The patient slumps forward in his chair. His face is covered with scrapes, and his right hand and wrist are so swollen that the skin looks ready to burst.
Stephen Hwang ’88 knows that the 56-year-old is a long-time crack and methamphetamine addict. That profile is not unusual at Seaton House, a 434-bed homeless shelter in Toronto. One morning a week Hwang volunteers to staff the clinic there, seeing patients in a cluttered exam room amid shouts and obscenities from the hallway outside.
“So what happened?” Hwang asks.
“To tell you the truth, I beat up a crack dealer,” the man says in a quiet, gravelly voice.
Hwang examines the swollen hand. Nothing is broken, but there is a serious infection, probably acquired when the patient cut his hand on his opponent’s teeth.
“I think you may have to go to the hospital and be admitted for IV antibiotics to treat this,” Hwang says. “Would it be okay if we arranged a cab to take you to the emergency room right now?”
“No, I really think we should make sure you get there.” Hwang knows from experience that his patients don’t always manage the five-minute walk to the hospital. As he begins typing up paperwork, his assistant arranges for a cab. But she pokes her head in after a few minutes to tell him the patient walked out. Hwang rushes out of the office and catches up with him in the corridor. But the agitated man waves him away.
“Don’t head off yet,” Hwang urges him. “If you don’t go to the hospital you could lose your hand.”
“I don’t feel like going by cab and then I get stuck there and I lose my underwear and my shoes. I’ll lose everything!” (“Actually that happens a lot,” Hwang says later. “They lose their clothes in the emergency room, they lose their shoes. “)
Finally Hwang gets him to agree to take oral antibiotics, and heads back to his office to write the prescription. He’s not happy about the decision, but the patient can’t be forced to the hospital.
It’s a frustrating encounter for Hwang but not a discouraging one. He has dedicated his career to working with homeless people, both as a clinician and a researcher. He’s used to difficult working conditions and difficult patients.
Hwang is an epidemiologist at the Centre for Research on Inner City Health at St. Michael’s Hospital, a teaching hospital affiliated with the University of Toronto. He is known internationally for his research into the health issues of the homeless. Over the past 12 years, his studies have addressed questions like: What’s the leading cause of death among men on the streets of Toronto? What prevents homeless women from getting mammograms? What role might brain injury play in leading to homelessness?
Leading activists for the homeless praise the soft-spoken Hwang for being “the real deal”—a scientist whose research is grounded solidly in the years he’s spent in the trenches, providing hands-on clinical care to society’s disenfranchised. And the results of his scientifically rigorous studies, they say gratefully, have added legitimacy to their advocacy and helped support long-term public policy solutions. “A lot of us go to him to raise concerns,” says Cathy Crowe, a street nurse and advocate for the homeless in Toronto, who has described Hwang as “a breath of fresh air.”
With an undergraduate degree from Harvard University, a medical degree from Hopkins, and an MPH from the Harvard School of Public Health, Hwang is the kind of medical heavy hitter who could have written his own ticket anywhere. And yet he ended up in Toronto, working in often trying conditions with a group of patients whose problems can seem intractable.
Hwang couldn’t be happier.
“It’s something I get a great deal of joy and satisfaction doing,” he says. “I find it very gratifying, to be able to help someone who might not have had optimal experiences with a physician in the past—to have a conversation and to make them feel like someone has listened to them.”
STEPHEN HWANG’S CONVICTIONS are rooted in his Christian faith. The child of Chinese immigrants (his father worked as an aerospace engineer, his mother was a homemaker), he grew up in a comfortable suburb of Los Angeles before following his older brother to Harvard. It was during his years in Cambridge that he volunteered at the student-run University Lutheran Shelter, as well as the large Pine Street Inn shelter. The experiences turned out to be life changing.
“It showed me my limits, and my naiveté, and inexperience at times,” Hwang says today. “My eyes were opened to a whole new world of need and potential service I felt I couldn’t turn away from.”
Hwang went on to medical school at Hopkins, where he met the woman who would later become his wife, Angela Cheung ’88. Also an evangelical Christian, Cheung is the daughter of immigrants from Hong Kong who had settled in Toronto. The duo chose that Canadian city for their residencies (and Stephen rose to be a chief resident at University of Toronto), before returning to Boston for Angela to pursue her doctoral studies in health policy at Harvard.
In Boston, Hwang met up with Jim O’Connell, president and founder of the Boston Health Care for the Homeless Program, which had been set up in 1985 to provide medical care at homeless shelters. O’Connell was struggling to recruit doctors willing to stay for the long term. Many young physicians wanted to help out for a year or so as a sort of “urban Peace Corps” experience before going on to their “real” careers, he says. O’Connell wanted instead to cultivate a core of physicians who would make a career of homeless health care.
