We firstly commend the addition of planetary health content to The University of Melbourne (UoM)’s Master of Clinical Audiology curriculum in 2025. Since the department's appointment of a Sustainability Lead, Dr Michelle Todorov, in 2024, there has been increased impetus to update the core curriculum, and advocacy for education for sustainable healthcare.

In 2025, a new lecture titled ‘Planetary Health’ was delivered by guest lecturer Associate Professor Keneth Winkel, from the Melbourne School of Population and Global Health in conjunction with Michelle Todorov in the first year subject Professionalism and Clinical Processes B. The lecture covered principles of sustainable healthcare, healthcare carbon footprints, the need to advocate for preventative healthcare, and current sustainability challenges within the audiology, along with strategies to minimise their environmental impacts.

However, this first year ‘Planetary Health’ lecture is a standalone lecture, without examinable content. Planetary health is not otherwise integrated throughout the curriculum, which creates the risk of students not engaging with the messages of this lecture on a deeper level. There is also minimal teaching on the current and future impact of climate change on access to audiological care.

The department’s internal audiology teaching clinic employs sustainable practices, like sanitising consumables for reuse, and students learn about benefits of reusable hearing device batteries, and helping reduce need for MRIs.

1. A follow-up lecture in second year to refresh these learnings regarding planetary health may help to instil a sustainable healthcare mindset, as students are closer to entering the audiology workforce. It could further explore how climate-related disruptions affect long-term audiological rehabilitation, particularly for cochlear implant users requiring mapping, paediatric patients in early intervention programs and older adults reliant on routine device maintenance. The curriculum could incorporate disaster preparedness planning in clinical training. Students could learn how to develop contingency plans for device supply shortages, telehealth backup systems and emergency communication strategies for vulnerable patients.

2. We commend and acknowledge that there are developments underway such that in 2026, a planetary health-related lecture will be delivered to second year students in the Complex Audiological Cases stream, with assessable learning outcomes. However, as this lecture has not been delivered yet, it will not be commented on in the 2025-2026 report.

3. In the ‘Global Audiology’ lecture from the Professional and Clinical Processes A stream, we recommend explicit teaching on the impacts of extreme weather events on access to audiological care, including service disruption, device maintenance challenges, and continuity of care. Discussions can be embedded on the disproportionate effects of climate change on marginalised, regional, and remote communities within core subjects. This could include case-based learning using Australian and global examples to contextualise climate-related barriers to hearing healthcare.

4. As part of PCPA and B assignments, reflective practices should be encouraged and interdisciplinary learning that links planetary health principles to everyday clinical decision-making 

5. The Clinical Audiology Student Association (CASA) has the capacity to create a new executive role, similar to the Sustainability Officer role in the Melbourne Medical Students’ Society (MMSS). This would facilitate improved sustainability at organised events in line with the University of Melbourne’s Sustainable Event Checklist, including the management of waste, reasoned venue choices, and education and awareness of environmentally friendly initiatives the event has incorporated. We anticipate such a person could work alongside the CASA Education and Welfare Officers to critically analyse the application of ESH in our core curriculum, and advocate for further incorporation.

Thank you for meeting with me today, Ali. To start us off, can you tell me why you decided to become an audiologist?  

Ali: Okay, sure. I think I'll start by giving a little bit of background on audiology and hearing care in Tanzania. It's a very underdeveloped field in general in Africa, especially sub-Saharan Africa. In Tanzania, there are very few audiology departments, even to this day. There is very little awareness of audiology, hearing loss and of all sorts of ear related issues. Until 2011, in fact, there wasn't even a private clinic in the country. In 2011, we opened the first private audiology clinic. It's a family-owned clinic that I work at. I was still at school at the time, so I was just volunteering and helping out; mostly over summer holidays. Hearing about the work the clinic was doing, the people it was reaching out to, learning firsthand about hearing loss and the sorts of problems people face and how little people know of what to do about it really motivated me to look further into it. I realized how barely anyone was informed about this and how hardly any facilities were available, not only in Tanzania, but in Eastern Africa, and many people were suffering when there were simple things that could help them. I decided I would pursue audiology as a career to try to help advance things by taking things forward, helping people, and improving the business as well.  

