Category: Practical guides

Feet are the most common medical problem among people living outside and the least often treated. They are also the one where a small intervention early prevents something that ends in an amputation.

Why feet, specifically

A systematic review of foot conditions in people experiencing homelessness found high rates of problems across every category studied — skin and nail conditions, corns and calluses, infection, and nonfreezing cold injury. The reasons are structural rather than personal: shoes that do not fit and cannot be replaced, socks that stay wet, walking most of the day, nowhere to sit down and take boots off, and no way to dry anything.

Add diabetes, which is common and frequently undiagnosed in this population, and you have a foot that cannot feel an injury developing on a body that cannot rest it.

The three that turn serious

• Nonfreezing cold injury. Wet and cold above freezing, sustained for hours to days. The foot goes numb, then white or mottled, then intensely painful on rewarming. Recovery is slow and can leave lasting sensitivity. It is entirely preventable with dry socks.
• Cellulitis. Spreading redness, warmth and swelling, often from a small crack or blister. This one moves fast and it is the common route to hospital admission and to sepsis.
• An unfelt wound in a diabetic foot. No pain, so no reason to look, so it is found late. This is the pathway that ends in amputation, and it is why we ask to look at feet even when nobody has mentioned them.

What actually helps

• Change socks before you change anything else. One dry pair a day prevents more harm than any dressing.
• Air the feet whenever there is a safe chance to. Twenty minutes with boots off matters more than it sounds.
• Look, or ask someone to look. Tops, soles and between the toes. If you cannot see the sole, a phone camera works.
• Do not cut calluses or corns yourself, and do not use over-the-counter corn removers on a diabetic foot.
• Boots one size up, with room for a dry sock. Tight boots cause more of this than worn-out ones.

Ask us to look

There is no threshold for this. A dressing changed and nothing else is a complete visit, and nobody is asked to accept anything further in order to get it. Barriers to foot care in this population are well documented and most of them are about how services are set up rather than about whether people want care.

Street medicine outreach brings this to where people are, and socks and boots are always on the in-kind needs list for exactly the reasons above.

Sources

• To MJ et al. Foot Conditions among Homeless Persons: A Systematic Review. PloS one, 2016. PubMed 27936071
• Zafren K. Nonfreezing Cold Injury (Trench Foot). International journal of environmental research and public health, 2021. PubMed 34639782
• Mistry K et al. A review of trench foot: a disease of the past in the present. Clinical and experimental dermatology, 2020. PubMed 31309614
• Benadda I et al. A Preliminary Assessment of Barriers and Facilitators to Accessing Foot Care in Homeless Shelters: A Scoping Review. Annals of vascular surgery, 2025. PubMed 39613026

It is the question families ask most often, and the honest answer is not the one people want. You usually cannot make someone accept care. What you can do is keep the route open, and that turns out to matter more than it sounds.

Why people say no

Rarely because they do not want to feel better. Qualitative work on the primary care experiences of people who are homeless describes the same reasons repeatedly: having been treated badly before, being asked to prove eligibility they cannot prove, being told to stop drinking or using before being helped, losing possessions or a place in a queue by leaving to attend an appointment, and being spoken to as a problem rather than a person.

Read that list again and most refusals stop looking like refusal. They look like an accurate assessment of what accepting care has cost before.

What actually changes the odds

• Stay in contact without conditions. The single strongest predictor of someone eventually accepting help is that somebody was still there when they were ready. Contact that carries a requirement tends to end the contact.
• Offer the small thing. Socks, a sandwich, a dressing, a phone charge. This is not a trick to get to the big thing; it is a complete transaction that also demonstrates that you can be dealt with safely.
• Do not make sobriety the price of being taken seriously. Low-threshold approaches — treating people where they are, without abstinence as a precondition — have a growing evidence base, and they are what we practise.
• Say what is available and then stop. Repeating it turns an offer into pressure, and pressure is what most people are already refusing.

What to do about the fear underneath

Most families are not really asking how to persuade someone. They are asking how to live with the risk. That is a fair question and it deserves a direct answer: the mortality data in this population is genuinely bad, and worrying about it is proportionate rather than catastrophic.