So O’Connell was thrilled to hire Hwang, who had impeccable medical credentials and intended to dedicate himself to the field. Hwang became the first long-term, full-time physician at the program.
“I think he opened the floodgates. We have doctors who have been here 10, 12 years, and embrace this as a professional career. Stephen was the first doctor to grab that and lay the groundwork for the rest of us,” O’Connell says. “Part of what has always been so magnificent with him is that he comes armed with this intellectual ability that is astonishing. But he is a completely humble and down-to-earth human being.”
Hwang stayed on for four years as staff physician with Boston Health Care for the Homeless, eventually becoming medical director. He liked being a primary care physician, he liked his colleagues, and he liked knowing his patients.
He remembers one woman who had immigrated from Vietnam, worked as a meat packer, and ended up on the street after leaving her abusive husband. She came to see Hwang many times with symptoms like aches and general fatigue. “Over the months I came to realize what she had was an overwhelming sadness that she was expressing in these terms. I never found a miracle treatment for her, but I kept reassuring her.”
Just before he left the clinic, the woman brought him a gift—a pink and purple porcelain fairy castle with a little light inside. “I realized after a second that this was an incredible gift from her, from someone who lived on an amount of money each month that just allowed to her to scrape by. I still have that little ceramic castle to remind me of her kindness.”
While still at the Boston clinic, Hwang started thinking about applying to the MPH program at Harvard. O’Connell had been interested in studying death rates among the homeless, and suggested that Hwang could tackle the project while he was in the program. That’s what Hwang did, matching records of Boston Health Care for the Homeless patients with Massachusetts death records.
The findings, published in 1997 in Annals of Internal Medicine, painted a stark picture of life and death on the street. Homicide was the leading cause of death in homeless men ages 18-24 and women ages 25-44. AIDS was the leading killer in the overall 25-44 age group. Heart disease was the leading killer in the 45-64 age group—a rate three times higher than in the general population.
There were some unexpected findings, too. Death was most likely to occur in the first week of every month, possibly because the arrival of disability checks leads to a flurry of substance abuse. Surprisingly, the homeless were no more likely to die in winter; in fact only four people died of exposure to cold.
When Hwang came out of the MPH program after two years, he knew he wanted to pursue a research career. After he and Angela returned to Toronto to be closer to family (they are the parents of three young children), Stephen began work at St. Michael’s Hospital, which at the time had just added a research arm to its inner city health program.
“When I first started 12 years ago, the research unit was basically my desk,” Hwang says. Today, the Centre for Research on Inner City Health covers the entire floor of an office building, and houses 15 investigators.
One of his first studies in Toronto, a survey of 8,938 homeless men over two and a half years, concluded that they are eight times more likely to die than men in the general population. “It’s something we quote all the time now,” says Baric German, who works with Toronto’s nonprofit agency Street Health.
Most recently, Hwang published in the Canadian Medical Association Journal a headline-grabbing study on head injuries among the homeless. Hwang found that 53 percent had suffered a traumatic brain injury. Those who had were more likely to experience seizures, mental health problems, drug problems, and poorer physical and mental health generally. Most surprising: About 70 percent of the brain injuries occurred before the people became homeless, and often occurred at a young age. That suggests, Hwang says, that the brain injuries could actually have contributed to the people becoming homeless in the first place. The study findings gained attention in the Canadian media, and inspired an article in Lancet Neurology in March.
Other Hwang studies have looked at risk factors for cardiovascular disease, how the homeless are affected by HIV and SARS, GI pain, chronic pain management, and group A streptococcal infection.
HWANG CURRENTLY SPENDS about a quarter of his time in clinical practice. For a couple of months each year he is attending on the general internal medicine ward at St. Michael’s. And one morning a week he makes the 10-minute walk to the Seaton House clinic, where he tends to whoever walks through the door. The shelter clinic work isn’t part of his job description, but he thinks it’s important.
“It’s a little too clean and easy to just do the research and be insulated from the nitty-gritty struggles of patients who often are very difficult, or very complex, or very problematic. It keeps my work real to have that experience,” says the 47-year-old.
Hwang plans to continue working on homeless health care issues for the foreseeable future. But he’s been kicking around an idea for a new career direction. “My wife and I have thought about doing some work in the developing world. The needs are even more acute there than in North America,” he says.
What about settling down in a regular practice, with a nice office and patients who have homes?
“Do something easy?” Hwang smiles. “I don’t know. That wouldn’t be very fun.”