Can you tell me what would a typical day looks like for you in Tanzania as an audiologist? 

It's a bit of a tough question to answer because most of the times I don't know. Let me give you an idea of what we do now. When we started in 2011, we were doing basic hearing tests and hearing aid fittings. Over time, we started doing digital hearing aids and making our own ear moulds in house. Then, we saw a lot of cochlear implant patients who were implanted in other countries and would need access to spare parts and programming. Once we noticed this gap, we started looking at what we could do to help them. My father, who is also an audiologist, started working with various implant companies, MED-EL in particular, and we started working with Siemens in terms of hearing aids. Then we also started working on training audiologists and technicians in other hospitals. In the public health care system, such as the hospitals in Dar es Salaam and in Zanzibar, we started conducting trainings to try to improve proficiency and infrastructure as well. We helped with equipment, set up, things like that, and in creating a referral network to channel patients appropriately.  

That went on from 2014 to 2017, and at the time we were starting to prepare ourselves to perform implants locally. In 2017, we performed our first batch of cochlear implants, and since then, we've done about 60 cases. We have another one tomorrow, in fact! Along with this, since 2018 we've been doing vestibular testing and tinnitus management as well. We have our own 3D printer, so we do all the ear moulds locally, and can even produce custom in-the-ear devices if required. 

Going back to your question, I actually have no idea what I do on a day-to-day basis. Some of it is just hearing tests and fittings, sometimes it's newborn screening days, sometimes it's ABRs and vestibular patients, another day could be making ear moulds or doing repairs and then also, we have our implant patients so some days you're in the operating room all day.  

I see, so little bit of everything then! 

Yes, it's a bit of a mixed bag. It's nice.  

That's great. You mentioned you've been working on building up the referral process there. Can you tell me a little bit about how people in Tanzania get access to these hearing services, either the ones that you provide or those through the public system?  

Through the public system, there's very few institutions that have access to these services and for the most part, it's diagnostic services, it's hearing tests and that's it. What happens generally is, let's say a patient will somehow end up with an ENT, the ENT will refer them towards audiology services. They'll generally tell them what they need to do and send them for testing, either in the public systems or towards private care. That all depends on what is easiest to access. Unfortunately, it's not very easy to find services. As I said, they can go and look for an ENT doctor, but those are quite rare as well. There are around 70 ENT specialists in the entire country, which is a country of about 60 million people. As for audiologists, there's about 15. 

Wow! 

A lot of the people we see are actually referred by friends and family, as word of mouth goes a long way here. There will be people who have a problem and will have given up. And then, friends or family tell them that there's this place they can go to, so as you can see, it's not exactly a system. It works for some, but we're definitely still trying to reach more people.  

That makes sense, yes. So, we've spoken a little bit about the limited number of audiologists and ENTs being a major problem with access to services. Can you think of any other challenges or barriers to the people in Tanzania, or Africa in general, in accessing hearing health care? 

Yes, the lack of availability is one problem; you don't have enough people to go around. The fact that most of these professionals are concentrated in cities or bigger towns means that people from rural areas don't have the easiest time in getting to them. The other thing is, of course, the cost of these services. You need a certain amount of funding available for implants and hearing aids, and that funding has to come from somewhere. If the patient is not paying privately, the government or insurance has to fund it. The cost is definitely a challenge for the majority of people in a place where the average income is very low to begin with. This is one of the main challenges which I think you'll find across all of Africa and across most of the world, actually, even in more developed countries, where you don't have funding available.  

Another thing I would mention is the availability of these devices. It's easy to access them in Europe, for example - if you want a hearing aid, you can get it the next day from the manufacturer. If we want a hearing aid, it can take about a month to six weeks from the time that we place an order to the time that it's in our hands. Then, let's say something breaks down. If you don't have a replacement, there's not much you can do, except send it back to wherever you got it from and then have them return it to you, which will also take a month or so. Calibration is another challenge; if you send equipment off for calibration, again, you're looking at about a two month process, whereas in developed countries, it'd be something like two days.  

