New Delhi, Aug. 29: Several ear-nose-throat (ENT) surgeons have sought government intervention against what they say is a "cartel" of fellow surgeons that is obstructing the spread of cochlear implants - devices used to treat deafness - to other surgeons.

The surgeons in independent pleas sent to the Prime Minister's Office and the government's medical pricing regulator have claimed that the cartel, colluding with suppliers of the devices, effectively decides who may perform cochlear implant surgeries in the country.

Cochlear implants, which are available at prices that start at about Rs 5.5 lakh and climb to around Rs 15 lakh in the private healthcare market, are tiny electronic devices that provide a sense of sound to the profoundly deaf by directly stimulating the auditory nerve.

Sections of ENT surgeons estimate that about 100,000 children born deaf each year in India would qualify for cochlear implants, but say less than 5,000 procedures are carried out, primarily because of the implants' high costs.

The surgeons say their complaints to the government reflect concerns shared by many ENT specialists that fellow surgeons operating under the banner of the Cochlear Implant Group of India (CIGI) have ensured that the implants are not available to other surgeons and their patients.

The CIGI has restricted access to cochlear implants by imposing "unrealistic and unscientific" criteria for ENT surgeons to handle cochlear implants and by insisting that only "mentors approved by companies" should train surgeons for the implants, the complainants have said.

"The criteria create a misleading impression that only a select few qualified people can perform cochlear implants, and others cannot - this is very wrong," Prahlad Basanth, professor in the ENT department at the Basveshwara Medical College in Chitradurga, Karnataka, told The Telegraph.

The issue, largely unknown to the public, has generated intense controversy among India's ENT surgeons over the past five years. One surgeon from a corporate hospital wrote to his own medical board saying a "mafia-like ring" of a few surgeons "are threatening and keeping implant companies under leash".

Shankar Medikeri, a senior ENT surgeon in Bangalore and the CIGI president, has asserted that the group is an "academic association" with no regulatory authority. The guidelines, he said, are intended to ensure that only competent surgeons perform cochlear implant procedures, but added they are not mandatory.

"The implant itself is a small component of the procedure," Medikeri told this newspaper. "Patients need to be evaluated appropriately before the procedure and, most important, require post-operation speech therapy for learning to listen and speak -- these should be available to all patients receiving the implants."

Basanth, who is among the surgeons who has written to the PMO, said the complaints follow nearly six years of repeated pleas with decision-makers in CIGI seeking changes in practices and unsuccessful attempts to procure cochlear implants from device manufacturers.

"At first, we didn't have a clear understanding of what was going on -- the suppliers would not send us implants, our patients were being diverted by audiologists to select surgeons," said Sumit Bhatti, an ENT surgeon in Pune. "Then, the dirty business became clear," Bhatti said.

The complainants, echoing concerns Basanth had first expressed to CIGI in August 2011, have now written to the PMO and National Pharmaceutical Pricing Authority that the cartel is driven by "kickbacks". Anecdotal evidence, they say, suggests that surgeons receive kickbacks of Rs 50,000 to Rs 200,000 per implant.

"Companies do not provide cochlear implants to surgeons unless those surgeons have been approved by so-called mentors," said Rakesh Srivastava, an ENT surgeon in Lucknow, who has written to the NPPA pointing out that companies offer one free implant for every five to 10 implants purchased.

The surgeons seeking government action believe a crackdown on the cartel will help reduce the prices of implants through the competition emerging from more ENT surgeons performing the procedures.

All cochlear implants in India are now imported and supplied by a company each from Australia, Austria and America.

The representative of one company who requested not to be named said the decision to provide implants depends on "the infrastructure at the clinic or the hospital" and the company's "capacity to initiate a cochlear implants programme with the clinic or the hospital". A query sent to the second company remained unanswered, and executives from the other company were not immediately available.

"One thing puzzles us though," Bhatti said. "Why do the companies play along with some surgeons? The more ENT surgeons doing the procedures, the more their sales. So, that's still a mystery."

The CIGI guidelines demand that before an ENT surgeon can do cochlear implants, the surgeon should have done 500 ear surgeries, observed five cochlear implants, served as assistant in five additional cochlear implants and have worked under the tutelage of a "mentor" surgeon approved by the company.

"This is tantamount to saying only mentors and companies decide who can do the surgery," said Basanth, who has email correspondence that suggests he was consistently denied cochlear implants by two companies until last week when one agreed to supply him implants.

Even within a hospital, some surgeons may be denied the opportunity to perform the implant procedures.

In 2015, an ENT surgeon in Bangalore with over 15 years of experience sent an email to his own hospital pointing out that only one surgeon conducts cochlear implants and requesting that he also be granted permission to undertake the procedures in the hospital.

"It's been two years since then, and I'm still not allowed to touch a cochlear implant on my own - if I want to do the surgery, I'll have to do it under a so-called mentor," said the surgeon, Satish Babu K. "This practice has gone beyond limits now."