Why this deafening silence on price of cochlear implants?

The human ear is an unbelievably complex organ. Many who are hard of hearing may be suffering from a disease or non-functioning of the cochlea – a part of the inner ear. Among the several diseases that could affect this cavity, the auditory portion of the ear, one strikes at birth itself, rendering the child deaf. As a result, the child also fails to develop speech capability. This is what we recognise as being ‘deaf and mute.’

It is important that every child between the age of two and six years has hearing capacity. Otherwise, he/she will subsequently not develop speech capability. Although some of them acquire the skill of lip-reading or communicating by sign-language, they still remain handicapped in this respect throughout their lives.

Over the years, research in medical science and technology has led to the development of ‘cochlear implants’ (CI) which, when used at a proper age along with appropriate care and follow-up, can conquer the inability to speak. The only stumbling block to obtaining this life-changing treatment is corporate greed for insatiable profits – the cochlear implant costs lakhs of rupees.

It is estimated that only around 3,000 affected children get the benefit of this treatment while a vast majority is denied the intervention. Those without a cochlear implant end up living in a world of deafening silence.

The cost of CI, around Rs 6.5 lakh, remains the single most important barrier for most people who need it. This cost crashed to almost half, however, when the central government placed a bulk order. However, it is still not available to a retail user at this comparatively more affordable price. Unfortunately, patients who need the implant cannot buy cochlear implants on their own either from a company that makes them or from any other source. No Indian company manufactures these devices. Most CI manufacturers are either in Europe or Australia. They have agents in India.

The manufacturers have established links with a few CI surgeons (popularly known as ENT surgeons) who are the only source of the device for the patient. Consequently, the prices of these are fixed at the whims of the surgeon, who decides what to charge depending upon his or her reading of the paying capacity of the patient. In addition, hospitals charge anywhere from 5% of the cost to as much as 50% as ‘handling charges’, which, of course, excludes surgical, hospital and rehabilitation charges.

This unholy nexus between the manufacturing companies and the surgeons is due to the commission that former pays the CI surgeons, which varies from 10% to 25% of the cost. This is in addition to the offer of one free cochlear implant device for the surgeon for every four or five purchased, which he can then sell at full rate to unsuspecting patients.

The manufacturing companies also organise ‘conferences’ for CI surgeons at 5-star hotels. These companies play many unethical games to retain their hold over the market. This nexus goes still deeper and wider. The manufacturers identify and deal with a few senior CI surgeons. Each senior surgeon in turn supervises four to five surgeries of a junior surgeon and earns a huge sum for his ‘mentorship’. These few senior surgeons have carved up territories for themselves and thereby maintain an absolute oligopoly.

According to Dr N B Prahlada, a leading ENT surgeon in Karnataka, “Even the various government CI programmes are divided up between a few surgeons who are in the expert committees and introduce restrictive clauses. Because of this, students at most medical colleges in the country are deprived of CI science. Therefore, there is no opportunity for self-reliance or to work on making indigenous CI.”

No doubt, the government can do much to reduce the cost. For example, CI is included under price regulation as per the letter dated March 5, 2012, by the Drug Controller General of India under the Union health ministry. Unfortunately, however, the government has bowed to the wishes of the nexus that rules this ‘business’.

Break the nexus

There is an urgent need for patients and consumers to appeal for a review of the whole situation by the Competition Commission of India. The Medical Council of India can intervene and address the unethical practices of the CI surgeons and ensure that CI science is available in all medical colleges. Much work needs to be done in this area so that the cost of the CI falls.

Apart from affordability, most patients who use CI also need continued monitoring and guidance. Unfortunately, this follow-up care is missing in CI programmes that have been initiated with the government’s financial support. It is estimated that around 80% of such treatments have failed because all patients need rehabilitation with auditory-verbal therapy for a minimum of three years. Every month, the patient will need around 12 to 15 therapeutic sittings. The therapy costs about Rs 1.5-2 lakh a year.

Cochlear implant devices also need consumables such as batteries and a connecting wire to the processor, which add to the financial burden on patients. The warranty period for external processors are only two years and they are also phased out regularly, thus forcing patients to buy a new processor, which currently costs anywhere between Rs 2.5 lakh and Rs 6 lakh.

It is obvious therefore that parents who want to get their child out of that “silent dead world” face too many hurdles. While cost is the biggest hurdle, inadequate follow-up and guidance is the other. It is time to introspect why, despite the availability of medical technology, the powers that be are deaf to the cries of those who need cochlear implants.

(The writer is President, Drug Action Forum – Karnataka)