Late last month, the United Nations Human Rights Council made public a communication by seven U.N. experts criticizing the U.S. government on the state of medical care for detainees at Guantanamo Bay. The communication, filed on January 11 (the 21st anniversary of the opening of Guantanamo Bay), highlighted the case of Abd Al-Hadi Al-Iraqi (Nashwan al-Tamir), a detainee in his 60s, who is suffering from a degenerative spinal disease, has undergone six back and neck surgeries at Guantanamo since 2017, and whose health continues to deteriorate. 

The experts found “systematic shortcomings in medical expertise, equipment, treatment and accommodations at the Guantánamo Bay detention facility and naval station.” The communication also served as a reminder of the government’s responsibility to provide “adequate redress and reparation for any human rights abuse and other international law violations committed in the delivery of detainee healthcare.” 

Disclosure of the experts’ communication came on the heels of an article in Just Security by Mort Halperin and Steve Xenakis (the latter is a retired brigadier general and psychiatrist) explaining the legal and moral imperative of providing torture rehabilitation – and adequate medical care more generally – to the men still detained at Guantanamo. This article highlights an aspect of the problem that arose at a recent military commission hearing: the closely tied roles of trauma and culture, and the astonishing hypocrisy with which Guantanamo’s medical care system approaches them. In short, culturally competent medical care, including to the extent possible care provided by independent medical experts of the detainees’ nationalities, is needed at Guantanamo now.

Trauma and Culture in Guantanamo’s Medical Care System

In February, two medical expert witnesses testified in the latest pre-trial hearings in the USS Cole bombing case: Dr. Sondra Crosby, an expert on torture and trauma, and Guantanamo’s senior medical officer (SMO). (Note that the SMO is different from the Chief Medical Officer, a position Congress established several years ago that reports outside the Guantanamo chain of command.)

Dr. Crosby testified about torture methods that Abd al-Rahim al-Nashiri, the defendant, was subjected to while in CIA custody from 2002 to 2006, with a particular focus on “rectal feeding” in 2004. Carol Rosenberg at the New York Times called it the “most detailed public account of the procedure, from a medical perspective” to date.

The SMO followed. He testified he is currently treating Mr. Nashiri for “active issues,” and was informed, when taking on his role, that his patients were subjected to “CIA enhanced interrogation.” However, he was unaware of the methods Mr. Nashiri was subjected to because after reviewing Mr. Nashiri’s medical history, he found no records from when Mr. Nashiri was in CIA detention, and “no evidence that anyone on the Guantanamo medical staff took a trauma or torture history of him” when he arrived there in 2006. 

Failure to ask about and document such a history is a clear, and now longstanding, violation of the applicable standard of care, born of continued secrecy around CIA torture, that cuts across the detainee population. To prepare his testimony, the SMO reviewed external sources such as the 2014 Senate Torture report, an ICRC report, and previous statements, including Dr. Crosby’s. 

His testimony was filled with other admissions that were at once significant, ironic, and outrageous, including that he was not trained in treating torture survivors, and “he received no specific cultural sensitivity training for this assignment ‘on how to treat Muslim men.’”  

The SMO’s testimony was significant because no government official has publicly confirmed that culturally competent medical care, recommended by independent medical experts  as required for adequate treatment, is not available at the detention center. It was ironic and outrageous because, in the early stages of the so-called War on Terror, the U.S. government used knowledge of Islam and cultural norms to torture and otherwise torment Muslims, but in the over 20 years since apparently has not considered it relevant to their medical care. 

It’s commonly known that religious beliefs and cultural norms were weaponized against Muslim men in Abu Ghraib, Bagram, and Guantanamo. A list of authorized tactics by then Secretary of Defense Donald Rumsfeld included removal of religious items and forced shaving of facial hair. Qur’ans were burned and defaced. Olive oil labeled a “culturally sensitive material,” was used to lubricate tubes for force-feeding. Underpinning these specific torture and cruel treatment techniques, Islamophobia was institutionalized — courses at military schools taught officers Islam is their enemy. A 2012 military investigation into the burning of Qur’ans in Bagram found “troops were exposed only to about an hour-long PowerPoint presentation about Islam,” prior to deployment to Afghanistan. 

On more than one occasion, independent medical experts have emphasized the importance of culturally competent care for treatment of detainees. It is also referenced in Article 30 of the Third Geneva Convention, to which the United States is a party, which states, “prisoners of war shall have the attention, preferably, of medical personnel of the Power on which they depend and, if possible, of their nationality.” 

