Access to health care for homeless people - Interview with Dr. Stephen Hwang

We have a system in Canada which admirably ensures that almost everyone has health insurance but which doesn’t necessarily ensure they have access to a primary care provider whom they trust and have confidence in and coordination of the care they need for their complex physical and mental health conditions.

Where are you from and where did you study?

I was actually born in Los Angeles California, and did my medical school training at Johns Hopkins University in Baltimore, and my residency in internal medicine at the University of Toronto. And I also have a Master’s of public health degree from Harvard’s school of public health.

What area of homelessness research are you involved in?

Most of my research is focused on the health of homeless people. I got started looking at deaths in the homeless population and mortality rates and the causes of death, but since then I have branched out to look at chronic diseases and health care of homeless people and barriers that they experience to obtaining health care as well as issues around how we can improve on their medical care and their health.

What in you opinion makes this research area important in addressing homelessness?

Well, I guess it’s because I am a general internist that a lot of my research has focused on physical health of homeless people and primarily on mental health and substance abuse issues among people experiencing homelessness. Which I think is reasonable given the fact that they are common problems among people experiencing homelessness and at the same time there is not enough attention given to the physical health problems that they experience. So, I think that it is an interesting and really important area to focus on because often the physical problems are what cause a lot of death and disability in homeless people. And the other reason they are useful, on a very practical level, is that often we can identify fairly straight forward interventions that can improve their health.

Based on your research and/or practice what in your opinion are the key issues that need to be addressed?

That’s a huge question.

Based on my research looking at the health and health care of homeless people, the challenge of providing coordinated primary care for homeless people’s physical health needs is a real challenge. We have is a system in Canada which admirably ensures that almost everyone has health insurance but which doesn’t necessarily ensure they have access to a primary care provider whom they trust and have confidence in and coordination of the care they need for their complex physical and mental health conditions. So, I think that is where the system falls short and a there is lot of room for research and practice to improve that.

The other important thing that we need to look at is the fact that so much research on homelessness and health has focused on describing the problems that homeless people have and telling us how bad the situation is and not really giving us solutions that we can move forward through. I think we need to do more work that gives us more practical answers about solutions and interventions to make things better

What are the policy implications of these issues? What do you see as the key policy priority in effectively addressing the problem of homelessness in Canada/Toronto?

The problem of homelessness is characterized purely as a housing problem or primarily a health problem. I think the greatest challenge or the greatest thing we need to address is that it is both. Many homeless people need affordable housing with rent supplements or rent subsidies that allow them to live with dignity. And at the same time they have a lot of health problems that need integrated management and I think efforts to do one without the other are doomed to fall short of addressing the real problem. We need to integrate those two approaches rather than saying we just need more housing or better health care.

Who needs to be involved in implementing your suggested policy/practice changes?

It is recognized that there are many different ministries or silos within government that need to be brought to bear to address the problem. We should also be thinking more broadly in terms of engaging members of the business community, people who are in the general public who are engaged in the issue and trying to work together and build a consensus that it is an important issue that can be solved and find the resources needed to address problems.

Clearly there is a lot of room for government agencies that address either housing or health or mental health or physical heath to come together and address the problem.

Rather than waiting for Government intervention we need to encourage Canadians in general to hold themselves and our society accountable to meet the needs of those who are most vulnerable in our society

What is the next in terms of your homelessness research?

The 2 most exciting projects that we are working on are:

1) “Health and Housing in Transitions Study” or HITS study that’s going to follow homeless and marginally housed people in Toronto, Vancouver and Ottawa over a 2 year period to see what happens to homeless people and how often they get out of homelessness and what happens to their health and use of health care services when they make the transitions in and out of homelessness.

2) Mental health commission of Canada’s project which is going to provide housing first with rent supplements and case management services for homeless people with mental illness. That’s an intervention study that is a randomized controlled trial that will hopefully provide really important evidence of what works, how cost effective an approach to end chronic homelessness can be.

What is the most controversial question in your field right now?

I think the most controversial area is that of harm reduction for people with substance abuse and I have written on this area and people who have read my material have assumed I have a very dogmatic approach.

Harm reduction is something we need to be talking about and really consider in more nuanced terms. It is an issue that lends itself to black and white extremism, where people say either it’s a wonderful thing that we don’t try get people who use substances to stop, but rather to reduce harm. That is pitted against those who say that that approach is enabling or encouraging substance use and not really helping people. What we have to do is get beyond this conflict and realize that some individuals who are homeless and severely addicted to substances that harm reduction may be a useful approach among many other approaches that we need to offer. But it is not the be all and end all; harm reduction is not necessarily the ideal solution for helping people with addictions. It is simply one tool that we should consider using where the evidence supports it.

We need more studies that look at harm reduction in a rigorous way. We need more light and less heat on the situation.

Final comments

I certainly find doing research on homelessness incredibly exciting and it’s a very gratifying and very satisfying job that I have. In consider myself to be very fortunate to have the privilege do what I do.

It is intellectually stimulating and it’s also nice to think the research may help people who are disadvantaged and struggling with the basic necessities of life.

It’s a wonderful thing do be doing. I guess reflecting on my life as a clinician, physician and a researcher, I find that ability to see patients in the clinic who are homeless and also to be doing research that addresses some of the problems and issues that I observe with the patients who are homeless is a really important link to the real world problems and challenges that we face when we’re working with people who are homeless. Their struggles are really important to informing how we do research rather than sitting in a research office dreaming up an idea for a project.

Publication Date: 
Toronto, ON, Canada