Lastly, another barrier that we see people face is actually something that we see the world over, which is stigma and people’s belief systems coming into play. I think some people aren’t very keen to act on hearing loss, and while a patient might have their own beliefs, their relatives, and the people around them also play a role in enhancing those. Here, there's also all sorts of alternative medicine and natural remedies. There's many people who trust these, and it's not because they don't think that something else is available, it's just because there's not enough of what can actually help them.  

Building on from that, my last question is, what changes to hearing health care within Tanzania or in Africa more broadly would you like to see moving forward?  

Well, there's a few fronts that we're trying to develop services on here. The first is better training facilities. We can have as many diagnostic facilities as we want, but if the people aren't there to use them, it doesn't really help much. One thing that we're trying to do is train more people. Partnerships with institutions, partnerships with companies and manufacturers and other alliances are helping us try to develop training programs and facilities for surgeons and for audiologists as well, because that's something that we're trying to develop concurrently. In February this year, we actually launched a state-of-the-art temporal bone lab for the training of surgeons, when previously, they would have to travel to other countries to do this and a single workshop could cost them something like $3 - 4,000. Now they can just go in and use the lab as they like.  

We've also been working on increasing research. There is a very huge gap in research in Africa in general, and health research is not very prominent, especially in this field. You can imagine, when you only have 70 ENTs in the entire country, not many of them have much time, but we're trying to promote it. As I said, we're trying to work with institutions to further this research, to identify the gaps and see what we can do with the data that we have to improve service availability and quality.  

I think the other thing that I would want to change very much is collaboration on the continent. I feel like it is very important for regional surgeons, audiologists and anyone working in hearing care in Africa to come together and identify the unique challenges that we face and work out how to go about tackling them. Collaboration is quite high with organizations in other regions; I know many facilities that work with the University of Melbourne in Australia and UCSF in America, for example. We work with MED-EL and the University of Alexandria in Egypt to develop these services, but more collaboration between us and our neighbours could make these things a little bit easier and help us improve the services in the region as well.  

The last thing I would highlight is newborn screening. We started newborn screening at a private hospital in Dar es Salaam in 2018, and it was the first newborn screening program of its kind. At the time when we started it, parents had to opt in to get their baby screened. The numbers were quite low because people weren't very proactive. But now, about five years later, we're seeing quite high volumes of babies getting the screening done. This is because of increased awareness. Now, we have people coming in from other hospitals saying, "Hey, can we get our baby screened?". So, while there's only one center currently, it's a good model, and I believe it's something that can be transferred over into other centers to develop a newborn screening program, specifically in this region. In our context, I think that will, not only help people get access to services when they need it, but also help us push for the development of policies that can increase this access as well.  

That's amazing. Thank you so much, Ali. This has been so informative, so thank you again, on behalf of HEARGlobe, for making time for this interview. We will certainly be watching this space and keeping an eye out for all the incredible work you and your team are doing for hearing health care in Tanzania, and in Africa overall.

Why did you decide to become an Ear, Nose and Throat Specialist?  

I decided to become an ENT doctor because I love ear surgery - the instrument’s small and the doctors do the surgery by sitting. When I did my ENT residency, I know that patients have to [wait on] a long list for [surgery overseas] so I want to become a doctor who can perform ear surgery and I don’t want the patients waiting on long lists to [wait for a long time for treatment] with their hearing disability. 

What are the most common pathologies that patients present with to the Children’s Surgical Centre? 

Mostly ear, nose and throat problems. The diseases that I see, the patient has chronic suppurative otitis media with eardrum perforation, or with cholesteatoma. Also, some children with sleep apnoea or allergic rhinitis and nasal polyps, and some disabilities like microtia.  

How do people access hearing and ear care in Cambodia?  

The Cambodian people access ear and hearing [services] in different ways. They can go to the ENT government hospital. Some of them go to NGOs like my hospital, CSC. [There is also] All Ears Cambodia, [which is an] impact organisation. Or they can go to a private clinic. But we do it in different ways. Some departments provide only ear surgery, some departments provide all the ear and hearing assessment and hearing management like hearing aids or cochlear implants. Some departments only provide hearing tests and fit hearing aids. And some organisations [do] outreach and … take patients to get surgery in town. Or foreigners come down to Cambodia to perform surgery or fit hearing aids.  

