Interview with David Citron, Ph.D.

Topic: Rotary Audiology Service Project in India

David Citron, Ph.D.

CAROLYN SMAKA: Dr. Citron, welcome to AudiologyOnline and thanks for your time today.

DAVID CITRON: It's my pleasure.

SMAKA: Can you begin by speaking about your background?



CITRON: Sure - I've been an audiologist since 1973. I've worked in a variety of settings - a community speech and hearing center, a medical center, a university, an ENT practice, and a rehabilitation hospital. In 1982, my wife Louise (who is also an audiologist) and I opened our own private practice, South Shore Hearing Center, www.sshc.com. It's in Weymouth, MA, or south suburban Boston for people who aren't familiar with the area.

I was one of the founders of the American Academy of Audiology, president of the Academy of Doctors of Audiology from 1988 - 1990, and I became a member of the Rotary Club of Weymouth (www.weymouthrotary.org) in 1983. Currently I am club president.

SMAKA: The topic of our interview is an international audiology service project that you undertook, involving a trip to India in February 2009. Was this was a Rotary (www.rotary.org) project?



CITRON: Yes. I have always wanted to be involved with a humanitarian project, preferably linked to Rotary.



Dr. Raj Desai

This project first began because of the efforts of a physician who is also a Rotarian from Southern California, Dr. Raj Desai, whose daughter was born deaf from complications from rubella. Dr. Desai made it his life's passion to reduce hearing loss in India. He founded an organization called Project Deaf India (www.projectdeafindia.org) that began with money donated by individual Rotary Clubs that was then matched by the Rotary Foundation.

One of the goals of Project Deaf India was to reduce the incidence of hearing loss in India through immunizations for measles, mumps, and rubella. And, vaccinations are now becoming standard protocol within India due in part to his efforts.

The other goal of Project Deaf India involved early hearing loss identification through setting up a newborn hearing screening program. That's where we participated.

SMAKA: Have you had the opportunity to meet Dr. Desai?

CITRON: Yes. At first, we e-mailed back and forth. Then he came to Boston to give a talk on consanguinity and hearing loss at a pediatric meeting in October. So I met with him along with three other Weymouth Rotarians who were potentially interested in participating in the service project. After learning more details about the overall plan and especially after hearing the passion with which he speaks about this subject, we decided to move forward.

We then started working in detail with our Indian Rotarian partners to apply for a Rotary Volunteer Service Grant (VSG) and to organize the mission.

The project came about with Dr. Desai's assistance. His local Rotary club in Newport Beach, California, along with other Rotary clubs both in his area and in India, raised a total of $25,000. This was then matched by Rotary Foundation for a total of $50,000. Those funds were used to purchase 10 Maico ERO-SCAN™ OAE screeners. In addition, we knew that it was likely that older children - not just babies - may need to be screened and there may be middle ear pathology that would confound OAE screening. So with the help of a grant from our Rotary Club of Weymouth and the generous donation of GN ReSound (gnresound.com/) North America, we received four Otometrics OTOflex tympanometry screeners.

The audiology infrastructure in India is not what it is here in the US. In India, there are only approximately 1,000 audiologists for the country's population of one billion people.
While there are currently projects underway to recruit and train more audiologists in India, at the present time there is still clearly a shortage.



Dr. Citron training healthcare workers in Goa, India on
OAE screening.

Our team's role in this project was to therefore train the local medical residents, nurses, and other healthcare workers to use the OAE equipment to screen newborns, and to use the tympanometry equipment to check middle ear functioning when needed. We also had to unpack, calibrate and configure the equipment and ensure it was functioning properly.

We trained the workers, let them practice on each other, and informed them of pitfalls and troubleshooting. We were confident that after we left, they had a viable screening program in place.

Our project was focused on a state called Goa, which is about 260 miles south of Mumbai. It was a former Portuguese colony that became part of India in 1961.

Goa was chosen as the focus of our project because it has birthing hospitals as well as solid infrastructure. The infrastructure is necessary to not accomplish this project involving a newborn hearing screening program, but also to accomplish the long term management of the children who are identified through the program.

