Silently lost in a sea of infections.

KEY MESSAGES: This article highlights some of the problems faced in working in resource poor settings. While the situation may differ from general practice in London, many of the same principles apply.It highlights the importance of keeping hearing loss in mind when seeing children with other conditions.It shows some of the principles in the Alma Ata declaration, such as the inequity in treatment between developed and developing world settings, health care rationing and the concept of health including social well-being.

WHY THIS MATTERS TO ME: This article relates to my time working in Pakistani Kashmir for a medical NGO in both primary and secondary care paediatrics. It describes trying to help a young girl with hearing loss. Particularly in a setting like this, you tend to prioritise the immediate problems (mostly infections in infants) and ignore other things however difficult they may be for the child and family. Most importantly I feel this article provides a different perspective, giving a first hand account of dealing with a difficult problem in a difficult setting. While not directly related to general practice in London, this article provides many important and relevant messages. Neonatal hearing screening may mean that congenital hearing loss is picked up at birth, but other forms will present at a later stage and children who have not been screened (who missed the screening, parental refusal and those who came from overseas) still need to be considered. Thirty years on from the Alma Ata conference the world is still blighted by many of the same problems. This personal account shows many of the difficulties spelt out by the declaration. In particular it highlights the persisting inequity in treatment between the developed and developing world. It shows the importance of health including social well-being. The girl in this story lacked a disease, but being unable to hear, or more importantly communicate, would mean an inability to live an independent life in the future. Another concept highlighted is health rationing, which is faced almost daily in any field of medicine. This is especially so in fragile states and war zones. External health funding goes predominantly to 'fashionable' diseases such as HIV, which has lead to organisations trying to promote the 'neglected' diseases, for example trypanosomiasis. Despite its debilitating effects hearing loss achieves even less attention than these.