You’ve contributed to research that has found that often people in Cambodia wait a long time before accessing hearing and ear care after they first notice symptoms.  What are some of the reasons for this long time between onset of symptoms and treatment? 

When I started [as an] ENT, I found that disease stays for a long time. [Patients] have a history with chronic ear discharge as a child which stops and starts to recur. Some of them know about hearing loss but some patients don’t. Some patients might have only one [ear] with chronic ear disease and the other ear still has good function so they might not notice that they have a hearing loss.  

Some patients have bilateral hearing loss, so they don’t notice that they have a hearing loss. I think because the Cambodian people talk loud, that’s the reason the patients themselves don’t notice they have a hearing loss. And [some patients] don’t know where to go to get the treatment, so they just go to the pharmacy to get medication and then they stop [treatment] and don’t know that they have an eardrum perforation, or cholesteatomata, or hearing loss from an inner ear problem. 

How does the cost of treatment potentially stop people from accessing hearing and ear care?  

Before two years ago, we didn’t have [health insurance] that the company had to pay for their own staff. So, the patient had to pay for health treatment by themselves. So, the cost would be expensive for them. One surgery from 9 years ago cost $300 to $500 (USD)... but right now, compared to the factory worker’s salary, which is about $120-250 per month... the price is high to get the surgery. And the hearing aid cost, it would be - some private hospitals that I know charge $250-350 [for one hearing aid]. 

What about the quantity of hearing healthcare and ear care professionals in Cambodia – is that a barrier? 

Not really... I think right now we have about 100 [professionals with] ENT training. I think the problem is not the amount of healthcare workers, the problem is they only stay in the capital city.  

It must take a long time to travel from far regional areas to Phnom Penh, right? Does this potentially prevent people from accessing care?  

Yes, transportation is expensive too. They can pay about 5-10 dollars, or 5-25 dollars for one return ticket. Also, Cambodian patients don’t like to go to the hospital by themselves, they need [to be] accompanied by someone, a relative or neighbour – two or three people come with them.  

Could you tell me a little about why, for some Cambodians, treating hearing loss is not a priority? 

Yes, I saw some patients that need ear surgery to improve their hearing, to stop serious disease, or need hearing aids to improve their hearing, but they decide not to choose that treatment, because hearing loss is not a serious disease [for them].  We see that they can sit and work, but they don’t know that they have a hearing loss or [understand] the effect on their [concentration]. So that is [why] people don’t want to get surgery to stop from work, to stop from the ability to earn money.  

What are some ways to reduce the barriers that we’ve spoken about?  

The services provided need to improve; the department [should completely fund] ear consultation, ear surgery, hearing assessment and hearing management. [We need to] reduce the transportation costs and provide good service and quality to make patients keep coming.  

Also, the patient themselves has to understand about the ear and hearing loss problems. They [need to become] aware about the problems that affect [their] ability to think, ability to work, and need to decide to get the surgery quickly. The cost of treatment should be afforded [by] the government or by the health insurance for the patients that cannot afford the cost. 

Cambodia is a poor country, everything is imported. We don’t make surgical equipment, we don’t make hearing aids or hearing assessment equipment, so we need to … work together to [provide] fast education training to [teach people] how to work on ear and hearing disability. This will help to improve the ear and hearing health in the developing countries.  

Certainly, a lot of work [needs] to be done in that space. We look forward to seeing how you’ll be involved in reducing these barriers in the future.  

Yes, thank you. I’m very [motivated] to improve my department ... right now, I work on ear and hearing assessment from adults to children with hearing tests - pure tone and VRA*. So I hope to receive more equipment like the ABR* to easily test children because it is an objective test. I think if I can have an objective result from a machine it would help me to make diagnoses for hearing loss early. 

*VRA = visual reinforcement audiometry; ABR = auditory brainstem response

Why did you decide to become an audiologist?  

