Editorial

778 www.thelancet.com Vol 381 March 9, 2013

Homelessness, health, and inclusionSexually abused at 14 years old by an alcoholic father. Left home for the streets. Alcohol dependent by 15. Sex work. Intravenous drug dependent by 17. Hepatitis C by 19. Epilepsy and anxiety disorder. In and out of hostels, hospital, and prison (for violence, theft, drugs) in 20s and 30s. Not registered with a general practitioner. Rough sleeping at times, hostels at others. Tuberculosis at 35. Discharged from hospital in pyjamas without shoes back to under the railway bridge. Chronic leg ulcers. Violent, aggressive behaviour. Four children, no contact with them. Died at 40 of haematemesis. Two of his children now homeless, addicted, depressed.

This man, his father, and his children, have been failed by their health system and society. Look around the streets and see the people on the benches, in the bus shelters, under the bridges, by the canals, and in the hostels. How can they best be helped?

Government leadership is crucial, especially in times of economic hardship. Employment, housing, and welfare policies, and a legal framework to iron out inequalities in health, are fundamental. But health-care workers can

do more to ensure that excluded groups, such as the homeless, sex workers, prisoners, migrants, and gypsies and travellers, receive the health care they need.

Inclusion health, also defi ned as health care for excluded groups, was the subject of the inaugural conference of the UK Faculty for Homeless and Inclusion Health, held in London last week. Passionate and inspirational leaders in inclusion health shared their experiences of providing specialist health care for the homeless in primary care centres in London and Oxford. Street medicine practitioners in Boston, Pittsburgh, and Dublin were praised by service users attending and speaking at the conference, for their commitment in founding services in their cities. Rapid access to integrated services—health, housing, social care—is needed. Training of students is crucial. Never give up on anyone was the resounding message. We agree. To encourage research and best practice, The Lancet commits to a Series on inclusion health, which we hope will promote research and continuing debate, and ultimately make a diff erence to those currently excluded. The Lancet

For more on homeless and inclusion health see http://

www.collegeofmedicine.org.uk/faculties/faculty-care-

homeless-people

For more on street medicine see www.streetmedicine.org

Being born without, or losing, the ability to hear can be devastating. More than 360 million people have disabling hearing loss, according to new global estimates released by WHO for International Ear Care Day on March 3.

Disabling hearing loss refers to hearing loss greater than 40 decibels in the better hearing ear in adults and loss greater than 30 decibels in the better hearing ear in children. Hearing loss can be congenital; for example inherited, following maternal infections (eg, from maternal rubella), or following complications during labour (eg, birth asphyxia). Other causes include ageing, certain infectious diseases such as meningitis, chronic ear infections, use of ototoxic drugs, and exposure to excessive noise. Prevalence of disabling hearing loss is highest in South Asia, Asia Pacifi c, and sub-Saharan Africa.

People with hearing loss often experience social isolation, stigma, and discrimination, have poorer access to health services, and have higher rates of mental health problems. Their physical health may also be poorer than that of hearing individuals.

What can be done? First, countries can do a lot more to prevent hearing loss; half of all cases of hearing loss are avoidable through primary prevention such as childhood vaccination programmes and improved antenatal and perinatal care. Beyond prevention, people with hearing loss can benefi t from devices such as hearing aids, cochlear implants, and access to sign language, and educational and social support. Additionally, health professionals must understand the needs of those with hearing loss and help tailor health facilities for this community—a lack of adaptation to hearing loss in society is often what disables an individual rather than their condition.

As the population ages globally, more and more people will lose some of their ability to hear. One in three people older than 65 years (165 million people worldwide) already lives with hearing loss. Scaling up prevention and care services will be essential to reduce the burden of hearing loss, and improve the lives of those living with the condition. Hearing loss can be devastating for an individual but it doesn’t have to be disabling. The Lancet

Promoting healthy hearing

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