The ICRC commentary to Article 30 explains that “medical personnel of the same nationality… may … increase the availability, and potentially also the quality, of medical services…” as they would “have expertise in the treatment of endemic diseases unfamiliar to the Detaining Power or where being of the same cultural background may help to manage prisoners’ mental health conditions.” It also notes that “medical personnel of the same nationality as the prisoners may help create trust” between the detaining Power and prisoners. Given the role of U.S. military medical personnel in the torture of many detainees at Guantanamo, and the trust deficit it created, it would be wise for the government to heed this recommendation.

In 2009, three behavioral health professionals in Guantanamo’s Joint Medical Group published an article in which they acknowledged how difficult it is to understand and manage health conditions without cultural context. “[T]he acceptance of Western diagnostic formulation among the detainees is low,” they wrote, “and its appropriateness debatable. At times a patient’s presentation is inconsistent with any formulation using the traditional diagnostic criteria found within the Diagnostic and Statistical Manual of Mental Disorders-IV… and some individuals appear unable or unwilling to accept Western terminology.” For example, certain mental illnesses – as understood by detainees – are caused by ‘jinns,’ or supernatural beings and spirits, which “in the Muslim imagination… occupy a shadow world.” The authors explained that: 

“mental health providers have had to learn a great deal about the various cultures the detainees come from… [The providers] have access to an Imam and cultural advisor for consultation, are provided mentoring as needed from mental health providers who have already served in GTMO and incorporate culturally specific training into staff education.”

All of that may be true as far as it goes, but none of it meaningfully addresses the problem. Neither the Imam nor the cultural advisor are qualified medical providers and detainees come from many more cultures than the two could represent. Moreover, information the two would need to provide adequate advice and consultation – specifically about detainees’ torture – was, and still is, mostly classified. 

Even if these limitations were somehow resolved, “access” to the Imam and cultural advisor doesn’t mean that military medical professionals would actually get from them the information that they need. This is, to some extent, a structural problem. The Imam and cultural advisors (like Guantanamo’s medical staff) have to balance “dual loyalties” to their employer and to their profession, the latter as it relates in particular to moral, ethical and humane treatment.  When the employer is engaged in extra-legal detention of men it long-branded “the worst of the worst,” this can be a near impossible line to walk. For example, former Imam Captain James Yee believes that his legal troubles, which included criminal charges of espionage, spying, and aiding the enemy– stemmed from advocating for humane treatment of detainees. All criminal charges against Yee were later dropped due to lack of evidence; he was reprimanded on minor non-criminal charges and honorably discharged. On the other end of the spectrum, long-time cultural advisor of Middle Eastern descent, Zak Ghuneim, accused detainees of participating in hunger strikes to “discredit the US.” In 2007, he called “complaints of prisoner mistreatment ‘baloney.’” 

And even if there was cultural training and staff education in 2009, the current SMO’s testimony that he did not receive any cultural sensitivity training means there is clear problem at Guantanamo today. 

How to Solve the Problem of Culturally Competent Medical Care

The UN experts recommended the U.S. government “ensure a human-rights-based and gender- and culturally sensitive approach to the provision of health care services to all detainees…” They further offered technical support to assure compliance with international law. 

The Biden administration needs to understand that there have been – and continue to be – real, human consequences of the decision not to call torture what it is. But it is also not too late to begin to correct the failings of the Bush, Obama, and Trump administrations before it. The Department of Defense, working with both interagency experts on culturally competent medical care and – to the extent possible – independent medical experts of the detainees’ nationalities, can begin to provide culturally appropriate medical care at Guantanamo now, including for those whose cultural beliefs were used as implements of torture. Medical staff can, and must, take medical histories that include the torture and other traumas detainees were subjected to, and can do so in culturally appropriate ways that inform ongoing and future treatment. 

Of course, while it is necessary and required, just culturally competent medical care is not sufficient to adequately address the U.S. government’s long-term dehumanization of the men at Guantanamo. As Xenakis and Halperin explained, the government is also obligated to provide torture rehabilitation. And General comment No. 3 on the implementation of article 14 of the Convention against Torture requires that effective rehabilitation services and programs established by State parties consider a victim’s culture. It specifically provides that “culturally sensitive collective reparation measures shall be available for groups with shared identity.” 

The participation of independent medical experts is pivotal in this process. Their role should not be minimal, it is the only solution to the quagmire the government has created by involving military medical personnel in the torture and trauma of detainees and weaponizing culture. U.S. military medics who are Arab, Middle Eastern, Muslim, and South Asian, while helpful, may face challenges in building trust and navigating dual loyalties. 

All of this must be done with the sense of urgency appropriate to the task – a failure to do so only lends credence to the view that dehumanization, racial and cultural injustice, and willful blindness of past wrongs are acceptable to the Biden administration and the U.S. military.

IMAGE: A physical therapy room for older detainees is seen at the US Guantanamo Naval Base on October 16, 2018, in Guantanamo Base, Cuba. (SYLVIE LANTEAUME/AFP via Getty Images)