When I was coming to the end of my Biomedical Science degree, I was working in research on a clinical trial but wasn’t thrilled with the possibility of becoming a researcher. It’s funny saying that now because that’s where I have ended up.  

I knew I really wanted to have that interaction with people and to really help them. So, when I came across an audiology flyer at the end of year seminar, I started really considering this path. I did some work experience at a few clinics around Melbourne and found it really interesting, so I decided to pursue my Master’s in Audiology. 

What inspired you to go into public health research? 

I had the opportunity to take part in a program called Australian Youth Ambassadors for Development to do health worker training in Vietnam. I was posted in Hue City for 12 months where I spent time training nurses and even academics on how to perform hearing tests and rehabilitation.   

During the time I was there, I was seeing a lot of two-year-olds whose mothers reported a “fever and rash” during pregnancy. These children weren’t speaking and it turned out that they had profound hearing losses. Through some more inquires I found out there was a rubella outbreak in Northern Vietnam 2 years earlier.  

This was so eye opening as a privileged Australian who had always taken their vaccines for granted. This was what really inspired me to go into public health and learn more about prevention and what can be done to help improve access to health care, hearing healthcare and vaccinations more specifically. 

What has been your particular research focus? 

I did my PhD over in London at the London School of Hygiene and Tropical Medicine. I focused on developing a survey methodology to measure hearing loss in population-based surveys with a focus on understanding prevalence and the causes of hearing loss, particularly in low-middle income countries.  

So, I planned and conducted three surveys in Malawi, China, and Gambia to test the survey methodology and also contribute to the data availability as there hadn't been surveys done in those countries before. This was kind of the first data available to be able to look at what the main problems facing that population were.  

I worked closely with a World Health Organization Expert Group to shape the methodology, get heaps of expert input and to incorporate the findings into a WHO tool. So the research I did was actually able to translate into policy and practice, not just research for the sake of research.  

Now I work at the Melbourne School of Population and Global Health in the Indigenous Health Equity Unit led by Professor Cath Chamberlain. We're working on a couple of big projects called “Healing the Past by Nurturing the Future” and “Replanting the Birthing Trees”. These projects are community-based, which have involved many years of co-design working with communities and service providers to shape the work. They aim to develop and test perinatal awareness, recognition, assessment and support strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma. 

This has been a really different direction of research for me given my background as an audiologist, but the work is so important and I’m really happy to be working with this amazing team. 

What does a normal day look like in the research field? 

It’s quite diverse. I attend and chair a lot of meetings with the project team and key community partners. Working in the space of Aboriginal public health, it's really important to work collaboratively and to get input on the research at every stage. 

I also get involved in project management to make sure we are meeting our milestones. I get to also be involved in a lot of the research side of things like collecting and analysing data, doing a lot of writing and reading literature and thinking about future directions for research. 

What innovation or change in hearing healthcare would you like to see and why? 

To improve access to services for the people most in need. There is always a disparity in access for those with the highest need like in lower-middle income countries or remote communities in Australia that have the poorest access. So making sure that there’s a health provider nearby to those communities, even a primary health worker or an Aboriginal health worker who can conduct some basic screening tests so people don’t have to travel days to get to a hospital that has any kind of service.  

I'd like to start off by finding out about why you decided to become an audiologist.  

I actually retrained as an audiologist. Before that, I finished high school, did a Bachelor of Science, and then found myself not really sure what to do at the end of that study. So, I did an internship, I worked in the physics lab a little bit, and then I was going around the careers fair one day and I stumbled across [audiology] and it reminded me of an experience I had when I was a young teenager. I got my hearing tested because my parents had some concerns about my hearing. Turns out that I had a unilateral hearing loss, and I have some theories about how that happened, but we'll save that for another time. Then I thought, "Oh, I do like working with people. I’m not a super expert, but I enjoy working with technology as well. I do have some experience," and so I decided to go for it. 

Zooming out a little bit, how do people access audiological and ear health services in Tonga?   

