TORONTO - It's about 9:30 on an icy-cold January morning, and Dr. Stephen Hwang is greeting his first patient of the day at Seaton House, a 434-bed shelter for homeless men on a quiet street in downtown Toronto.
The man, in his early 50s, has been living at the shelter for about a month after returning home to Canada from a Caribbean island, where he had worked and raised his family for 25 years.
He says he has come home seeking rehabilitation for alcoholism. He remembers the flight to Pearson International Airport, but admits that a subsequent two-week stay in St. Michael's Hospital and his arrival at Seaton House are foggy at best.
Hwang asks if he is still drinking.
"I had a beer the other day, last weekend," the man says.
"Any trouble holding your urine?" prods Hwang.
"I did last week for some reason," but just the once, he insists. The acrid odour emanating from his stained and rumpled clothes in the cramped examination room belies his words. "I'm not normally a coffee drinker, but around here I seem to be up to six cups a day."
Hwang puts the patient through a series of memory and cognitive tests — he does well on all but those related to immediate recall — then checks his blood pressure, listens to his heart and palpates his chest and abdomen.
The doctor tells the man his drinking has affected his memory, and it may be reversible if he stops.
"If you keep drinking, you could get worse to the point that essentially you have to be in a nursing home, where you can't even take care of yourself," he says gently but firmly. "You're at the point now where you stop drinking or you essentially pickle your brain."
After some hesitation — "Let me check my diary," he deadpans — the man says he'd be willing to speak to an addictions counsellor about entering a detox program. Hwang sets up the appointment for the following week, but it's anyone's guess whether the patient will follow through.
He may choose not to go. He may not remember.
Such are the challenges of providing health care to homeless and marginally housed Canadians across the country.
"So often the chaos in people's lives and the lack of stability in their lives interferes with their ability to maintain regular health care," says Hwang, a general internist who is among a cadre of doctors, nurses, therapists and counsellors at St. Michael's Hospital who specialize in reaching out to vulnerable populations in Toronto's inner city.
"Sometimes the lack of social supports and a lack of family and friends to help them seek care is a major factor."
At nearby St. Mike's, known as Toronto's "Urban Angel," Frank Fournier is also starting his day in the hospital's emergency department.
Since 2010, Fournier has been the community support worker who helps the homeless and others on the economic fringe who come to the ER seeking care.
He is perhaps the ideal person for the delicate job of shepherding sick and often anxious patients through what can be an intimidating experience for those living on the streets or close to it.
Fournier has been where they are.
More than 10 years ago, the IT systems analyst was severely injured after being hit by a car. In the process of recovering, he lost his income and ended up for a few years with no home to call his own.
While living in a shelter, he began volunteering to help others in his situation, then began doing outreach work with Toronto Public Health before being recommended for the position at St. Mike's.
"It would have been hard for me to imagine what being homeless was like before it actually happened to me," concedes Fournier, who says a lot of people who come to the ER recognize him from his previous work.
"So it's a familiar face when they come into the hospital and it's someone they know that's been in the same place that they are in."
Some patients are referred to him by the triage nurse. But often, experience will red-flag a person in the waiting area: they may look agitated or confused; they may seem reticent.
"I will go up and talk to them and assess whether they need my help or if they need anything else," he says. "Sometimes they just need someone to listen to them, someone that they can vent on ... Sometimes it's just a shoulder to cry on.
"They feel isolated and vulnerable because of their economic status or their housing status. So really, you're just giving more of a compassionate touch."
Typically, though, people come through the doors with a specific health issue, one that's often been exacerbated by time on the street.
Many of those health conditions are the same ones that affect other Canadian adults, but they may be more chronic and under-treated among the homeless, notes Jim O'Neill, director of the hospital's inner-city health program.
"So there are respiratory problems, asthma, emphysema. TB is sometimes an issue," he says, as are diabetes and cardiovascular disease. "Mental health and addictions. Broken bones, scrapes, cuts, cellulitis. I mean the list goes on."