This project was successful primarily because of Rotary's help. Rotary paid for the screeners, and Rotary also paid for our airfare through a Rotary program called the Volunteer Service Grant. Through this Rotary program, Rotarians can apply for up to $6,000 in funds to travel to an area where assistance is needed. So Rotary supported this project with $56,000 worth of funding. And the Rotary also proved invaluable when it came to managing logistics for us within India.

SMAKA: Logistics, such as?

CITRON: Our team was hosted by the Rotary clubs in Goa, and they could not have been better hosts. They handled logistics of our trip that would have been very difficult for an outsider to manage. For one thing, they arranged our lodging. While it is typical for Rotarians to stay in individual homes of host families, the Rotary Clubs in Goa arranged for a guest house so that our team could be together. This was very thoughtful and proved to be critical for us to accomplish our goals. Since our project team stayed together, evenings could be spent efficiently managing unfinished business and making plans for the following day. They were even so thoughtful as to stock the guest house with food! Throughout the entire week, they were always there for us if we needed anything. They were just terrific. I cannot say that enough about them and their warm hospitality. It is typical of Indian culture, and in accordance with a time-honored Indian expression "Your guest is your G-d" (non-religious). They even arranged a driver for us. Do you know what it's like to drive in Rome, Carolyn?



Local Rotary clubs in Goa, India, were key to the project's
success, providing needed logistical support.

SMAKA: Sure - it's like suicide.

CITRON: Right - and driving in India is ten times worse than driving in Rome, if you can imagine. Many of the roads between villages are not paved and not well marked. They drive on the left side of the road and have every kind of vehicle on the road imaginable - motorcycles, little motorized rickshaws, carts, bicycles, pedestrians, trucks, buses, cars - you name it. Having a driver helped us to focus on the project and maintain our sanity while traveling around a foreign country!

While we were there, we also attended four Rotary club meetings and met the people responsible for sponsoring this project. We also attended their major district conference, which coincidently was being held while we were there. This kind of fellowship was a wonderful opportunity to learn about the local culture and how Rotary functions in India, and also reinforced our shared goals in the project's success.

So just in terms of logistics, it's clear that without Rotary's help this project would have been much, much more difficult if not impossible to execute.

SMAKA: How many people were on your project team?



Project team left to right: Helen Blowers, Dr. Citron,
Deepak Shah, Louise Citron, Daryl Ann Cook.

CITRON: There were five people: two audiologists and three other Rotarians from our Weymouth Rotary Club. My wife, Louise, was able to participate under the Volunteer Service Grant because she's my spouse, and since she is also an audiologist, we provided most of the training. However, the three Rotarians who are not audiologists were equally as important as the audiologists to this success of this project.

The additional Rotarians, in order to qualify for the grant, had to possess special training to accomplish the mission set forth in the application. They spent several sessions at Boston Medical Center in the newborn nursery learning and practicing OAE and tympanometry screenings, so they could assist as necessary under our direction.

When we departed for India, we were not certain of the size of the group of health care practitioners that would require training. It turned out that we broke up into smaller groups, so although my fellow Rotarians provided some assistance with the training, their greatest value was to chronicle this trip in detail. We have amazing photography and a journal about what we accomplished. It will be important for planning future programs by providing information to Rotary International headquarters. The team also assisted with details like securing needed accessories such as voltage converters.

One of the Rotarians on our team from Weymouth was an Indian expatriate who has lived in the U.S. for past 30 years and functioned as our interpreter when needed. Overall, we were pretty fortunate that most of the people we worked with in India spoke English.



Louise Citron, MA, performs an OAE screening. As the only other audiologist
on the project team, Ms. Citron provided audiological expertise, training,
planning and was critical to the project's overall success.

So we spent five days in Goa explaining the basics of OAEs and tympanometry, how to use the screeners, how to interpret the results, and troubleshooting/pitfalls. By the time we were finished, the healthcare workers in Goa were reasonably comfortable using the equipment. We also were able to screen some babies and children in each site before we departed, but we moved from hospital to hospital. There was more than sufficient practice for the groups so that it was clear that the workers were trained and comfortable with the process, and that screenings would occur once we left.



Waiting for infant hearing screenings.

SMAKA: How many hospitals did you visit?

