The Lynn Clinic and Health Equity: Transforming Good Intentions Into Effective Clinical Practice

“Medicine is a social science, and politics is nothing more than medicine on a grand scale.”Rudolph VirchowEquity in health care is not a new idea. It has long been recognized that social status and health outcomes are inextricably linked. Mid-19th century, Virchow’s observations on the contribution of societal factors to a typhus epidemic evolved into public health medicine as we know it today.1 More recently, the societal factors that contribute to health outcomes have been brought to the forefront of global health policies, with the World Health Organization (WHO) recognizing social determinants of health (SDHs) as a key pillar in achieving sustainable development goals.2 The WHO has also stated that addressing health inequity and the knowledge that lower socioeconomic groups have worse health outcomes is ethically imperative, with 1 in 3 premature deaths worldwide attributable to socioeconomic inequality.3,4 The fact remains that while modern medicine continues to expand the sphere of what is possible in diagnostics and therapeutics, there are still people for whom access to even basic health interventions is challenging.4,5 Inclusion health (IH), as a concept, aims to develop care pathways that are patient centered and focused on overcoming visible and invisible obstacles to engagement with health care services for people with poor health due to poverty, marginalization, and multimorbidity.4While this article focuses on a local population of children at risk of social exclusion needing medical care, many of the factors impacting their health will be well recognized in a global context. These children experience social exclusion and are facing a life impacted by adverse childhood experiences (ACEs). They are children who have already overcome and may still be experiencing significant social adversity and who, through no fault of their own, cannot engage with the hospital care that they need. This is a narrative of how a pediatric clinic with the purpose of providing equitable access was established in Ireland, with the historical, sociopolitical and local context as a backdrop. In order to truly understand health inequity, clinicians must appreciate the seemingly insurmountable forces that create the inequity. Every health system is different and has its own administrative and operational idiosyncrasies; to describe in detail one particular system is beyond the scope of this article. Suffice to say, no system has yet to obtain true universal, equitable access, and clinicians must familiarize themselves with the pitfalls and challenges inherent within their own context to create bespoke solutions.For example, in the case of a child from an ethnic minority background with chronic malnutrition, living in homelessness, and exposed to domestic violence, diagnosis is only the first step. Treatment and achieving a sustainable outcome must address the challenges of: Single parenthood living in emergency accommodation.The constraints placed on adequate nutrition by homelessness (eg, lack of refrigeration/cooking facilities, food insecurity, and safety of young children when cooking in communal facilities).Limited adherence to treatment plans because of challenges in health literacy and limitations placed on affordable prescribing by our health system.The ongoing effects of physical and psychological trauma on the mother and child as a result of exposure to abuse.The history of Ireland encompasses the progression and evolution of SDHs. A rural, impoverished island at the turn of the 20th century with a population decimated from the effects of the Great Irish Famine, it was a land where institutional abuse and exclusion of those living outside perceived social norms were “supported by, contributed to, and condoned by, the institutions of the State and the Churches.”6 In 1911, 36% of Dublin’s population lived in tenements, and infant mortality rates in Dublin in 1919 were 141 per 1000, considerably higher than any other city in Ireland or Britain.7 Some of these institutions, including mother and baby homes (institutions for unmarried mothers and their children) and Magdalene Laundries, remain within in living memory.8In this time of rampant communicable disease, malnutrition, poverty, and high infant and childhood mortality, Ireland’s first infants’ hospital, St. Ultan’s Hospital for Sick Infants, was founded by Dr Kathleen Lynn and Madeline ffrench-Mullen in 1919 to “make some effort to check the needless waste of life in Dublin.” Dr Lynn was a pioneering physician who recognized that impoverished women and children of the Dublin slums were disproportionate victims of malnutrition and diseases during the early phases of the 1918–1919 influenza pandemic.7 The hospital reports noted that the high infant mortality was directly linked to poverty and malnutrition. This institution thrived, even in the context of extremely limited resources, throughout the global influenza pandemic and worsening national conflict (the War of Independence followed by the Irish Civil War). In the first year of operations, the death rate in the hospital fell from 55% to 39%.5 A