Earlier this year, in a rare and refreshing moment of candor, the admiral who was in charge of the U.S. military prison at Guantánamo Bay, Cuba, expressed concern about the military’s ability to provide medical care to the detainees still held captive there. Many of the 40 remaining prisoners are entering old age and there is seemingly no prospect of their release. Speaking to reporters in April, Rear Adm. John Ring said:

“Unless America’s policy changes, at some point we’ll be doing some sort of end of life care here…. A lot of my guys are prediabetic…. 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 … I’m sort of caught between a rock and a hard place…. 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.”

But what Ring did not tell reporters was that, when it comes to concerns regarding the state of medical care at Guantánamo, complications associated aging are just the tip of the iceberg.

Today, my organization, the Center for Victims of Torture (CVT), along with Physicians for Human Rights (PHR), released a joint report finding that Guantánamo’s medical care system has long been broken in a number of respects. The legacy of U.S. torture—and in particular medical complicity in that unlawful and immoral project—is at the root of many of the medical care deficiencies we identified and continues to exacerbate all of them.

The report—Deprivation and Despair: The Crisis of Medical Care at Guantánamo—compiles and analyzes opinions from over the years of independent civilian physicians who have managed to access detainees, review medical records, and otherwise interface with Guantánamo’s medical care system. Our analysis was further informed by consultation with several of the physicians and with counsel for detainees. (The full report is available here; a stand-alone executive summary here; and a selection of some of the civilian medical experts’ findings and conclusions regarding the treatment of various detainees here. The report also includes case studies for four detainees, three of whom remain at Guantánamo).

Our findings include, but are not limited to:

Medical needs are subordinated to security functions. For example, prosecutors in one detainee’s military commission case told the judge explicitly that the commander of Guantánamo’s detention operations is not bound by recommendations of Guantánamo’s senior medical officer. Another detainee—who was tortured extensively at several CIA black cites—repeatedly refused to see treatment providers because doing so required him to wear a “belly chain,” which would trigger unbearable flashbacks.

Detainees’ medical records are devoid of physical and psychological trauma histories. This is largely a function of medical professionals’ inability or unwillingness to ask detainees about torture or other traumatic experiences during their time in the CIA’s rendition, detention, and interrogation program, or otherwise with respect to abusive interrogations to which the U.S. was connected – which has led to misdiagnoses and improper treatment.

Both expertise and equipment are increasingly insufficient to address detainees’ health needs. For example, a military cardiologist concluded that an obese detainee required testing for coronary artery disease, but that Guantánamo did not have the “means to test” him, and so the testing was not performed. With regard to mental health, effective torture rehabilitation services are not, and cannot be made, available at Guantánamo.

Detainees’ access to medical care and, in some cases, their exposure to medical harm, turn substantially on their involvement in litigation. For example, it appears extremely difficult, if not impossible, for detainees who are not in active litigation to access either independent civilian medical professionals or their own medical records. For detainees charged before the military commissions, prosecution interests have superseded medical interests, as with a detainee who was forced to attend court proceedings on a gurney writhing in pain while recovering from surgery.

We asses these, and the balance of our findings broadly, against the standard of care that Guantánamo officials claim to provide, and which is required by the military’s own regulations implementing the Geneva Conventions—that detainees receive medical care equivalent to that afforded U.S. service members—and more specifically against the United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), which the United States has championed. We conclude that the United States is not meetings its obligations in a host of areas, and detainees are paying the price.

However, our findings and conclusions, distressing as they are, should not be taken as a sweeping indictment of front-line medical personnel at Guantánamo. Many of the deficiencies in medical care that we describe are structural, operational, and/or cultural, and cannot be fixed by even the best intentioned of the staff working there. Some of the deficiencies can be mitigated, but only to a degree, as long as Guantánamo remains open. Lack of torture rehabilitation services, for which there is widespread and urgent need, cannot be remedied at all—at least not in a meaningful way—in a facility antithetical to the core requirements for effective treatment (including instilling a felt sense of safety and allowing the victim control over elements of the rehabilitation context, content and process).

Stepping back, all of this is yet another reason why Guantánamo should be closed. Recognizing that day is a long way off, though, we recommend a series of steps that one or more of the executive branch, Congress and the courts can take at least to improve the status quo in the interim. They include:

Lift the legal ban on transferring detainees to the United States and mandate such transfers when detainees present with medical conditions that cannot be adequately evaluated and treated at Guantánamo.

Ensure detainees have timely and full access to all of their medical records upon request, including when requested through counsel or another authorized representative, while otherwise maintaining confidentiality of those records (especially with regard to access by prosecutors).

Create the new role of chief medical officer at Guantánamo—a senior civilian physician who would oversee the provision of medical care to detainees, report outside the Guantánamo chain of command, and have final decision-making authority over any decision related to medical care for detainees and medical accommodations to detention conditions of confinement and operating procedures.

Allow meaningful and regular access to Guantánamo by civilian medical experts, including permitting such experts to evaluate detainees in an appropriate setting.

In a welcome sign, both Democrats and Republicans in Congress have begun to acknowledge, to varying degrees, the medical care crisis at Guantánamo and are working toward pursuing some legislative improvements consistent with what we recommend. Of particular note, the annual defense authorization bill (NDAA) as reported out of the Republican-led Senate Armed Services Committee (SASC) would create a chief medical officer for Guantánamo very much along the lines we suggest. The SASC bill would also, as it has in year’s past, create an exception to the statutory ban on U.S. transfers for detainees who require emergency medical care that Guantánamo cannot adequately provide.

The House Armed Services Committee’s companion bill, while much more ambitious on Guantánamo in critical respects—like prohibiting the administration from sending new detainees there, and dropping the U.S. transfer restrictions altogether—is surprisingly less robust on medical care specifically. The bill includes a sense of Congress on the provision of medical care at Guantánamo that does not sufficiently reflect the scope or gravity of the problems, and it calls for a report by the Government Accountability Office on the quality of medical care detainees receive—a positive development in a vacuum, but far less so if it serves to delay (or worse yet displace) other legislative changes that can and should be made now.

There is a long way to go before the NDAA becomes law—including consideration on the floor in both chambers and subsequent conference negotiations to reconcile the versions that the House and Senate pass, respectively—which presents both opportunities and risks. I hope lawmakers will look to protect, and where possible enhance, the types of medical care provisions that we are recommending at every turn. The problems our report identifies will only worsen over time. If left unaddressed, as our report warns, “complex medical conditions that cannot be managed at Guantánamo should be expected to accelerate in frequency and escalate in severity.” The costs of such inaction, first and foremost for the remaining detainees, but also for the United States, would be devastating.

Image: The detainee hospital’s operating room is seen in Camp Delta which is part of the U.S. military prison for ‘enemy combatants’ on June 26, 2013 in Guantanamo Bay, Cuba. Photo by Joe Raedle/Getty Images