CITRON: We visited three government hospitals. One was Goa Medical College in Panaji;one was Asilo, located in a town called Mapusa;and the third was Hospicio, like the Portuguese word for hospital, in the town of Margao. Goa Medical College is an active medical school, and the largest of the three. There is an audiologist at Goa Medical College, as well as ABR equipment so we knew that there would be follow up. We worked with the audiologist while we were there. She will determine thresholds if necessary on babies who do not pass the screening and be responsible for further follow up. She is the only audiologist in the state of Goa for a population of 3 million.

In any humanitarian program, the single largest challenge is follow up. The second largest challenge is follow up, and the third largest challenge is the same as the first two.



Nurses sharing a laugh while practicing use of OAE equipment on each other.

SMAKA: [laughs]. Exactly what I've heard.

CITRON: We were certainly mindful and concerned about that going into this project. We could do all the training we wanted and identify every baby, but in the end we were most concerned about what would happen after we departed.

As I mentioned, that's one of the reasons Goa was selected. In addition, it's important to understand that as much as Rotary was critical in the successful creation of this project, Rotarians are also going to be instrumental in insuring the project's long term success and viability for several reasons.

First, since Rotarians made an active contribution toward the screening equipment, they are committed to monitoring its utilization. At least 10 Rotary clubs invested in the grant to purchase the equipment, and they are now emotionally invested in this project.
They are passionate about seeing this project through its completion.

Second, Rotarians are very well connected in the medical and business communities. Some Rotary officers are physicians themselves. They're the movers and shakers in their communities in India, and they have contact with the health minister, who also makes decisions about the provision of hearing aids. Thus, it is clear that Rotarians have a significant voice in the community as well as influence in the infrastructure of India. That is true about Rotary in most nations, but particularly in developing countries. Rotary not only helps to fund initiatives, but provides follow up to insure successful outcomes.



Nurse in Goa performing infant OAE screening.

SMAKA: In terms of follow up, what is planned for babies who need amplification?

CITRON: That's a more difficult challenge, and one we're totally dedicated to addressing.

In India, as you know there is both extreme poverty and extreme wealth. There is also an emerging middle class, so things are gradually changing.

There are private hospitals and government hospitals. Even within the private hospitals services do not compare to typical U.S. standards. For example, I learned that the average Indian that visits a government hospital for hearing aids will be fitted with body aids without earmolds, just ear tips.

There is a commitment on the part of the Healthy Ministry, at least in Goa, to improve the situation and provide at least reasonable analog BTE technology. So that's a start. And the Rotarians will insure that happens. They have contacts in the Health Ministry and will assist in follow-up.

In addition to better amplification options, the other piece necessary to move our project forward is to provide more audiologists in India who are trained to fit hearing aids. It is my understanding that most audiologists in India have very little have experience fitting young pediatric patients. Certainly, there is unique expertise required for the pediatric population.

Training for Indian audiologists to fit amplification on children could either occur in India, or outside of India. For example, with the assistance of a grant from Rotary, audiologists from India could travel the U.S. for a few weeks to receive immersion training in pediatric hearing aid fitting and assistive technology such as FM systems.



Dr. Citron training healthcare workers on use of OAE and immittance equipment.

And once a few audiologists in India are trained, the network could be expanded. And when you do the math, you see such a program would work in Goa. In Goa, there are 30,000 births per year. If you consider U.S. hearing prevalence data of three to four per 1,000 births, it means there are approximately 120 new infants identified with hearing loss per year in Goa.

That number can be managed with one audiologist training other professionals to help provide some of the follow-up. We're very keen on what is needed for such a project to succeed and there are many of us working together to move it forward.

As I mentioned, there is currently an audiologist at Goa Medical College, and we have received assurances that there will soon be an audiologist at Hospicio in Margao.
For early detection and intervention to succeed, having more trained audiologists is clearly a top priority.

SMAKA: So future initiatives will focus on taking the programs in Goa all the way through management of hearing loss, instead of expanding the hearing screenings to other areas in India outside of Goa.

CITRON: Absolutely. Otherwise, you have areas that are identifying children but with no effective follow up. Of course, it would make sense to expand screenings to other states if there is adequate infrastructure in place to fit amplification and manage the children.

SMAKA: It sounds like you accomplished quite a bit in a short time!

