Care of Refugee, Homeless & Incarcerated Patients

Refugee and immigrant health

Screening on arrival. A domestic screening visit in the first months after arrival targets infections common in regions of origin, lead exposure, missing immunizations, and the psychological effects of displacement.

Parasites and eosinophilia. Many refugees receive albendazole for soil-transmitted helminths, ivermectin for Strongyloides, and praziquantel for schistosomiasis before departure. Those who were not treated need Strongyloides serology (and Schistosoma serology if from sub-Saharan Africa) with an eosinophil count, or presumptive treatment after arrival. Unexplained eosinophilia warrants a helminth evaluation. Ivermectin can precipitate encephalopathy in people with heavy Loa loa infection, so loiasis must be excluded in those from endemic Central Africa.

Strongyloides hyperinfection. Because Strongyloides stercoralis completes its life cycle inside the host, infection can persist silently for decades. Corticosteroids, HTLV-1 coinfection, and transplant immunosuppression accelerate autoinfection; migrating larvae carry enteric bacteria into the bloodstream, causing gram-negative sepsis and meningitis with high mortality. Anyone from an endemic area needs serology or empiric ivermectin before corticosteroids are started, or alongside them when treatment cannot wait.

Communication and trauma. Use a trained medical interpreter — in person, by phone, or by video — rather than family members, especially children, who may distort or omit information and compromise confidentiality; federally funded providers must offer language services at no cost under Title VI. Many refugees have survived torture, violence, or family separation, so explain each step, ask permission before examining, and screen for PTSD, depression, and anxiety.

Health care for people experiencing homelessness

Disease burden. Crowded shelters foster tuberculosis transmission, so screening and directly observed therapy are important. Injection drug use and unsafe sex raise the risk of HIV and hepatitis C. Alcohol and opioid use disorders are common: offer naloxone and buprenorphine. Serious mental illness, skin infections, and premature death are all more frequent.

Cold and foot injury. Hours to days in cold, wet footwear at temperatures above freezing cause trench (immersion) foot: the foot is pale, numb, and swollen, then becomes red and painful after rewarming, with blisters and, in severe cases, ulceration or gangrene. Treatment is drying, gentle warming, elevation, dry socks, and daily foot care. Frostbite, by contrast, involves frozen tissue that is hard and white-gray; it is rewarmed rapidly in 37–39 °C water only when refreezing can be avoided. Hypothermia, cellulitis, and tinea pedis are also common.

Body lice and Bartonella quintana. Body lice live in clothing seams and transmit Bartonella quintana, which causes trench fever (relapsing fevers about every 5 days with shin pain), chronic bacteremia, culture-negative endocarditis, and bacillary angiomatosis; treatment is doxycycline-based, with gentamicin added for bacteremia or endocarditis. Body lice can also carry epidemic typhus and louse-borne relapsing fever. The lice themselves are eliminated by bathing and hot-washing or discarding clothing and bedding.

Adapting care. Prescribe once-daily or long-acting agents, minimize pill burden, avoid drugs that need refrigeration, dispense small supplies or hold medications at the clinic, and use directly observed therapy when possible. Ask where the patient sleeps and stores medications, since theft, lack of refrigeration, and missing identification derail treatment, and link patients to case management, shelters, and Housing First programs.

Care of incarcerated patients

A right to care. Incarcerated people have a constitutional right to adequate medical care; deliberate indifference to serious medical needs violates the Eighth Amendment. Intake screening covers tuberculosis (a congregate setting), HIV, hepatitis C, and sexually transmitted infections, and medication for opioid use disorder should be continued or started. Overdose death risk is extremely high in the first 2 weeks after release, so provide naloxone and arrange treatment before discharge.

Ethics. Incarcerated patients retain confidentiality, with disclosure limited to what security genuinely requires, and the right to informed consent: a competent inmate may refuse treatment. Physicians must never participate in punishment, torture, or executions, including certifying that a prisoner is fit for punishment.

The physician's duty is to the patient's health, not to the custodial authority; a warden cannot consent on an inmate's behalf.

Screening for social determinants of health

Food insecurity, unstable housing, lack of transportation, unaffordable utilities, and unsafe relationships drive missed visits and poor control of chronic disease. Screen all patients with brief validated questionnaires, document identified needs, and act: connect patients to food assistance (SNAP, WIC), housing and transportation programs, and community health workers, and shape regimens and follow-up to fit their circumstances.