Funnily enough I'm actually the first audiologist that's been hired by the Ministry of Health in Tonga. Prior to that, we had an Ear, Nose and Throat specialist who was trained in New Zealand and anyone that had anything to do with a hearing problem, whatever the cause was, they went to this guy. So, he set up the ENT clinic in 1987. It basically serves as the access [to ear and hearing healthcare], mainly through the hospital. So, it's a little bit different to some other countries, say in New Zealand … there's not really that GP model and then referral to the hospital. There are few private clinics which people can access outside of normal business hours. But most of the time, if someone has a problem, they'll come to the outpatient area in the hospital and be seen by a doctor. 

So, once I came on, we just started to create a little pathway. The majority of people will be seen by the doctors first, just to make sure that the ear is healthy, there's no foreign body or middle ear effusion or something like that, and then we can do further investigation by pure tone audiometry or [further testing].  

What are some of the challenges or barriers that people face when accessing ideological and health care in Tonga?  

Currently, it's a very centralized service, so people have to come to the hospital to access it. And it's been like that for as long as it's been around. But slowly we’re trying to move away from that, so last year we did some outreach to different health centers. How it works is there's one main hospital on Tongatapu, which is the largest island in Tonga, and home to about 70% of the population. There's one main hospital in town, and then there are seven health centers spread out across the island as well. Those health centers will have nurses and in-house trained health officers, [who have] basic medical training.   

Last year, we did some outreach to those health centers to try and make it easier for people in the rural areas particularly to access those ENT services. But at the moment, the way most people access it is by going to the hospital. 

Another one of the barriers would be the distance. Some villages are close, but others are further away so getting transport [is more difficult]. Sometimes there are long wait times as well and some people don't want to wait in the queue for a long time. I think sometimes people don't quite know where to go as well. 

Among the general population, is there much awareness of the things that can go wrong [with ear health]? In terms of pathologies, is there much public health awareness around that, or education?  

We've been trying to jump on World Hearing Day stuff recently the past couple of years. So that's been a good opportunity for us to raise awareness about [ear health]. But I think maybe it’s that public general knowledge about [ear problems]. So sometimes people have pain or discharging ears or something like that, but they just don't think, "Oh, I should get that checked out." They just tough it out or [say] "Oh, it'll go away soon..." Sometimes people only come in when it's quite serious or they've tried other things and it hasn't worked. So that’s a barrier as well, not knowing when to come in and not leaving it too late before coming in [for treatment]. 

You've spoken about being the only long- term audiologist [in Tonga]. Is that a barrier in terms of the number of hearing health professionals in Tonga?  

Hopefully I haven't been too much of a barrier myself, but I think word gets out slowly. I think because our services are not that wide ranging at the moment that also maybe people don't know that I'm there. And part of my hesitancy is that I don't exactly have much to offer them at the moment.  

Our access to assistive technology, for example, is not consistent; there's no regular source of it. So sometimes I might get some donated hearing aids from a former colleague and then I give them to patients and then there's nothing again. And then we have to wait for the next round of funding or the next donation. If we had announced “we have 3000 devices coming, come and get them,” I'm sure there'd be a queue two hours down the road. So, I think that the lack of solutions [for hearing loss] may also be a barrier as well.  

Could you tell me a bit about some of the ways that the barriers that we've spoken about are being addressed in Tonga?  

Yeah, I'm trying my best to find some sustainable long-term solutions, especially with getting assistive technology. I’m trying to form new networks, to help people know I'm here and what I'm doing. I’m also working with the hospital [to see] what's the right way to do stuff or what's the format we do it in.  

Long term we'll need to increase that access of even doing more regular outreaches or having another audiologist or audiometrist or even just someone that's trained locally [who has] those skills. And then we haven't even talked about the outer islands yet. But just even being able to provide that service on the main island [is something we’re still working on].  

I think one of the other challenges is that we have no screening systems in place regularly. So, it's hard for us to pick up unless they come to me or to come to us for the service. We don't know what's out there. There's a couple of Rotary clubs that are involved in the hearing screening project that will hopefully take place later this year, aiming to start about May. So, we're [screening] five- and six-year-olds in the primary schools. That will be the first large scale hearing screening program, so that's quite exciting for us. Hopefully that will be the start of more regular screening programs to increase their access and awareness as well.