century ago, Dr Lynn demonstrated that focusing on overcoming the consequences of social deprivation can improve patient outcomes.7Ireland has undergone a dramatic economic and cultural shift over the last century. Today, a global hub for multinational corporations with a much more heterogenous, secular, and affluent society, over 15% of Ireland’s population now speak a language other than English or Irish at home.9 Alarmingly, just over a century after the founding of St Ultan’s hospital, and in the aftermath of yet another global pandemic, we still live in a country struggling to achieve basic health equity. Marginalized ethnic minorities continue to have poorer health outcomes than the general population, a recognized issue internationally.10–14 The challenges of homelessness are not recognized or incorporated into acute hospital infrastructure. The volume of people entering Ireland seeking international protection has exponentially increased in the past 2 years, and many clinicians are unfamiliar with the multitude of physical and mental health issues caused and exacerbated by the pre-, peri-, and postmigratory journeys.15,16 We continue to support institutionalization of certain socially excluded groups, such as those seeking international protection, who are housed in transitory accommodation through our inadequate system of Direct Provision that consists of state-provided food, board, and necessities. This system has “failed to respect the dignity and human rights of individual.”15 The Royal College of Physicians in Ireland published a report in 2019 calling for the abolishment of the Direct Provision system because it “cannot adequately meet the needs of children and their families in terms of security, family autonomy, nutrition and access to education and health services.”16While Ireland now has a highly developed infrastructure of public, primary, and acute health services, there has been a widening of the deprivation gap, with a 35.57% increase in people living in extreme deprivation observed from 2016 to 2022.17 Of those living in extreme deprivation, 25% live in the region covered by the catchment area of our hospital, Children’s Health Ireland at Temple Street (CHI-TS).18 Over the last 9 years, 2 large adult university hospitals in Dublin have established IH teams in response to growing numbers of patients experiencing homelessness. The formation of dedicated teams to care for patients experiencing social deprivation has had an overwhelmingly positive effect on patient outcomes and use of hospital resources.19,20 The challenges for patients who are marginalized because of social exclusion begin well before adolescence or adulthood and can have long-lasting implications for their physical health as well as their development, emotional well-being, and mental health.21–24 Children experiencing social exclusion experience higher rates of illness, poorer educational opportunities, and increased barriers to accessing care and supports than their peers.25Our hospital, CHI-TS, is located in Dublin’s city center, the area where 72.4% of the total registered homeless population of Ireland are located, with 49% of families and children experiencing homeless registered in the city center.26 This area has been renowned for poverty and social exclusion for generations and was once reputed to be the largest red-light district in Europe.27 Also on the doorstep of CHI-TS was the second-largest and last Magdalene Laundry in Ireland, which closed its doors in 1996.8 In 2019, a 29% increase in presentations of children in homelessness was noted in the CHI-TS emergency department.28Recognizing through our day-to-day practice and from national research reports that our acute hospital pediatric services struggled to engage children and families experiencing social exclusion, we looked for an approach that would support equitable access to care.12,28–30 While advocacy and supporting policy change must remain within our scope of practice, the very first step to supporting equitable access is designing operational frameworks that scaffold attendance and support feasible and sustainable treatment plans. We also identified certain broad cohorts of children clearly at risk of social exclusion in our local area who might benefit from an IH approach.In May 2024, 4316 children were registered as homeless nationally through relevant local authorities, a 476% increase in a decade.31 There is a range of transitory accommodation including family hubs, hotels, and bed and breakfasts; reception centers; and repurposed commercial properties. The common theme is the precarious nature of this accommodation that impacts family life. It is never a home, rarely even a house, mostly just a room, without a secure base from which children and their guardians can become part of the local community.In Ireland, children from the Roma and Irish Traveller communities constitute the majority of children from ethnic minority groups at risk of social exclusion. Traveller Community means the “community of people who are commonly called travellers and who are identified (by themselves and others) as people with a shared history, culture and traditions, including historically, a nomadic