'Degrading': Aging detainees describe health care woes at Guantanamo 18 years after 9/11

At 72, Saifullah Paracha is Guantanamo Bay’s oldest detainee by some stretch. A number of health problems could be expected to befall any man his age, let alone one who has spent the last 17 years in the notorious offshore U.S. military prison.

He suffers from "debilitating chest pains," an "overactive bladder and enlarge[d] prostate," diabetes, coronary artery disease, diverticulosis, gout, psoriasis and arthritis, his lawyer, Shelby Sullivan-Bennis, told ABC News. He has also suffered two heart attacks, one of which occurred when he was held in Bagram, in Afghanistan, before his transfer to Guantanamo, according to his attorney.

Despite this, Paracha, who is alleged by the U.S. government to have been a "significant member of the international al-Qaida support network through his business associations in Pakistan," was one of 24 low-value detainees who participated in a boycott of medical services this summer to protest what they say is inadequate and culturally insensitive treatment at the facility. They are referred as "low-value" by attorneys and journalists familiar with Guantanamo because they live in more communal cell blocks, where they are able to take part in group activities.

Paracha’s attorney said she was fearful for his life, given his complex medical needs.

None of the 24 low-value detainees, including Paracha, have been charged with a crime. Instead, they are being held indefinitely under the laws of war, which apply while conflict with the Taliban and al Qaeda are ongoing.

In total, there are 40 detainees left at Guantanamo (down from nearly 700 at the peak), ranging in age from their early 40s to early 70s, only nine of whom have been charged with a crime. The subject of detainee care has been an issue of increasing debate in recent years, with the facility now reportedly considering end of life care services for the remaining detainees, according to the New York Times.

Historically at Guantanamo, detainees had been restrained during medical check-ups with a single ankle restraint to the ground, according to detainees’ statements provided to Sullivan-Bennis and shared with ABC News.

But prisoner advocates say a new policy, which allegedly began in late 2017, involved detainees being brought to medical examinations being placed in handcuffs which are attached to a leather brace fitted around their stomach, prohibiting their ability, in one detainee’s words, to even "lift their arms to hold onto a medical record."

That policy was partially overturned after the boycott, with the leather brace now removed for these medical visits. Detainees remain handcuffed during the medical visits, according to Sullivan-Bennis, who also represents several other inmates at the facility.

‘Last thing a person expects’

One of the detainees, Khaled Qassim, described what he said was the new shackling policy in a June 2019 letter to the human rights charity Reprieve, whose lawyers represent him.

"In the worst days in GITMO, when the number of detainees was in hundreds, doctors used to have the authority to ask the guard force to take some of the restraints off the patient detainee while treating him in the medical space," Qassim wrote. "Recently, after seventeen years with the number of detainees is far less than before, just in tens, and easier to control, the restraining rules have changed unnecessarily to something much worse."

He claimed that under the new rules, detainees undergoing medical exams were put in "hand shackles, belly chain and the leg shackles are all on," and described it as "a scene that would always remind you about the tragedy of the slavery time."

"This time, unfortunately, it happens before a doctor," he wrote in the letter, which was reviewed by ABC News. "The last thing a person expects…. Unlike any other meetings."

Another detainee, Abdul Latif Nasser, who remains detained more than three years after being cleared for release and who was profiled by ABC News in June, appeared to corroborate these claims in a recent meeting according to Sullivan-Bennis, who serves as his attorney as well.

Sullivan-Bennis says Nasser claimed that at routine monthly medical appointments, he had to wear ankle restraints, a stomach brace with handcuffs attached to a leather brace around his waist, with extremely tight restraints. All this took place, he alleged in declassified notes from the meeting with Sullivan-Bennis, in the presence of two guards at all times so, in his words, "nothing is private," and due to the lack of confidentiality, detainees "cannot discuss private topics."

Nasser also claimed that detainees don’t know who their doctors will be because of rotating staff and feel uncomfortable discussing personal medical matters and undergoing certain procedures, such as prostate exams, with female doctors, for religious reasons.

According to Sullivan-Bennis, when she asked Nasser how inmates would respond to a colonoscopy being performed on them by a female doctor, Nasser said: "some detainees would prefer to die."

"Access to a private doctor is more important to my religion than allowing me to pray," she says he told her.

Shackling, boycotts and veering policy

Over the summer, frustration with circumstances surrounding medical care came to a breaking point. When Sullivan-Bennis received Qassim’s letter in June, she says she thought to herself "Oh my god, that’s new."

