A child is woken up in the middle of the night by gardaí raiding their house. The child’s parents are on the wrong side of the law, battling with addiction, poverty and unemployment.
The child goes to school the next morning, exhausted, anxious and stressed. As a result, they’re unable to focus on their education, affecting their learning, life path and – most surprisingly – their health.
This, according to Dr Anne Dee, consultant in public health medicine, is a situation children in some areas of the midwest region – Limerick, Clare and north Tipperary – experience due to levels of extreme deprivation.
But these adverse childhood experiences, she says, are more than just about poverty or crime. Such incidents, she says, are a significant determinant for the health of the people in the area.
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“Internationally, we know well that people who live in areas of deprivation or who are unemployed, or who have poor levels of education, or poor housing, that they have poorer health,” Dr Dee says.
“People who live with disadvantage are more likely to have chronic disease, which is heart attack, asthma, diabetes, respiratory disease.”
According to the 2022 Census, the population in the midwest is more deprived than the national benchmark.
We have double standards around what is acceptable and what is not, who we need to consider and who we need to dismiss
— Dr Anne Dee
In 2022, the most recent year for which figures are available, 24 per cent of the population in Limerick were considered disadvantaged, very disadvantaged or extremely disadvantaged; 21 per cent in Clare; and 23 per cent in north Tipperary.
“Children are more prone to having adverse childhood events if they’re living in poverty. If their father or their parents are unemployed. If their communities are unsafe. If we can start changing that, we can create communities and environments that are much more healthy.”
In light of this, Dr Dee, the recently-appointed president of the Irish Medical Organisation (IMO), is leading a new project in the midwest that seeks to examine the social determinants of poor health and reduce them.
Under the project, which is sponsored by the newly-elected mayor of Limerick John Moran, and Sandra Broderick, regional executive officer in the HSE, the “big players” in education, employment, the probation service, Tusla, the HSE and other organisations will come together to try to improve the health of the region.
“Data from Scotland would show that about 30 per cent of children who have more than four adverse childhood experiences will go on to potentially succeed in life. Seventy per cent of them will not. They’ll either end up dead, incarcerated, addicted or with chronic mental illness,” Dr Dee says.
“It’s about looking at our population of children and saying, how can we change the trajectory of their life in terms of outcomes? There are really excellent healthcare initiatives but they’re not across the whole population. We need to make sure that where the need is greater, there is extra available.”
The midwest consultant analysed a random sample of emergency department attendances at hospital in Limerick, and coded them by deprivation.
“We were able to show if you lived in extreme deprivation or severe deprivation, you were around 2.5 times more likely to use the emergency department than if you lived in an area of affluence,” she says.
“They were also more likely to be hospitalised and more likely to wait to be seen than people from other areas of deprivation.”
These people are “not spurious” users of the health system, she says, adding that often wait until they’re at crisis point before seeking help. There is a lack of trust among many of these vulnerable groups, and the project aims to mend that, she adds.
Part of the problem, she says, is the prevalence of a culture of blame. “Instead of judging them for their behaviour or telling them they need to stop smoking, stop drinking, stop eating rashers, we need to start supporting these communities to be able to function much better,” she says.
The unemployment rate in Ireland is 4 per cent, according to the CSO, but in parts of Limerick city it’s up about 70 per cent.
“It’s not just that people are lazy. It a very, very complex mix of poor educational attainment, intergenerational problems like addiction, no history of employment in living memory, a fear of authority or mistrust,” she says.
But how has this situation occurred? Dr Dee says Limerick in the 1800s and 1900s had “a lot of poverty”.
“I just feel, and I think quite a number of people would agree with me on this, that it hasn’t always been the priority when it comes to government funding,” she says.
Adding to this, future planning in health and other sectors such as housing is often based on population, Dr Dee says, though she admits work is ongoing in this area. She believes, instead, health planning must be based on need.
“They [policymakers] haven’t traditionally taken a lot of heed of the deprivation level within that population. So everybody gets the same. So you’ll hear some areas consistently crying out, saying ‘we haven’t enough’ and that’s because their need is greater,” she says.
There are specific cohorts of people who are particularly deprived, she says, including those with disabilities, or members of the Roma or Travelling communities.
The Census 2022 estimated the White Irish Traveller population as 0.6 per cent of the total population in Ireland. In the midwest, this is 0.9 per cent, and in the west Limerick community health network, the proportion is four times the national average.
The life expectancy of members of the Travelling community is 10 to 15 years less than those in the settled population.
Having worked in a leprosy hospital in Nepal 30 years ago, Dr Dee sees parallels in terms of the stigma directed towards Travellers and those with infectious diseases, and the impact that has on these people in relation to interacting with various systems in society.
“If you suffer from leprosy in most communities where people get leprosy, you will be stigmatised for having leprosy. And we look at that in the West and we say ‘oh, that’s really bad that people would be stigmatised for just having a bacterial infection’,” she says.
“But at the same time, with the same breath, we talk about Travellers in a way that is very stigmatising. We have double standards around what is acceptable and what is not, who we need to consider and who we need to dismiss.”
Though her pilot project is focused on the midwest due to its deprivation profile, Dr Dee believes healthcare should be provided in this way across the country – particularly in light of the spiralling homeless crisis.
The most recent figures from the Department of Housing, from May, showed there were a record 15,580 homeless people, of which 4,775 are children. Dr Dee says the country has yet to see the true health crisis that will arise from this.
“The life expectancy of somebody living in homelessness is around 40. That would be street homeless; I don’t think we’ve measured the kind of new homelessness,” she says.
“I can assure you all of these children growing up in homelessness are gathering up such enormous levels of adverse childhood experiences. The effects of poverty on children are long-term. The effect of adverse childhood events on children are long-term. The effects of both are additive.”
Are we not setting these children, and other vulnerable groups, up for failure? “We absolutely are. Absolutely. It really, really behoves us to do some serious prevention in the area of social determinants of health.”