way of life on the island of Ireland” (Equal Status Act, Government of Ireland, 2002). In the face of persistent discrimination and social exclusion, Irish Travellers were recognized as an ethnic minority in 2017. Irish Travellers continue to have demonstrable poor health outcomes with infant mortality 4 times that of the non-Traveller population and general mortality rate 3 times that of the general population.12,32 They experience much higher levels of racism, discrimination, and incarceration than their peers.13 In 2021, approximately 3000 Irish Travellers were living without access to toilets, running water, or electricity.33The Roma people are the largest ethnic minority in Europe, with an estimated 12 million Roma living in different countries throughout Europe. The national census of Ireland in 2022 recorded 16 049 Roma people, with 26.3% children aged younger than 14 years.9 Factors influencing Roma health include low education and health literacy levels, social exclusion, cultural differences, historical trauma, and financial constraints.12 Roma people have consistently shorter life expectancy than non-Roma people across the European Union (EU); in some countries, this can be more than a 10-year difference.11 The Roma have been victims of intergenerational trauma for centuries, with a history of slavery and persecution including preferential selection for medical experimentation in the Holocaust.34 The Holocaust, known to the Roma people as “Baro Porrajomos” (the Great Devouring) destroyed over half of the Roma and Sinti population in Europe.34 Even today within the EU, 85% of Roma children are living in poverty in comparison with 16.8% of children in the general population.13 Roma and Travellers remain victims of various forms of discrimination, including school segregation and a forced sedentary lifestyle as well as hate speech and hate-motivated violence in many member states.35The number of international protection applicants entering Ireland continues to rise year on year, with a 348% increase in annual applications for international protection between 2017 and 2023.36,37 Unfortunately, planned revisions of this system outlined by the Irish government, including the end of Direct Provision, have been deferred because of an acute crisis nationally in housing and accommodation.15 In May 2024, there were 30 027 people seeking international protection in Ireland; of these, 7314 were children aged younger than 18 years in emergency accommodation or Direct Provision centers.38More than 100 000 Ukrainians have come to Ireland as Beneficiaries of Temporary Protection since the Russian invasion of Ukraine began in February 2022.39 In May 2024, 13 124 children aged younger than 18 years were being accommodated in emergency, transitory, or unstable accommodation.40Intergenerational trauma is defined by the American Psychology Association as the “the transmission of trauma or its legacy, in the form of a psychological consequence of an injury or attack, poverty, and so forth, from the generation experiencing the trauma to subsequent generations.” More recent history confirms that the intergeneration cycle of disadvantage continues. Dublin’s North East Inner City (NEIC) was one of the first parts of Ireland to experience widespread heroin use and remains an area of high prevalence of substance misuse, with violent gangland killings a particular feature of the district’s drug-related crime.41 This region had the highest crime rate in Ireland in 2018 at over 5 times the national average.42 In 2016, 35.1% people in NEIC were living in deprivation.43 Numerous small areas (geographically defined units containing ∼50–200 households) within NEIC contain up to 80% single-parent households, and upward of 50% of adults had attended only primary-level education.44 Single-parent families, children living in the care of relatives, and children in foster placements are disproportionately represented in North Inner City Dublin.44 These children have encountered multiple ACEs, their already-traumatized family units often need scaffolding to navigate the acute hospital system, and it must be acknowledged that nonattendance does not equate with a lack of caring on the part of the primary caregiver.45Acknowledging the need for a change in the basic structure of traditional outpatient care delivery operations, we commenced the eponymous Lynn Clinic in October 2020. This community pediatric outreach clinic for children at risk of social exclusion aimed to deliver “Inclusive healthcare delivered with respect and understanding for every child.”Integrated care between the hospital and community and between governmental agencies and nongovernmental organizations became the cornerstone of our practice. Working together with children, their families, and community health and social care providers, we began to understand and overcome the barriers that health care and to deliver and of socially excluded and marginalized groups were not outlined because they are and of social deprivation are and between different community The Lynn Clinic aimed to not only address the very and facing these children also to the of trauma, and challenges children and families may have in