When she returned to Guantanamo to visit Qassim and her other clients, she says she found they had been denying themselves access to medical care. Although they did not expressly use the term "boycott," she found that all 24 low-value detainees were not attending their medical appointments.

"I’m extremely concerned for [Paracha] separately from the outrage and it was then that I learned that no-one was going to the doctor," she told ABC News. Her immediate fear was that medical harm would befall Guantanamo’s oldest detainee.

"You've got 24 people going to the same doctor and all refusing to go and my fear was that it wouldn't move the administration to engage in a conversation," she said. "And that the result that would come would be the death of one of my clients. I mean it sounds extreme but it's actually not very extreme."

So Sullivan-Bennis says it was a surprise when she learned that the boycott had been successful.

After a month, she says a doctor entered the detainees’ living quarters to find out why they weren’t attending their appointments.

The detainees told the doctor that they were upset with the treatment they had been receiving, and "shortly thereafter things changed," according to Sullivan-Bennis.

While the leather brace fitted around the stomach is no longer required, detainees still have to wear handcuffs during medical visits, the attorney said.

She also said that there used to be two doctors for low-value detainees.

"That has now dropped to one provider, whom none of the detainees trust to give advice or care," she said.

Department of Defense instructions say that the treatment of detainees held under the law of war should "be guided by professional judgments and standards similar to those applied to personnel of the U.S. Armed Forces." Furthermore, the latest official guidance from the DOD on shackling reads that such restraints, if used, will be applied in a safe and professional manner."

The DOD, in response to the allegations that detainees were being shackled, told ABC News it continues "to explore ways to provide adequate care for an aging population, with varying levels of mobility, by making appropriate modifications to existing facilities.

"Our medical facility is equipped with outpatient and inpatient services, a physical therapy area, pharmacy, radiology services, a dental treatment area, central sterilization and a single-bed operating room," the DOD added in the statement. "Detainees are continually assessed, as medically indicated, for signs and symptoms of any number of conditions and are treated at a dedicated medical facility by a medical staff of about 100 personnel."

A breakdown in trust

A recently published report about medical conditions at Guantanamo, co-authored by the non-profit Physicians for Human Rights and the Center for Victims of Torture, found that the central problems with medical care at Guantanamo were a "distrust of military medical providers" and the subordination of patient needs to "security functions."

Prisoners’ rights advocates contacted by ABC News emphasized that shackling a patient should only take place as a last resort because they say it fundamentally undermines the trust that serves as the foundation of any successful doctor-patient relationship.

Brig. Gen. Stephen Xenakis, a psychiatrist who has been advising attorneys for GITMO inmates and has been visiting the facility since 2009, says he "does not recall" a time when patients weren’t shackled during his psychiatric evaluations, a practice that he said impedes the work of counseling.

The justification he says he has been given is that as an adviser for the detainee’s attorney, who is always in the room during his evaluations, he does not have one-on-one access, nor the ability to unshackle them.

"It's a kind of relationship that people have to have with priests or rabbis or imams or in fact with their attorney," he told ABC News. "So I mean there are some relationships that in order for them to be effective and for the person to be helped there has to be absolute confidentiality. And to have a third party in the room completely disrupts that confidentiality."

When evaluating individuals who have been convicted of capital offences and terrorism in the United States, there is never a third party present, he said, nor does he himself require them to be shackled. Not only does it undermine trust, but interferes with the psychiatric evaluation, which could prove critical if the men are ever brought to trial, he said.

"If you take the issue of what these people have disclosed after they've been tortured, my ability to be able to explore that with them in confidentiality means that I can accordingly advise the attorneys better about the validity of what they've said or not," he said.

In Guantanamo, the threat detainees could pose is "significantly diminishing" because of their age, he said.

"I mean I don't feel like I need to fear for my personal safety," he said. "I don’t think any of us feel that we’re particularly threatened."

When asked if he had seen or heard of any security incident that could justify shackling based on his experiences at Guantanamo over the past 10 years, Xenakis said: "No not that I know of."

The biggest problem at the facility is not a lack of resources or equipment, but rather the breakdown in trust between doctors and patients, according to Clive Stafford Smith, the founder of Reprieve, a legal human rights charity that represents a number of GITMO inmates.

"There are, as the men say, some medical issues that you would not discuss in front of your spouse, your family or your best friend, and you sure would not discuss this with guards there who are going to gossip about you," he told ABC News. "And it makes no sense as nobody ever attacks a doctor."

"Frankly, some of the prisoners are becoming fatalistic that they will die here," he added.