CITRON: Thanks mostly to Rotary, we were able to achieve what we had set out to accomplish. We also had some other interesting opportunities while we were there.

One of Rotary's main goals is the eradication of polio worldwide. They started the effort over ten years ago and this goal is almost complete. India is one of the countries where there are still some remaining cases of polio, not in Goa, but in the northeastern section of the country near the Bangladesh border.

There are large structured immunization projects underway in India. February 1, 2009 was National Polio Immunization Day, so on the first day of our mission in India we had the opportunity to participate.



Poster for India's National Polio Immunization day in 2008.
Dr. Citron and his team participated in the 2009 event.

We learned about how they implement these vaccination projects;they actually go house to house conducting immunizations. They have records of all the births, and they travel to homes to identify and vaccinate all the babies who have yet to be immunized. Following vaccination, they mark each child's pinky finger with permanent marker as an indicator.

It is really down to a science. We learned to perform the immunizations, but the Indian nurses and healthcare workers could immunize 20 babies in the time it took us to do one! They were that fast.

SMAKA: Dr. Citron, if other audiologists would like to get involved either in this project, or other similar humanitarian audiology projects, what would you advise?

CITRON: In terms of this mission, it's clear that it would not have been possible without Rotary's help. And there are other Rotary opportunities for audiologists. There are many audiologists who are Rotarians, and it is not difficult to join Rotary if someone were interested.

SMAKA: How would an audiologist become a Rotarian?

CITRON: Let me answer that by briefly giving you some background about Rotary. Rotary International is a service organization of business and professional men and woman that was founded in 1905. Rotary's motto is "Service Above Self."

The object of Rotary is to encourage and foster the ideal of service as a basis of worthy enterprise and, in particular, to encourage and foster four things.

The first is the development of acquaintance as an opportunity for service. For me, this particularly rings true. Through Rotary, you meet great people, you roll up your sleeves and you work together to serve the community. You really form life-long friends and fellowship while performing service projects.



Dr. Citron and his project team in formal Indian dress to attend a family
wedding of a fellow Rotarian in Mumbai, India.

The second is high ethical standards in business and professions, the recognition of the worthiness of all useful occupations, and the dignifying of each Rotarian's occupation as an opportunity to serve society. So, I'd paraphrase that by saying you're using your particular occupation to serve society, which is what we did through our audiology project in India.

The third is the application of the ideal of service in each Rotarian's business and community life.

The fourth is the advancement of international understanding, good will and peace through a world fellowship of business and professional persons united in the ideal of service.
In our project, this was realized through our Indian hosts. We learned so much about the culture - things that we could bring back and communicate to our own Rotary club.

In regard to your question, to become a Rotarian you have to be a manager in a business or profession, so being an audiologist would certainly qualify. Rotary clubs meet weekly either over breakfast, lunch or dinner. There are 32,000 rotary clubs in 200 countries and 2 million Rotarians, so it's not difficult to locate one. Audiologists can use the club locator on the Rotary Web site to find a club in their area.

The audiology mission in India is an example of an international service project. Rotary is also involved in local community service projects. Our Rotary Club of Weymouth supports a food pantry, a homeless shelter, a van for the Council on Aging, a Rotary Santa project for needy families, and college scholarships for outstanding students in the high schools.

Typically, local service projects significantly outnumber international projects. Most clubs are involved in one or two international projects a year. Polio eradication is a world-wide effort from Rotary Clubs all over the world.

SMAKA: Do you plan on going back to India?

CITRON: I will likely go back at some point, but I would like to see other Rotarians in the U.S. involved in this project. With this audiology project, we have a follow up plan and it's achievable. We have the right support system in place. Neither I, nor Dr. Desai, nor our fellow Rotarians will let this project fail. It may take a year or two, but it will definitely succeed. We helped to plant the seeds for this project, watered them, and now the goal is to turn this over to others to help it grow. I would like other audiologists to have the opportunity of bringing this to the next level.

SMAKA: I hope this interview will spark the interest of others - it sounds like a great opportunity for audiologists. Thank you, Dr. Citron, for passionately sharing your experience with us!

CITRON: I think I speak for everyone on our team when I say it's been an incredibly rewarding experience, both personally and professionally. Thanks to AudiologyOnline for its interest in Project Deaf India.