a In a hospital clinic in a primary care with supports the of clinic engagement for families, we aimed to some in addressing the very need by our the an approach was with a broad base from a of health and social care In the to a clinic of attendance is by a of on various social many families can only to when they have and with our of community support The address and numbers of are different to what was on the even over a of the need for this to an In families have significant challenges with (eg, or child they are in their attendance with new times are to a of health and social Every effort is to obtain an because are when or social history with experiences of and violence, human and is to more understand the context of family through a what can often be of of and the time to foster a of and understanding is as as history and There is also a on of in the context of supporting and nutrition (eg, of of secure number of family per prescribing is with the majority of through the national health is with by a that also any in In recent in the form of a and has been to children and when in response to numbers of to relevant to support health and is (eg, and violence support with a victims of or and mental health and in Ireland for community and primary care a system of forms is In the context of forms the of need and are often by the primary and health literacy are barriers by the this can access to These forms are by our with to support access to interventions and the there is ongoing any planned diagnostics prescribing is also a key in supporting ongoing engagement (eg, of a to In the case of (eg, our will often with to for more supports while interventions and are were from a of patients in to the Lynn Clinic over a through to understand our own practice and patient were into new and children for A total of children as new and as The basic are as in can be the majority of children the Lynn Clinic are living in transitory or unstable many without established primary care infrastructure in the form of a general half of are young children of school a time in which and development are to and of the children have forced or are of the Roma of the Irish Traveller population living in their low within the clinic must be and 2 for this are as higher levels of established primary care and access to hospital services are of Irish Travellers have medical because of established primary care, there may be of the Lynn Clinic Irish health on this has to on to and engagement with our to be to our within the Irish community because of in this does not of the for and with and nutrition more than half of in new were for and were for and from the of in and issues with and nutrition is a that care and very knowledge of such as accommodation cultural and mental of are population with national rates of in children aged from to October was with or a and history of the to the Irish or the of of in with national was to of and nutrition the of in of such as and In patients where were clearly were the for and were the for In those for whom was those aged were with a of at for and and were or These are of national the significant of of the and of such a in childhood is not to be can be with engagement and use of multiple of the majority of children who were new attended for medical In the of patients who were new to the clinic due for attendance over the patients were had multiple over the in these from the first or attendance as relevant were not at 1 Of these, 80% attended their A total of attended their first or In of patients in of their first of these, had the country or to another part of this care to be where possible to local are only for to first the time covered by our national at nonattendance the many barriers to hospital attendance by our it is a significant that over are to It must also be noted that ethnic are not in this national so that national nonattendance rates of marginalized ethnic minorities is not its for the Lynn Clinic from community and from the local community has been overwhelmingly a member of the Roma community and an with health services, to the of the Lynn Clinic the Roma community in This clinic has been a for many Roma families, providing healthcare services that we might to Health is much the health implications of social deprivation a in the how to address these challenges focused on pediatric the Lynn Clinic has established with children with medical or needs an of care, we that many of these children remain linked with the hospital and community health and social care in a way that and supports the possible outcome for the child This is the first clinic of its in Ireland and into care delivery to children on the of our knowledge and experience we continue to the of into practice and and understanding of the challenges these children face across hospital and community We are a of social exclusion and lived adversity that often in medical and our approach that bespoke are to such forms of in health is the and country has its own history that to SDHs. We must not these of and we must our to the very impacts these have on the children and families needing care in our local communities and hospitals in the the Dr child was an and must know or