This article was produced in partnership with the Pulitzer Center on Crisis Reporting.
GUANTÁNAMO BAY, Cuba — Nobody has a dementia diagnosis yet, but the first hip and knee replacements are on the horizon. So are wheelchair ramps, sleep apnea breathing masks, grab bars on cell walls and, perhaps, dialysis. Hospice care is on the agenda.
More than 17 years after choosing the American military base in Cuba as “the least worst place” to incarcerate prisoners from the battlefield in Afghanistan, after years of impassioned debates over the rights of the detainees and whether the prison could close, the Pentagon is now planning for terrorism suspects still held in the facility to grow old and die at Guantánamo Bay.
With the Obama administration’s effort to close the prison having been blocked by Congress and the Trump administration committed to keeping it open, and with military trials inching ahead at a glacial pace, commanders were told last year to draw up plans to keep the detention center going for another 25 years, through 2043.
At that point, the oldest prisoner, if he lives that long, would be 96. Another of the 40 people still held here — the Palestinian known as Abu Zubaydah, who was confined to a box the size of a coffin while held at a secret C.I.A. site and waterboarded 83 times to break him — would be 72. Like him, a number of the detainees are already living with what their lawyers say are the physical and psychological aftereffects of torture, making their health especially precarious as they head toward old age.
“Unless America’s policy changes, at some point we’ll be doing some sort of end of life care here,” the commander of the detention center, Rear Adm. John C. Ring, said during a discussion with reporters that highlighted the kinds of questions the prison is asking Pentagon policymakers to decide.
“A lot of my guys are prediabetic,” Admiral Ring said. “Am I going to need dialysis down here? I don’t know. Someone’s got to tell me that. Are we going to do complex cancer care down here? I don’t know. Someone’s got to tell me that.”
The prison is envisioning communal nursing home-style and hospice care confinement of detainees. Already, military commanders say, the detainees now suffer typical middle-age conditions: high blood pressure and cholesterol, joint pain, diabetes and, lately, sleep apnea.
But the military is grappling with an array of questions about how much medical care the prisoners should receive, how it should be delivered and how much Congress will provide to pay for it.
The closest major United States military hospital is in Jacksonville, Fla., 822 miles north. That is where Admiral Ring’s troops go for medical needs that the small base hospital cannot provide, like an M.R.I. But, by law, the military is forbidden to take Guantánamo’s Law of War detainees to the United States.
So most nonroutine medical care has always had to come to the prisoners. Cardiologists have for more than a decade come to consult on some prisoners’ cases. Other specialists have made regular visits to do colonoscopies and examine orthopedic injuries. A prosthetist comes for those with long-healed battlefield amputations.
For now, the military says, no prisoner has cancer and anybody using a wheelchair can get himself in and out of it. But, senior staff members are puzzling through how many cells they will need with grab bars and ramps, and bigger spaces for gurneys, wheelchairs and showers.
“You know, a lot of these folks had hard lives before they came here to Guantánamo Bay,” said the senior medical officer, a Navy commander whose name cannot be disclosed under the military’s rules for visits by journalists to the prison. “We are starting to see the use of canes and walkers and braces and so forth.”
Admiral Ring said the military had no geriatric or palliative care physicians. So he is sending a team to see how the federal Bureau of Prisons handles sick and dying convicts.
The Guantánamo Bay prison has a revolving medical staff of 140 doctors, nurses, medics and mental health care providers. They care for the detainees but also provide some services to the 1,500 troops assigned to the prison, who can go to the base hospital or to the United States for more complex medical care.
Now, the Pentagon is seeking $88.5 million to build a small prison with communal hospice care capacity for the 15 detainees brought here from C.I.A. black sites — six of whom await death penalty trials as alleged conspirators in the attacks of Sept. 11, 2001, and the American destroyer Cole in which nearly 3,000 people died.
The initial cost estimate for the project in 2013 was $49 million. Last year, Admiral Ring estimated it at $69 million. Congress declined to fund it, citing more urgent Defense Department infrastructure needs.
The former black site prisoners are suspected masterminds, deputies or foot soldiers linked to Al Qaeda, and their defense lawyers and medical experts they consult call them Guantánamo’s sickest. Some of the ailments the military attributes to aging, they say, are actually the aftermath of C.I.A. torture.
