Interview: Dr. Clíona Ní Chealliagh on inclusion medicine for people who are homeless

Dr Clíona Ni Cheallaigh is consultant and clinical lead for the Inclusion Health research service at St James’s Hospital, Dublin.

Her work focuses on ensuring that people who are homeless or in addiction have access to healthcare in a way that meets their needs. Working with homeless and addiction services, including Merchants Quay Ireland, as part of a multi-disciplinary team, Cliona helps prevent those on the margins of society from falling through the gaps.

Here, she speaks to MQI about how she came to be involved in ‘inclusion medicine’, the relationships between health and homelessness, and the impact of stigma.


Can you explain what inclusion medicine is?

People who are homeless or in addiction are often excluded from society and are much sicker than general population. As a healthcare system, we’re not great at dealing with this vulnerable group. Inclusion medicine takes the view that it’s the healthcare providers responsibility to make sure that everybody feels included, can come into clinic, and that we’re not leaving the responsibility on the person. That’s the idea behind inclusion medicine.


How did you get interested in inclusion medicine, and how did you identify the need for it in Dublin?

When I trained in James’s, we’d see a lot of people who are injecting drug users. As well as this, I worked with HIV and antiretroviral (ARV) treatment. That treatment works really well, yet there was a small number of people who didn’t take ARVs and as a result, they developed AIDS. I was interested in exploring what we were doing wrong, because we have all the tablets on the shelf but if they’re not getting to the guy who needs them, something’s not working. The tablets are no good to him on the shelf.

Then I heard Austin O’Carroll [founder of Safetynet] speak and I was really struck by his approach. He puts the responsibility back onto the healthcare provider to ensure its patients get the care they need.  Usually people think “that patient didn’t turn up, it’s their fault”. Austin challenged that idea and asked ‘Well what did we do wrong that they didn’t turn up?’. So, my interest in inclusion medicine started from there and I’ve just been lucky.  It’s an emerging area, so I keep meeting people who are interested in this area. We share learning and incorporate it into our work.


How have your clients or your patients responded to ‘inclusion health’? Would they notice a difference?

I hope so!  They’re brilliant.  They’re so good and they’re always offering to help.  I think that’s one of the hard parts of living in homelessness and addiction is feeling you’ve nothing to offer anybody.  We’d see that a lot with patients in the ward.  Like the homeless or patients with addiction, keeping an eye on the older people in the ward and helping them.  They’d be helping the nurses clean up.

Everybody just wants a bit of dignity and respect. If you can give that to people, it’s an important achievement.


What would you say is the short and the long-term impact of homelessness on health?

It’s absolutely huge.  If you look at its effect on life expectancy, homelessness knocks around 40 years off a person’s life expectancy.

In the short-term, so many homeless people are sick: either they were sick before they became homeless, or they’ve become sick because of being homeless, or a mixture of the two.  For example, I saw a guy in Merchant’s Quay who had cirrhosis, which is scarring of the liver. The treatment of that is to take diuretics which are water tablets and laxatives. He’d very advanced cirrhosis and he was out during the day from his hostel, he’d no access to a toilet, so of course he didn’t take his medication.

In the longer term, the chronic stress of being homeless is awful.  That affects people’s health.  It affects their immune system, it affects their brain, it affects their ability to plan and to do things that could get them out of homelessness.


To what extent is it possible for someone to ‘recover’ from homelessness in terms of physical and mental health?

It’s definitely possible.  People who survive homelessness are resilient. To stay alive, they’ve had to develop amazing skills.  A lot of what leads into homelessness is usually a very, very difficult childhood. This leaves severe marks on that person; but can their health improve?  Definitely.  We see that time after time.


Given the link between trauma and addiction, would you agree that deeper understanding of addiction by medical staff would improve care?

I think that’s a big thing: the understanding of addiction. One of the great things about going to Merchant’s Quay is seeing how addiction is understood there, and I try to share that insight with my colleagues.

In mainstream medicine addiction is very much seen as being a choice: someone chooses to use heroin and the way to get them to stop is to punish them or to tell them that it’s dangerous to their health. There’s no understanding of what function this substance has in their life.  Usually it is an attempt to cope with trauma.


We have a theme in our newsletters this year around “stigma and silence” – where would you see that stigma most acutely?

Stigma is absolutely huge.

For example, almost half of people who are homeless leave A&E before they’re seen.  That’s a real problem because a lot of people in that group are really sick.  They’re often leaving because they are ashamed of being ‘smelly’, for example.  So, that stigma negatively impacts a person’s capacity to look after their health in many ways.

On some level, it’s the foundation of looking after somebody’s health: You’re a person and you have the same value as every other person.  I see you and I value you.  You’re trying directly to address that internalised stigma and sense of shame.


You can follow Cliona on Twitter here.

If you are homeless and need help with your health, check our MQI’s primary healthcare services here.

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