The People's Republic of China may date to at least 551 B.C., but the professions of speech-language pathology and audiology in the country date back to more recent times—the 1980s.
In an educational exchange, several ASHA members took a two-week journey to China last summer. We visited the Children's Hospital and the School for the Deaf and Mute in Xian, and four locations in Beijing—the modern, well-equipped audiology program at Tongren Hospital, the China Rehabilitation Research Center for the Deaf and Deaf Recovery Center, the China Association of Rehabilitation of Disabled Persons, and The College of Pre-School and Special Education at East China Normal University.
People to People International's Ambassador Program, which sends scientific, technical, and professional delegations to meet with their overseas counterparts, organized the trip. Our delegation was led by former ASHA President Dolores Battle and included Constance Dean Qualls, ASHA vice president for research and technology; Roberta Aungst, then ASHA vice president for professional practices in audiology; and ASHA members Audrey Kunz, Miriam Romero, Cara Stein, Rachel Vasquez, and Laura Young Campbell.
After a long period of being ruled by dynasties and political control that closed the country from the western world, China opened its doors in 1978. Through the 1980s, the walls that had excluded the world came down, and health providers who had relied on traditional Eastern medicine began using Western medicine and technology. This change included treatment of speech and hearing disorders, although many families still rely on traditional Chinese medicine, including herbal treatments and acupuncture.
China is a country with 1.3 billion people from 55 ethnic groups who live in a vast area of 3.7 million square miles with 23 provinces, four municipalities, five autonomous regions, and two special administrations.
According to the Gallaudet Encyclopedia of Deaf People and Deafness (1987) and the Encyclopedia of Deaf and Hearing Impairment (2004), there are an estimated 62 million individuals with a disability in China, including an estimated 20 million with speech and hearing disorders: 3 million who are deaf and 17.7 million who have hearing loss. According to Chen Zhen Sheng, professor at the China Rehabilitation Research Center for the Deaf, major causes of hearing loss in China are presbycusis, otitis media, infection, ototoxic drugs, heredity, and noise-induced hearing loss among those working in construction and in industry who labor without hearing protection. Hua Zhang, director of otolaryngology at Tongren Hospital, reported an estimated 800,000 children under age 7 with hearing loss, a number expected to increase by 20,000–30,000 every year. Only 2% have access to hearing aids.
A Universal Newborn Hearing Screening Program (UNHSP) was established in 1996. According to the Chinese Ministry of Public Health (2002), statistics from this program indicate that an estimated 30,000 children are born with hearing loss each year.
Audiology and Aural/Audiologic Rehabilitation
According to Hua at Tongren Hospital, audiology is a relatively new profession in China, with the first audiologists identified only 20 years ago. Most were physicians trained in otolaryngology with an additional six months' training in audiology in the United States or Australia. The first program for training audiologists in China was established at Capital Medical Sciences University in 1996; the first six audiologists completed the program in 2001. Since that time, other programs have been established at West China Medical School at Sichuan University (Chengdu) in partnership with Sichuan University and Dalhousie University. Today there are about 400 audiologists in the country—about one for every 300,000 people. (In contrast, there are 42 audiologists for every 300,000 people in the United States.)
The Clinical Audiology Center at Tongren Hospital provides 40–100 pure tone tests each day, and is well-equipped to provide otoacoustic emission, auditory brainstem response, videonystagmography, and other assessments.
The UNHSP at Tongren Hospital estimates that 120,000 children—or six to eight of every 1,000 births (0.604%–0.82%)—will be identified with a hearing loss each year. Many families initially seek treatment with traditional herbal medicines and/or acupuncture, both of which are available at the hospital. More recently, families are also opting for cochlear implants; Tongren has provided 600 implants since 1996, and expects to implant more than 200 in 2007.
Education of the Deaf
The first school for the deaf in China was opened in 1887 in Shantung Province by American missionaries. It was not until 1927 that the first public school for the deaf was opened in Nanjing (now Shanghai); the first school for the deaf in Beijing opened in 1935. In 1986 the Ministry of Education mandated that all children with disabilities receive at least nine years of basic education.
An estimated 3 million children in China are deaf, but only 33,000 are enrolled in the 664 schools for the deaf. Children brought to the major cities for identification and treatment are generally returned to their home provinces for education. The government runs special-needs schools, located mostly in urban areas, including those for the deaf and those for children with more severe developmental disabilities, but children with mild to moderate hearing loss generally receive no intervention services.
