1991 report of the Royal Commission into
Aboriginal Deaths in Custody did not identify or remark on any relationship
between ear health, hearing impairment and Indigenous Australians' engagement
with the criminal justice system. The very few notes pertaining to ear health
were made in the context of overall Indigenous health programs, and not in
relation to criminal justice.
The report did comment on communication difficulties between medical
professionals and Indigenous Australians from non-English speaking backgrounds.
These difficulties were attributed by the report to language and inter-cultural
The committee has considered a large amount of evidence on the
particular hearing health issues facing Indigenous Australians, and is alarmed
at the ongoing disparities between Indigenous and non-Indigenous hearing health
in Australia. The committee recognises that the particular hearing issues
affecting Indigenous Australians are in addition to those facing all
Australians, and that the combined weight for Indigenous Australians is great.
The committee would like to take this opportunity to acknowledge the
commitment, dedication and passion of the many people and organisations working
with Indigenous communities to address hearing health problems. They exhibit
great resilience and energy in the face of a seemingly intractable problem, and
continue to seek innovative solutions and set in place evidence-based good
The committee understands that Indigenous hearing and health outcomes
are intrinsically bound up in a complex array of social, economic, cultural and
historical factors. No single clinical, pharmaceutical or technological
intervention can provide a 'magic bullet' solution for otitis media and its
effect on people's lives. This is not to say that interventions should not be
targeted and specific, but rather that they should be undertaken holistically,
within the social and medical realities of the day to day lives of Indigenous
Australians. It is for this reason the committee's recommendations emphasise
the importance of cross-agency and inter-jurisdictional efforts, and of putting
research and information in the public sphere wherever possible.
The committee is deeply concerned about the impact of hearing impairment
on Indigenous education outcomes, and is persuaded by the weight of evidence
that its impact may be very great indeed, particularly for children from remote
areas where English is a second language.
The committee has formed the view that there are practicable,
evidence-based approaches being implemented in some places, and that there is a
need for a single national body to facilitate the sharing of good practice in
education of hearing impaired Indigenous children, and develop long term
planning that will meet the future needs of children and educators.
The committee was persuaded by the evidence that there are demonstrable
educational benefits for all children to installing sound field systems and
acoustic conditioning, particularly in classrooms where there is a significant
number of Indigenous children.
The committee further believes that families of hearing impaired
children choosing schools for their children should be able to easily find out
where such facilities exist.
The committee notes that many education providers, school leaders and
teachers are aware of hearing impairment issues in education. Nonetheless, the
experiences of parents and hearing health professionals attempting to engage
the support of schools suggest to the committee that more needs to be done to
raise hearing impairment issues with educators. The committee believes that
some teachers may be unaware that they are dealing daily with behaviours in
children that are symptomatic of hearing impairment. Furthermore, that even if
teachers are aware they may lack the appropriate skills, resources and support
to address them.
The committee believes that the Goldfields Ear Health Conference is of
enormous value to ear health research and professional development in
Australia, especially in regard to Indigenous ear health and education. This
event should be a fixture in the calendar of people working in this field, and
in light of the crisis in Indigenous ear and hearing health its future should
The committee believes that Menzies School of Health Research and
Australian Health Infonet are making a vital contribution to Indigenous ear
health research and practice through the Ear Health Infonet. This resource
makes evidence based good practice and resources available to even the most
remote practitioner, and provides a site where people can share ideas and seek
help. The sharing of knowledge will be crucially important in improving
Indigenous health outcomes, and in light of the crisis in Indigenous ear and
hearing health the future of Ear Health Infonet should be guaranteed.
The committee is gravely concerned about the potential implications of
hearing impairment on Indigenous Australians' engagement with the criminal
justice system. Those most vulnerable are Indigenous people from remote areas
who do not have English as their first language, or indeed who, due to early
onset untreated hearing loss, have little means of communication at all.
The case has been made to the committee's satisfaction that there is likely
to be a link between hearing impairment and higher levels of engagement with
the criminal justice system. The committee believes that any improvements in overall
Indigenous hearing health may also come to be seen 'downstream' in lower
engagement with the criminal justice system, improved educational outcomes, and
improvements in other health and social wellbeing indicators.
Witnesses gave evidence that communication difficulties between Indigenous
people, the police and the courts may, in some cases, be caused by hearing
impairment, and that it could be mistaken for cross-cultural or language
communication difficulties. Poor communication at a person's first point of
contact with the criminal justice system can have enormous implications for
that person, and indeed for the integrity of the system as a whole. As has been
noted above, the High Court has set a precedent that a conviction where the
accused was not able to hear or understand the proceedings is not safe.