Treatment ‘degrading’ and ‘fluctuating’

Nasser summed up what he said was the plight of his fellow detainees according to notes taken by Sullivan-Bennis at a Sept. 23 meeting.

"So that’s the problem, to be honest with you, is just to stay alive, not to enjoy our life," he said. "I have no objective in my life. My life has no meaning. That is the problem that detainees suffer."

Qassim claims that the "fluctuating treatment" he has received at Guantanamo has had an impact on his mental health. At 41, he says his legs began to swell around May this year. His legs were eventually "drawn to twice their size form ankle all the way up to his knees", according to Sullivan- Bennis and Reprieve.

Despite this obvious physical symptom, and the potential for such a swelling to be caused by cancer, or a blood clot, he was not treated for "several months," Sullivan-Bennis says he told her. Then, when he had a blood test, Qassim, who raised complaints about the treatment, says he was told that the blood results were "fine."

Last week he was provided with the medical records from those tests, meaning he is still unsure of whether the situation has worsened – which can happen if swelling of this kind is left untreated - nearly five months after the appearance of swelling. Sullivan-Bennis has still not seen the document, and says his legs are "failing to this day."

The "degrading" and "fluctuating treatment," Qassim wrote in a letter to his attorney, Mark Maher, had left him with "cognitive disturbance" and "concentration problems."

"Guantánamo is gradually becoming the world's most unjust, most brutal, most expensive nursing home because the Trump administration has decided that none of these men held without charge for decades - many of whom have been cleared for release – should be allowed to rebuild their lives," Maher told ABC News. "It is hard to conceive of a more cruel, more counter-productive policy."

Another detainee, Abd al Hadi al Iraqi, has sued the government, claiming his medical care amounted to "deliberate indifference" of a serious condition" and violated his constitutional rights. Al Iraqi has a long history of back problems, had a CAT scan in January 2017 which showed evidence of "severe neural encroachment" that could "easily progress to spinal stenosis" which if untreated can result in spinal cord compression and permanent neurologic disabilities, according to court filings by Physicians for Human Rights.

However, al Iraqi did not receive surgery until Sept. 5, 2017.

"They waited until the absolute last minute right before a hurricane [to perform the surgery]," Sullivan-Bennis said. "He’s since I think had seven or eight back surgeries because of that because they’d let it get to such a terrible point, essentially. But then they took such a risk by flying in."

Judge Emmert G. Sullivan of the District Court in Washington D.C. rejected Al-Iraqi’s constitutional claim and his request for an independent medical evaluation in October 2019, ruling that assertions that his care was negligent do not amount to a constitutional violation. Al Iraqi is set to go on trial for war crimes for his alleged role as a commander of the Taliban next September, according to the New York Times.

Ahmmed Ghulam Rabbani has also challenged his care on constitutional grounds. Rabbani had been on hunger strike for four of the previous 13 years at GITMO. In September 2017, the Senior Medical Officer determined that he no longer needed to be force fed, according court filings. Rabbani’s attorneys argued constituted "deliberate indifference to his serious medical needs in violation of his Eighth Amendment Rights."

Rabbani said in the court filings that even if he wanted to end his hunger strike, he could not do so because he is "entirely unable to eat normal food" because "suffered from bleeding, indigestion, colon problems [and] ulcers."

In an emergency federal court motion, his attorneys requested access to all his physical and psychiatric records since July 2017. They also wanted to appoint a medical practitioner to evaluate Rabbani, and compel GITMO staff to "facilitate that treatment" deemed necessary and appropriate. The court denied the motion after finding that the government was addressing his needs, and had ultimately provided the enteral feedings briefly before Rabbani opted to consume a liquid diet on his own.

Government lawyers told a federal judge last year detainees could remain in Guantanamo for the next 100 years. That prospect led to the previous commander of GITMO, John Ring, to suggest that the authorities were in "the early stages of feeling this out," when asked about handling end-of-life care – in other words a hospice – for US prisoners. The comments were widely interpreted as being critical of GITMO’s medical care. Ring was fired shortly after due to "a loss of confidence in his ability to command," U.S. Southern Command said.

"This facility was built as sort of a stop-gap measure," the Senior Medical Officer, who oversees medical care at GITMO, told reporters then. "They’re going to have to look at a more permanent solution."

The idea of hospice at GITMO, according to Sullivan-Bennis, is "perfectly realistic," as the authorities focus on "extending their lives and essentially just providing care to avoid death."

"Simply an avoidance of death," she said.