What helps is narrowing the worry to the things that are actionable tonight — cold, feet, infection, overdose — and knowing the specific signs that mean call now. Emergency and crisis resources is that list. For families and caregivers covers the rest.

What we can do

We can go to the person. Street medicine exists precisely because requiring someone to arrive excludes the people who most need care, and the model is now well described in the literature rather than improvised. Nothing is required of anybody at first contact, and a person who says no this week is not removed from anything.

You can tell us where someone is and what you are worried about. We will not tell you what they said to us, and we will not stop going. Street medicine outreach explains how that works in practice.

Sources

• Ramirez J et al. Understanding the primary health care experiences of individuals who are homeless in non-traditional clinic settings. BMC primary care, 2022. PubMed 36572847
• Narayan A et al. Beyond Brick and Mortar: The Rise of Street Medicine. Journal of general internal medicine, 2024. PubMed 38937362
• Erickson BR et al. A Rapid Review of “Low-Threshold” Psychiatric Medication Prescribing: Considerations for Street Medicine and Beyond. Psychiatric services (Washington, D.C.), 2023. PubMed 36039554
• Aldridge RW et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet (London, England), 2018. PubMed 29137869

Most cold injury in St. Louis does not happen at the temperatures people expect. It happens between roughly 30 and 50 degrees, in the wet, over hours rather than minutes.

The temperature that actually hurts people

Hypothermia is widely assumed to be a deep-winter problem. In people living outside it is not. Research on cold exposure in this population repeatedly finds injury and death clustering in damp, windy conditions well above freezing, because wet clothing and wind strip heat far faster than still dry air at a lower reading.

That matters practically. A night forecast at 40 degrees with rain is more dangerous than a dry night at 25, and it is the night nobody opens a warming centre for.

What to watch for, in order

• Shivering that stops. Shivering is the body working. When it stops and the person is still cold, that is not improvement — it is the body losing the capacity to rewarm itself, and it is the point at which help is needed.
• Confusion, slurred speech, stumbling. These are frequently read as intoxication and treated as a behavioural problem. In the cold they are the commonest presentation of moderate hypothermia, and the mistake costs lives.
• Unusual calm, or undressing. Paradoxical undressing is real and it is a late sign. Someone removing layers in the cold needs emergency help immediately.

Feet, which are the injury nobody counts

Nonfreezing cold injury — trench foot — needs no ice at all. Prolonged wet and cold above freezing is sufficient, and boots that never dry are the mechanism. It is painful, it disables walking, and in a person who has to walk to eat, that is a cascade rather than an inconvenience.

Dry socks are a genuinely medical intervention here, which is why they appear on every in-kind list we publish. Foot care when you are outside covers what actually helps.

What helps, concretely

• Dry beats warm. A dry mid-layer under a damp coat does more than another damp layer on top.
• Cover the head and hands before adding torso layers.
• Get off the ground. Cardboard, a pallet, anything. Conduction into cold ground removes more heat than the air does.
• Alcohol feels warming and is not. It moves blood to the skin, which increases heat loss while removing the sensation that would tell you.
• Eat something. Rewarming is metabolically expensive and it fails without fuel.

What we do about it

The street medicine team goes out in exactly the conditions described above, because that is when it matters and when the fewest other services are running. Nothing is asked of anybody first. Street medicine outreach explains how contact works, and emergency and crisis resources lists what to do when it cannot wait for us.

Sources

• Zhang P et al. Cold Weather Conditions and Risk of Hypothermia Among People Experiencing Homelessness: Implications for Prevention Strategies. International journal of environmental research and public health, 2019. PubMed 31491874
• Akhanemhe R et al. Health impacts of cold exposure among people experiencing homelessness: A narrative systematic review on risks and risk-reduction approaches. Public health, 2025. PubMed 39879914
• Rathjen NA et al. Hypothermia and Cold Weather Injuries. American family physician, 2019. PubMed 31790182
• Zafren K. Nonfreezing Cold Injury (Trench Foot). International journal of environmental research and public health, 2021. PubMed 34639782