When a child is not developing speech, and traditional treatment methods are not producing results, the family will seek intervention with hearing aids and/or cochlear implants. Education and rehabilitation are often delayed or not provided, either because the family believes that medical treatment alone can cure the hearing loss or there are no trained personnel near the child's home; most rural families cannot afford to send the child to an urban school. (Even though the schools for the deaf are tuition-free, families are expected to make contributions in addition to paying for room and board.)
This cost delays access to intervention while the family saves the necessary funds, often until the child is 3 years old. If the family is not able to pay the additional costs, the child will remain in the local community for schooling, in classes led by teachers who may have some training for children who have special needs. Most teachers, however, learn on the job. According to consultants at the School for Deaf Recovery in Beijing and the Xian Deaf Mute School in Xian, there are fewer than 400 specially trained teachers of the deaf in the 664 schools with classes or programs that serve children with hearing loss. Most are employed in urban schools for the deaf.
Today, 34,000 children are enrolled in 1,700 special education schools or programs throughout the country, including 2,800 children with hearing loss who are in high school and 6,582 in 145 occupational schools, where they are trained in art, massage, or baking (Lytle, Johnson & Hui, 2005/2006). Although the incidence of children with hearing loss attending special schools has increased, an estimated 54,000 school-aged children who are deaf living in rural areas have no access to education.
We visited one such school for the deaf, the Xian Deaf Mute School, where children with hearing impairment attend special programs from pre-school through grade nine. Many of the children in the small (15 children) classrooms had hearing aids and some had cochlear implants. The teachers had little formal training as teachers of the deaf. Students who are deaf were prepared for careers in art, while students who are blind were prepared for vocational careers in baking or massage. There were no computers or other electronic devices for students' use.
While in Xian, the delegation was asked to consult on two cases treated at the Children's Hospital. In the first, a 21/2-year-old-boy was receiving weekly acupuncture for a profound hearing loss. He had been diagnosed in Beijing, and his family traveled to Xian from a rural town to receive treatment, which the family had been told would result in normal hearing in six months. The audiologists on the trip reviewed the boy's audiometric assessments and determined that he would be a candidate for a cochlear implant. The family would have to travel back to Beijing to have the procedure; however, there was no auditory rehabilitation program in his rural community. He would either have to go to boarding school in Xian (with charges for room and board) or attend a special education program in his community.
In the second case, a 4-year-old boy appeared to have significant developmental delays, and the family was seeking advice on a cochlear implant. The audiologists in our delegation reviewed the results of his audiometric assessment and determined that his hearing was within normal limits. There was some suggestion of an autism spectrum disorder, our group could not confirm this diagnosis. Autism is little-known in China and there are no special programs in the boy's rural community that would be able to provide an appropriate education or intervention.
Although Hong Kong has several trained SLPs, speech-language pathology is just emerging as a profession in mainland China. The first program to train SLPs was established in 1988 at the China Rehabilitation Research Center, a teaching hospital at the Capital University of Medical Sciences in Beijing (Shengli Li, 2007). China has fewer than 200 SLPs, but there are approximately 1.5 million persons who have had a stroke; as a result, physicians and neurologists often provide speech-language services. Nurses who receive three to six months of "advanced" education in the medical school or in other countries such as Korea and Australia also provide services.
At Tongren Hospital, much of the speech-language pathology treatment is provided by physicians or nurses who have received special training to treat persons with voice disorders, neurological impairment, and dysphagia. Most swallowing treatment, however, is done by nurses. At the Xian Children's Hospital, language diagnosis and treatment is usually provided by psychologists, who have limited training in the diagnosis of more complex communication disorders such as autism and developmental disorders. A large Children's Hospital is scheduled to open in Xian this fall; the director expressed the need for staff training in diagnosis and treatment of children with communication disorders.
China is emerging as an economic force in the world economy. As its professionals become more aware of the possibilities and potential of persons with disabilities, China will make advances in the identification and treatment of persons with speech-language and hearing impairments that will parallel its economic advances.
New hospitals and schools are being built with up-to-date facilities and equipment. The goal is to have an additional 5,000–7,000 special educators by 2015 to improve access to appropriate services, including an additional 5,000 teachers to provide rehabilitation services to children aged birth to 5 years. The hospitals and schools need 130,000 SLPs and audiologists to provide services, train new professionals, and provide professional development for existing personnel. It will be exciting to see how China will use its rapidly developing technology to identify and treat hearing and speech-language disorders.