Audiology was modernized in medicine's magic bullet era

In my last post, I argued that hearing loss is a disease treated as an illness. Here, I want to explore how the profession became centered on devices that address the hearing disability post hoc, after the fact, in parallel with research that was exploring the metabolic biology of hearing and developing the underlying oxidative stress model of cochlear dysfunction.

The postwar magic bullet template

Modern medicine ran a remarkable victory lap in the postwar era of the 1940s and 1950s. Antibiotics had turned bacterial pneumonia from a death sentence into an outpatient inconvenience. Polio and other fatal diseases were on the path to being defeated. Within the medical community and in the public imagination, the emerging shape of medical heroism was the molecular magic bullet that hit a target pathology in the body and made the patient well.

Penicillin was the springboard template. Starting with an accidental discovery of the bacterium in 1928 in Scotland, a decade later Oxford University researchers proved its incredible effectiveness. Scaled up manufacturing in the U.S. during World War II was propelled by another accidental discovery of penicillin growing on a moldy cantaloupe.

The era organized medicine around that template. New specialties formed around the premise that the right tool, deployed against the right target, would solve medical problems. That breakthrough model is still preeminent, and was also the point of beginning for modern audiology, which inherited that era's logic, emerged within it, and relies on it today.

How audiology fits the template

The audiogram, refined during and after the war, gave clinicians a precise measurement of compromised auditory function as they treated returning soldiers. Audiology mirrored the medical model of the physician prescribing penicillin and other drugs that followed: Measure. Diagnose. Prescribe. Follow up. The hearing aid was the targeted device.

Every framework has its shape

For audiology, this was a remarkable advance. Amplification has transformed lives. The profession has earned its place. None of what follows is a critique of the work audiologists do inside the magic bullet framework, but by definition, every framework has its limiting shape. The magic bullet framework works best when pharmacological or device-based interventions target discrete pathologies that respond with measurable changes in measurable time. It is less well-suited to address slow, continuous changes in complex metabolic processes that may degrade over decades. Consequently, the early stages of metabolic disorders are most often invisible within the disease treatment magic bullet framework. Sensorineural hearing loss, SNHL, a metabolic disorder with no approved disease-modifying drug, is an example.

The pathophysiology of SNHL is understood. The target is identified. And yet, in the language of magic bullet medicine, the condition has been orphaned. There is no pill for it. The institutional response has been to focus on the disability post hoc. That is an honest response; existing tools can remediate functional deficits. But the framework burdens the patent with carried costs.

The years that matter biologically

In the early stages, the patient is told their hearing is fine, or at least not sufficiently compromised to require remediation with hearing aids. Yet the biological damage continues, beneath the threshold of the test. The conversation shifts to amplification when the test catches up to the progression of the metabolic disorder. The clinician has done the job the framework asked of them. The patient has moved from the column where the framework cannot help to the column where it can. But the years between, the years that mattered biologically, were spent without any framework for early engagement in the time-course of the disease.

Deferred maintenance is a side effect

Expectation bias can increase the cost. Continued heavy investment in pharmacological research and recurring news reporting hearing regeneration drug development progress can distract attention from the present to the future, when a fix is available. That fix has been under development since the 1980s, and it may or may not arrive. If it does, it will embody the availability limitations and cost structures of the pharmaceutical model. The argument is not that pharmacological research is wrong. It is that for patients, deferred maintenance may be an under-appreciated side effect of magic bullet thinking.

The next post is about what we know about early stage auditory system functional decline, and how a recent paper by two audiologists and a physician contributes to expanding the conversation in hearing to include preemptive routine maintenance.