Rheumatology care in prisons: cruel and unusual punishment?

Abstract

Adequate healthcare is a universal right that extends to all members of society including individuals who are incarcerated. Indeed, according to the eighth amendment to the US Constitution, failure to provide adequate healthcare for incarcerated individuals constitutes cruel and unusual punishment. But are we meeting the needs of incarcerated patients with rheumatic and musculoskeletal diseases? The unfortunate reality is that access to and quality of care for the roughly 11 million individuals in prisons and detention centres worldwide often falls short of that of the general population, imposing formidable challenges for patients with chronic diseases—including rheumatic diseases—who require life-long care and often struggle with debilitating pain. This reality is compounded by an increasing number of older individuals who are incarcerated; in the UK, the proportion of prisoners aged 50 years or older increased from 7% in 2002 to 17% in 2020—far higher than that in other European countries. In the USA, an estimated 12% of incarcerated individuals are over 55, a 300% increase from 2 decades earlier. With an increasingly aging prison population, the prevalence of chronic musculoskeletal diseases in this population must also be increasing, although precise data are scarce. Estimates from the USA suggest that 15% of inmates in state and federal prisons have arthritis or another rheumatic disease, a staggering figure considering that the USA is home to 20% of the world's prison population. A 2013 analysis from two UK prison establishments reported that 20% of the prison population was coping with chronic non-cancer-related pain. Management of chronic musculoskeletal conditions is challenging under the best of medical circumstances, and individuals who are incarcerated face a multitude of additional challenges. One hurdle is the prison environment itself. Designed and constructed to prevent free movement, prison environments leave many patients unable to perform prescribed exercise regimens. General mobility can also be challenged by a predominance of narrow corridors and stairs (often without disabled access), along with difficulties in procuring mobility assistance devices such as canes and walkers, which can pose security risks. A 2010 UK report from the Inspectorate of Prisons and Care Quality Commission found that disabilities in general were not being adequately addressed, with a paucity of needs analysis or consultation with prisoners being done. Chronic musculoskeletal conditions require management by experienced multidisciplinary teams, which are rarely accessible within prisons, with doctors often regarded as equivalent regardless of specialty. Even on the outside, rheumatology services are scarce in many areas; in the USA, for example, the estimated demand for clinical rheumatologists exceeded the supply by 12·9% in 2015, with this disparity projected to rise to 102% in 2030, often leaving patients waiting months for an appointment. With evidence clearly demonstrating the importance of early diagnosis and treatment of most musculoskeletal diseases, and a focus on treat-to-target strategies that require frequent follow-up visits, the odds seem stacked against patients who are incarcerated. Another formidable barrier to high-quality rheumatology care in prison systems is access to appropriate medications. Drugs for management of rheumatic diseases—some of the most expensive on the market—must be ordered from a strict formulary decided by pharmacy benefit managers who often have little to no rheumatological experience. As such, many medications are simply not available. According to a 2015 report from the US Department of Justice, more than a third of inmates with chronic diseases lacked access to prescription medications because the doctor did not deem them necessary or the facility would not provide them. Another 20% of inmates said they had never seen a doctor for their condition. Perhaps not surprisingly, nearly half of individuals reported dissatisfaction with the health care services provided during their incarceration. Physiologically, individuals who are incarcerated are 10 years older than their chronological age, making provision of adequate care for rheumatic diseases even more critical in this population. A better understanding of the requirements of patients in prison and detention systems worldwide is vital. Rheumatological patients require input from a variety of clinical specialists to ensure not only that health targets are met but that functional daily life—without debilitating pain—is possible. Healthcare systems must work in conjunction with prison systems to ensure that the needs of incarcerated patients are met; to not do so would indeed be cruel and unusual punishment.