One prisoner, known as Hambali, 55, an Indonesian who is being held as a former leader of the Southeast Asian extremist group Jemaah Islamiyah, is due for a knee replacement, said his defense lawyer, Maj. James Valentine of the Marines. Major Valentine said the damage to Mr. Hambali’s knee directly resulted from his first year of C.I.A. captivity, when he was always shackled at the ankles.
Mustafa al-Hawsawi, 50, a Saudi man accused of helping the Sept. 11 hijackers with travel and expenses, has for years suffered such chronic rectal pain from being sodomized in the C.I.A. prisons that he sits gingerly on a pillow in court, returns to his cell to recline at the first opportunity and fasts frequently to try to limit bowel movements, said his capital defense lawyer, Walter Ruiz. He has become dependent on a narcotic painkiller called tramadol to make it through the day, Mr. Ruiz said.
It may strike some people as odd that the military is discussing complicated, expensive medical care for the detainees, especially those the Pentagon prosecutor wants sentenced to death.
“It is paradoxical,” said Dr. Stephen N. Xenakis, a psychiatrist and retired Army brigadier general, who has consulted on Guantánamo cases since 2008. “But we don’t let people just die in this country. It violates all of our ethics, our medical ethics.”
Even before most of the detainees reach old age, the prison has confronted the challenges of providing sophisticated medical care under the constraints imposed on it.
In summer 2017, guards found an accused war criminal, Abd al Hadi al Iraqi, incontinent in his cell. He had complained for years about debilitating back pain from degenerative disc disease. A hurricane was headed to the Caribbean, and the Pentagon rushed a Navy neurosurgical team to the base to do an emergency spine surgery.
Recently released court documents in Mr. Hadi’s case challenge the assertion of commanders who say they provide detainees with excellent health care on par with American service members.
He underwent three spine surgeries in September 2017, the first on his lower back, another on his neck and a third to drain a postoperative hematoma. Then, that October, a senior officer at Guantánamo’s community hospital declared in an email that the patient’s “cervical fusion has failed.”
The officer, whose name was redacted in the court record, offered three possible options: giving Mr. Hadi a neck brace and hoping for the best; bringing in a special screwdriver from a Navy hospital in Portsmouth, Va., to remove hardware inserted in the patient’s neck in an earlier operation, or transporting him to the Portsmouth hospital for complex surgery.
In a rare admission of the limits of medicine at Guantánamo, the naval officer added that “the prospect of attempting” that complicated operation at the base hospital here “scares the hell out of me.”
What happened next is not in the court records. But Col. Amanda Azubuike of the Army, a spokeswoman for the Southern Command, which oversees the prison, said by email that the idea of airlifting the prisoner “was obviously not pursued nor explored further given the legal restrictions.”
Two more operations on Mr. Hadi would follow at Guantánamo.
Court filings show Mr. Hadi has chronic pain and back spasms, for which he is prescribed a variety of painkillers and muscle relaxants. His surgeon has testified that Mr. Hadi may not improve. At a hearing on his case in March, guards brought him to court in a wheelchair; he used a walker to transfer to a cushioned rehabilitation chair. The hearing abruptly recessed when one of his lawyers said Mr. Hadi’s answers were not tracking with questions his legal team was putting to him.
Mr. Hadi, now 58, has a February 2020 trial date. To ensure his attendance, the Pentagon fast-tracked bringing a wheelchair-accessible holding cell to the court compound where legal proceedings take place. It was already on order in anticipation of a population of aging detainees.
It is triple the size of the court’s other five holding cells, large enough to hold a hospital bed and, according to a case prosecutor, will have a video monitor so Mr. Hadi can watch a feed of his trial from the bed. It will also have a phone to let him or a lawyer call the courtroom next door, if he has something to say.
The military has already figured out what to do when a detainee dies because that has happened nine times since 2006.
Muslim employees on base offered the deceased their traditional rites until a Muslim chaplain arrived to take over. The State Department then arranged to repatriate the prisoners’ remains.
For those who cannot be repatriated, there is a chain-linked-fence ringed plot of land marked “Entrance Islamic Cemetery” on an off-limits portion of Guantánamo. The last time a reporter was able to visit it, in 2016, it was empty.