Abstract
BACKGROUND: With the exception of alcohol abuse, hypertension is the most common chronic physical health problem encountered among homeless persons. The material conditions of homelessness greatly complicate the management of this disorder. Some of the complications and their solutions are discussed here, based on the experiences of health clinics for the homeless in large US cities. METHODS: In 1988, the Stewart B. McKinney Homeless Assistance Act established health care clinics for homeless persons in 108 cities. We surveyed medical directors in these clinics, asking about the management of hypertension in this difficult-to-treat population; 65 responded. RESULTS: Comparisons between our survey data and those obtained in two recent surveys of clinicians in "normal" clinical practice provide interesting lessons in how medical practice is adapted to respond to the unique needs and problems of the urban homeless. Although therapeutic goals are similar, the means chosen to achieve them often are not. CONCLUSIONS: The treatment of homeless hypertensives illustrates the problems inherent in strict biomedical models of disease and its alleviation. Preferred treatments, course of disease, and success of intervention are powerfully affected by social factors.