The committee also heard evidence that hearing assistance devices in
police stations and courtrooms are not always available, and believes that with
the very high levels of hearing impairment amongst Indigenous Australians these
facilities should be available as a matter of course. This is particularly the
case for jurisdictions which have high numbers of Indigenous people from remote
areas engaging with police and courts.
The committee heard that prison life is particularly difficult for
hearing impaired Indigenous Australians serving a custodial sentence. In a
world managed by bells and verbal instructions, daily life for the hearing
impaired is an extra challenge, especially if their impairment is undiagnosed.
The committee hopes that improved awareness of the level of hearing impairment
among Indigenous people serving custodial sentences will drive improvements to
the way correctional facilities are designed and run.
The committee is making this series of recommendations in the hope that
it will prompt the Australian Government to work closely with relevant
authorities in all jurisdictions to review the convictions of hearing impaired
Indigenous prisoners to ensure that they can be considered safe. The committee
further hopes that systemic and procedural changes will follow that guarantee
the protection of this vulnerable section of our community in future.
The committee notes that recommendations 23, 25, 26, 27, 28, 30 and 33 are
directed at making improvements for all hearing impaired Australians. Whilst
the weight of evidence which informed these recommendations was presented in
the context of hearing impaired Indigenous Australians, the committee believes
all Australians will benefit from their broad implementation.
The committee recommends that the Department of Education, Employment
and Workplace Relations and Department of Health and Ageing jointly establish a
task force to work across portfolios and jurisdictions on a plan to
systemically and sustainably address the educational needs of hearing impaired
Indigenous Australian children.
The committee recommends that Australian Hearing be enabled under the Australian
Hearing Services Act 1991 to supply and maintain sound field systems for
classrooms in all new classrooms, and in all existing classrooms where there is
a significant population of Indigenous children.
The committee recommends that the Department of Health and Ageing work
with the Department of Education, Employment and Workplace Relations to develop
a program with Australian Hearing to:
supply and maintain sound field amplification systems and
acoustic conditioning in all new classrooms, and in all existing classrooms
where there is a significant population of Indigenous children; and
report publicly on where sound field amplification systems and
acoustic conditioning are installed to assist parents in making informed
choices about schools for their children.
The committee recommends that education providers ensure that teacher
induction programs for teachers posted to schools in Indigenous communities emphasise
the likelihood that hearing impairment among their students will be very high.
Induction programs for these teachers must include training on the effects of
hearing health on education, and effective, evidence-based teaching strategies
to manage classrooms where a majority of children are hearing impaired.
The committee recommends that the Department of Education, Employment
and Workplace Relations work with jurisdictions to develop accredited
professional development programs for teachers and school leaders on the
effects of hearing health on education, and effective evidence-based teaching
strategies to manage classrooms with hearing impaired children.
The committee recommends that the Department of Health and Ageing make
the changes to Medicare necessary to enable specialists and practitioners to
receive public funding support for ear health services provided remotely via
The committee recommends that the Department of Health and Ageing work
closely with state and territory jurisdictions to develop and implement a
national plan which:
resources to conduct hearing assessments for all Australians serving custodial
sentences who have never received such an assessment, including youths in
juvenile detention; and
facilitates prisoner access to those hearing assessment; and
encourages a high level of participation in those hearing
the findings of the hearing assessments available to the public (within privacy
The committee recommends that the relevant ombudsman in each state and
territory conduct an audit of Australians serving custodial sentences,
including youths in juvenile detention, and consider whether undiagnosed
hearing impairment may have resulted in a miscarriage of justice and led to any
The committee recommends that the Department of Health and Ageing:
provide funding and resources to manage a national biennial
Indigenous ear health conference;
make the outcomes of those conferences publicly available
researchers and practitioners in
the field of hearing health.
The committee recommends that the Department of Health and Ageing work
with state and territory health agencies to provide funding to support the
continuation, promotion and expansion of the Ear Health Infonet.
The committee recommends that guidelines for police interrogation of
Indigenous Australians in each state and territory be amended to include a
requirement that a hearing assessment be conducted on any Indigenous person who
is having communication difficulties, irrespective of whether police officers
consider that the communication difficulties are arising from language and
The committee recommends that the National Judicial College of Australia
work with state and territory jurisdictions to develop and deliver accredited
professional development programs for judges, lawyers, police, correctional
officers and court officials on the effects of hearing impairment on Indigenous
engagement with the criminal justice system, and effective evidence-based
techniques for engaging effectively with people with a hearing impairment in
The committee recommends that hearing loops are available in interview
rooms and public counters of all police stations, and in all courtrooms, and
that loop receiver devices be made available for people without hearing aids.
The committee recommends that correctional facilities in which greater
than 10 per cent of the population is Indigenous review their facilities and
practices, and improve them so that the needs of hearing impaired prisoners are
Senator Rachel Siewert
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