Dr. Aoibhinn Walsh:

I thank the Chair, clerk and members of the committee for inviting me to speak. I am a consultant general paediatrician with a special interest in inclusion health working for Children’s Health Ireland, CHI, and I am responsible for The Lynn Clinic, which is a community outreach clinic for children experiencing social exclusion. I provide healthcare for many marginalised groups, including but not limited to marginalised migrant children, such as international protection applicants, refugees, Ukrainian beneficiaries of temporary protection and Roma children. Unfortunately, I am the only such paediatrician with a somewhat resourced, temporarily-funded team to be able to provide this dedicated, holistic and much-needed service at present in Ireland, though many colleagues daily go above and beyond to try to address the challenges I will now outline. I will use the term “migrant children” throughout to refer to marginalised migrant children in need of an inclusion health approach and equitable healthcare access.

Migrant children attending our outreach clinic are presenting with serious medical problems that are a direct result of or exacerbated by their adverse social determinants of health. These children and families require culturally competent, trauma-informed care that our health service is ill-equipped to provide. For an individual child, migrant status can mean difficulty obtaining necessary medications in the absence of a medical card and high risk of being lost to follow-up as they are relocated, often multiple times, between different healthcare regions. Due to language and literacy barriers, their caregivers can have difficulty with understanding and being understood. Many doctors use Google Translate or equivalents when no other alternative is readily available. However, this is not conducive to a comprehensive and accurate consultation but, rather, one that makes do inadequately and unfairly.

On a population health level, it means migrant children have lower population vaccination rates, there is not yet a formal catch-up vaccination programme in place nationally and there is a lack of standard public health developmental checks and interventions. Due to staffing shortages, many infants I have met have no public health nurses. I have encountered very poor population nutrition with preventable nutritional deficiencies which, untreated, can have irreversible impacts on growth and cognition, including rickets and anaemia. At every clinic, we encounter severe dental decay and malnutrition in the forms of impaired growth or obesity that is then compounded by food insecurity and lack of adequate cooking facilities. Overcrowded accommodation directly results in increased screen times, disordered and disrupted sleep, lack of space for physical exercise, as well as limited normal play and development opportunities.

For migrant children with neurodisability and neurodiversity, our current system of support and diagnosis assumes a certain level of caregiver education and familiarity with the English language. Filling out the forms for access to disability services is a task our team takes on for many of the children under our care as it has proven impossible for the caregiver to convey their children’s significant and sometimes crisis needs without informed assistance.

These children who are living in confined, overcrowded spaces experience rapid escalation in challenging behaviours with worsening food aversions, physical aggression and self-injurious behaviours and no recourse for support.

The circumstances of disputed minors is opaque, very difficult to navigate for healthcare providers and has left children in the most appalling high risk situations that Dr. O'Reilly has outlined. Health professionals who come across these disputed minors are uncertain of their role, unclear as to pathways of advocacy and support and often are unable to provide necessary medical care. Greater transparency is needed into the process of how those declaring themselves children seeking international protection on arrival to our State are then deemed as adults by what seems to be an arbitrary and brief decision-making process that can have serious ramifications across all aspects of their lives.

We also must recognise that migrant children have experienced multiple adverse childhood events that will have lifelong impacts on their health and well-being. These children in time will become parents themselves, perpetuating an intergenerational cycle of deprivation, poverty and adverse health outcomes.

A proactive preventative inclusion health approach in our paediatric hospitals that supports early recognition of medical issues, comprehensive assessments and feasible management plans is essential to be able to meet the complex bio-psychosocial needs of these children and families. Time and space are needed as often much more is disclosed and diagnosed than what was originally felt to be the issue. Strong links with local community providers of healthcare enables integrated care. Our outreach clinic links regularly with many such local organisations, for example, Safetynet, Baleskin Reception Centre, the national transit hub, the HSE homeless healthlink team, international protection accommodation services, TUSLA and HSE dentistry, to ensure management plans are carried out effectively. We have also forged links with many community support organisations, as often identifying the medical issues is the easy piece and it is signposting towards freely available resources that can aid with their social, psychological and fiscal needs that proves the challenge.

Busy oversubscribed acute hospital infrastructure does not have the capacity, staff or resources to adequately meet the complex needs of these children and families but failing to address and meet their health needs perpetuates the cycle of deprivation that they have been trapped in. These children have experienced enough trauma and they deserve to be given the best chance at improving their lives.

I thank the committee for its attention and now welcome members' questions on how we can address these challenges facing the most vulnerable children in Irish society. Gabhaim buíochas leo.