The ER at St. Mike's has about 72,000 patient visits a year, and about 17 per cent of them are by the homeless or under-housed. O'Neill estimates that about 30 per cent of these patients are dealing with a mental illness or addiction.
"A lot of our homeless population have foot problems because of exposure," adds Fournier. "You might not have a dry pair of shoes to wear. You might not have anywhere to dry your shoes out or your socks out.
"I have clothing I can give to some of our more needy patients. Some of it's brand new, some are donations," he says, rhyming off the list of items: winter jackets, track suits, clean underwear, socks, boots, gloves and hats.
Besides helping patients get their immediate health problems seen to by ER staff, Fournier asks if they want to shower, when they last ate and if they need a meal, whether they need help paying for transportation when they leave.
"The big thing is to get the patient to almost buy into the system. They may feel reticent at first coming to a hospital. They may think, 'I'm going to get lousy service because I'm homeless or because I'm a drug addict or drug-dependent.'"
Many have felt stigmatized when dealing with the police, financial institutions and previous health providers, he says.
"You know, when you're homeless or under-housed, there's lots of self-esteem issues ... not to mention the anxiety of not knowing where your next meal's coming from, where you're going to be sleeping that night.
"So we try to put those patients at ease and let them know that they're going to be treated with dignity and respect. And more importantly, they're going to be treated like anybody else."
That's all part of the St. Mike's mandate, one that goes back to the hospital's founding in 1892 by the Sisters of St. Joseph, to care for the poor and sick during a diphtheria epidemic that was ravaging the city, says O'Neill.
Today, the inner-city program is connected to a network of agencies that provide a range of services to the disadvantaged in southeast Toronto.
"It's a big problem," says O'Neill, explaining that the program and its many partners try to remove barriers to health care.
In part, that means providing services in non-traditional ways, "bringing the care to the patient rather than expecting people whose lives are chaotic to conform to the norms most office-based or hospital-based services operate under," he says.
It also means organizing a continuum of care, not just for the ailing body part but also in the context of the person's life, stresses O'Neill. "What are they going back to? Can they follow a diet that's important to their medication, for example? Can they afford the medication? Can they take it at the times that it needs to be taken?"
Back at Seaton House, Dr. Stephen Hwang sees a man in his mid-80s with heart disease and a previous stroke, who says he had to return to Toronto from Florida because someone was trying to kill him. Neatly dressed and surprisingly healthy-looking for his age and medical status, he is upset with his fellow shelter residents. "They are always fighting," says the man, gesticulating with his hands to drive his point home.
The man is an example of how difficult it can be to look after this population, says Hwang, noting that the health-care team had tried to hook him up with a heart specialist, lung specialist and neurologist, but he missed all the appointments. His paranoia suggests he likely needs a mental health assessment as well.
"Unless someone navigates the system for him, he would never get care."
Out in the waiting room, Hwang stops to check on a man whose foot is infected, the result of scratching lice bites. He has several such sores on his body. "That's a common problem here," the physician says.
The man complains of a painful molar, but suggests a dentist just needs to pull it out of the socket, plug it in somewhere else and rearrange his teeth.
"He's missing a lot of teeth and the teeth that he does have are in terrible shape," Hwang says later of the resident, who has schizophrenia. "Likely it needs to be extracted, it's hanging and wobbling. But as you heard him say, he has this idea someone can 'rearrange' his teeth and put it back in.
"He really needs to see a dentist and hopefully he will agree to the appropriate treatment."
As he continues to see patients, whose health conditions are many and varied, Hwang agrees that looking after those who have fallen through the economic cracks is "always a challenge. It keeps you on your toes."
Yet, despite the obvious frustrations, Hwang says it is also rewarding helping people who are so much in need.
"I guess the goal is to light a candle rather than curse at the darkness. Even though we might not be able to solve all the problems that are there, we can try to address some of them and make things a bit better."