GUANTANAMO BAY NAVAL BASE, Cuba — The oldest man still held in military detention here is 71 years old. Many others are in their 50s.

It’s not entirely clear how the U.S. government plans to care for them in their old age.

The 40 remaining prisoners at Guantanamo Bay Naval Base have the same physical ailments of any aging population. They need hip replacements, eye surgeries, treatment for sleep apnea, mental health disorders and, one day, probably cancer and dementia. As the military commissions designed by the Bush administration lurch unevenly towards convictions — a federal appeals court recently tossed aside three years of litigation in the USS Cole case — it appears increasingly likely that many of these men will grow old and die on the U.S. taxpayer’s dime.

The aging population at Gitmo poses unique challenges for Adm. John Ring, the latest in a string of officers who have led the prison on one-year deployments. Defense attorneys say many detainees suffer the ill effects of brutal interrogation tactics now considered to be torture. The United States has committed to providing the same health care to the remaining detainees that it provides to its own troops, as required by the Geneva Conventions. But the secure medical facilities built to treat the detainees — Ring calls them “guests” — can’t cope with every kind of surgery geriatric patients typically need, and weren’t built to last forever. Congress has prohibited the transfer of detainees to the continental United States, which means any treatment they receive will have to take place at a remote outpost on the tip of Cuba.

“I’m sort of caught between a rock and a hard place,” Ring said. “The Geneva Conventions’ Article III, that says that I have to give the detainees equivalent medical care that I would give to a trooper. But if a trooper got sick, I’d send him home to the United States.

“And so I’m stuck. Whatever I’m going to do, I have to do here.”

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For now, with all of the detainees healthy enough to get around without assistance, that system is mostly working. Specialists and equipment are flown in as needed, including a handicapped-accessible cell sent to the war court facility so that a 57-year-old inmate recovering from emergency spinal surgeries could stay overnight at the complex rather than endure transport back and forth from the detention facility.

Officials on the island have been told to expect to keep the lights on for another 25 years. Most of the long-term planning Ring and his successors need to turn Gitmo into a nursing home for terrorists is up to policymakers at the Pentagon — and, it’s not clear how much planning has actually been done.

“A lot of my guys are prediabetic. Am I going to do dialysis down here? I don’t know. Somebody has got to tell me that. Are we going to do complex cancer care down here? I don’t know, somebody has got to tell me that,” Ring told reporters.

What is the Pentagon’s plan?

“We’re in the early stages of feeling this out,” Ring said. The long-term goal is to continue to house detainees in communal living configurations, so that they can help care for one another as they age. In the coming months, he is sending a team to study how Federal Bureau of Prisons facilities in the United States handle end-of-life care for elderly prisoners. And eventually, the senior medical officer, or SMO, expects to replace the detainee acute care unit, where surgeons have already performed both emergency and routine elective procedures, to include ramps, grab bars, and other amenities required by the Americans with Disabilities Act.

“This facility was built as sort of a stop-gap measure,” the SMO said. “It’s not the final solution. The detainee acute care unit is designed with a seven-year time frame so somewhere around 2025, they’re going to have to look at a more permanent solution.”

But experts say that still leaves a lot of unanswered questions about the breadth of care that will be available.

“I just can’t imagine being able to configure a suite of [operating rooms]. What you do in a neuro suite versus a cardiac suite are all a bit different. What are you going to do when you decide you’re going to do a cardiac bypass? You need a special OR,” said Dr. Stephen Xenakis, a retired military psychiatrist who has worked with Gitmo detainees and now advocates against the use of torture at the nonprofit NGO Physicians for Human Rights. “There’s constraints. And there’s realities. And at the highest levels, there’s going to have to be some very hard decisions.”

A Pentagon memo from February 2018 — shortly after President Trump announced that he would be keeping Gitmo open — says that U.S. Southern Command will provide the detainees with the same level of care as the U.S. armed forces only “when it is possible” and “to the extent practicable.” If the appropriate care can’t be provided on the island, according to the memo, “a panel will be formed to provide direction…on medical courses of action.”

The memo directs the chairman of the Joint Chiefs of Staff to develop an “execute order” that would, among things, “refine medical options, address urgent and chronic health issues, long-term medical treatment requirements, staffing requirements, and structural changes to camps and medical facilities.”

“This EXORD will assist in defining ‘the practicable extent’ of medical capabilities that could be brought to bear at GTMO in order to provide the appropriate medical care required by a detainee’s condition,” reads the memo, signed by Defense Undersecretary for Policy John Rood and obtained by Defense One.

But as of April, the order had not been issued — and is not expected until June, according to Col. Pat Ryder, a spokesman for the Joint Staff. “This EXORD is a first step towards addressing detainee healthcare policy guidelines tasked by the Undersecretary of Defense,” Ryder said in a statement.

And although the memo directs the Office of the Assistant Secretary of Defense for Health Affairs to update the DOD regulations governing medical program support for detainee operations, they have not been amended since 2006.

Just how old is old?

In one of Gitmo’s communal cellblocks, guards sit in a chilled, dim passageway called the “rotunda” and watch through one-way glass as inmates sip tea, gesture and talk, read and pop bites of food in their mouths. A handwritten reminder is pinned to the desk: “Fill out hunger strike meal inventory before and after meals go on/off block.”

Some detainees are starting to use canes and walkers, but none are showing signs of serious age-related illness yet, according to Ring and the senior medical officer.  The chief medical officer expects the first hip and knee replacements to be needed soon. And, he said, “I am seeing a few cases that may look like early cognitive impairment.”

But no one is making permanent use of a wheelchair yet and no one has cancer, they say. “I haven’t gotten anything that I would diagnose as dementia,” the SMO said. “Generally across the board versus an American population of age-matched controls, we have the same conditions, although they tend to be a little bit less [prevalent] here,” including high blood pressure, diabetes, high cholesterol and mental health illnesses.

That claim raises some eyebrows among current and former DOD officers who have worked with detainees at the camp. Maj. James Valentine, the government-appointed defense attorney for two of the detainees kept in Guantanamo Bay’s maximum-security “Camp 7”, believes that one of his clients has some kind of cancer. Mohamed Rahim has shown Valentine sequential CAT scans showing “nodules that are growing in at least five different body organs,” he said. “Typically that is an indication of some kind of precancerous growth when they’re growing all over different parts of your body.” Valentine emphasized that he is not a physician and does not have access to Rahim’s complete medical records.

Other detainees suffer various chronic conditions that defense attorneys blame on mistreatment by U.S. interrogators — in particular, “walling,” in which detainees were placed in a neck collar and slammed against a wall; and the use of stress positions, where the detainee was shackled in a painful position for an extended period of time.

Compounding the challenges of caring for an aging population in a high-security facility is a longstanding policy: medical caretakers are not allowed to ask detainees about the origins of any injury or illness that may have arisen from the use of torture during interrogations.

“That means you’re not getting the right clinical history. You need that history as a doctor. You need to know what’s happened,” Xenakis said. That history is particularly important when providing mental healthcare to elderly patients, he continued. “Their capacity to cope with things is diminished and so these experiences they had in their younger years revisit them very, very vividly.”

“Depression does increase with age,” the SMO said. “There are mental health diagnoses that do pop up more as people age.”

Even if they are healthy now, Ring acknowledges that some of the detainees may not be mentally competent by the time their case goes to trial.

“While the commissions processes are taking a lot of time, I think there are isolated cases where they might not be lucid and able to participate, but I think overall they will be,” said Ring. That determination is up to the Military Commissions, not Ring or his staff. 

Ring’s deployment began just over a year ago. A new commander will take over in June.