Reviewing Camp X-Ray - Guantanamo Bay, Cuba
Author Margaret Bone takes you behind the scenes to learn how U.S. military services, working together, converted a sleepy Caribbean base into a high-profile detention center with quality medical facilities in mere weeks.
By Margaret Bone

When the catastrophic events of Sept. 11 ripped through our nation, few people knew what the future would bring. Yet at Camp Lejeune, N.C., a Marine officer was willing to bet on one thing. Within hours of the terrorist attack, Brig. Gen. Michael Lehnert called his Marines together and said, "The United States will not stand for these actions. We are going to do something, and it's going to be dramatic. ... There will be [prisoners] we have to do something with, and the most likely place for that will be Guantanamo Bay." With that pronouncement, Marine contingency plans were pulled out, dusted off, and quickly revised for the call that was sure to come.

Meanwhile, the base commander at U.S. Naval Base Guantanamo Bay (GTMO), Cuba, Navy Capt. Bob Buehn, was receiving flash messages from U.S. Southern Command in Florida to go to Threat Condition Delta, the most extreme defensive posture for the base, while his office staff was watching the attacks on the World Trade Center towers and the Pentagon on television. The isolated base was about to change.

"This was a very sleepy little place," Buehn remembers. "It had been consciously reduced to minimum budgeting by the Navy to keep the lights on but not much else. Our requirements were to maintain the channel, keep the refueling ability of the port, and maintain the perimeter fence line between the base and Cuba."

By December, GTMO had been chosen for the incarceration of captured terrorists, by then officially labeled detainees, because, in Secretary of Defense Donald Rumsfeld's words, Guantanamo was "the least worst place." It would not be the first time the base had hosted displaced persons. During the migrant crisis in the mid 1990s, more than 40,000 Haitians and Cubans were encamped there. Lehnert had commanded the joint task force assigned to set up and run the migrant camps in Operation Sea Signal, and his knowledge of the base would soon pay dividends.

Buehn and Lehnert met in Guantanamo in late December 2001 to evaluate the new mission. At the time of the attacks, only 700 of the 2,700 residents at GTMO were active duty military. "We quickly got 50 Navy reservists in here to augment our security but still didn't know what role we would play because of the attacks," Buehn says. Once that role became clear, the new Joint Task Force (jtf) 160, a group of 1,700 military personnel assembled from the five armed services, was formed and placed under Lehnert's command. The base and its foreign nationals - a much-needed and highly respected workforce - would support the task force.

Lehnert also pulled Marine personnel from his command at Lejeune, the 2nd Force Service Support Group (fssg), to fill staff positions and form the nucleus of the task force. The Marine Corps fssg is responsible for performing migrant or detainee operations as one of its expeditionary missions. It would, in a matter of days, start running the detention facility that was to be called Camp X-Ray. "My guidance from the Joint Staff was to build a temporary holding facility that was humane but not comfortable," Lehnert says. "We returned to stay [Jan. 6], and by the 11th, we had the first group of detainees, with all the attendant media attention and force-protection responsibility."

Camp X-Ray, isolated on a far end of the base at the foot of the Cuban hills, was built with hurricane fencing and locally scavenged poles, with concertina wire around the perimeter. The small individual cells were contiguous, roofed, and surrounded by more fencing. Inside the compound were toilet and shower facilities that detainees were allowed to use at certain times. For transport to the plywood interrogation buildings on the edge of the camp, the shackled detainees were driven in white golf carts that looked oddly, almost comically, misplaced in the desolate, silent setting.

It is the medical aspect of this operation that may well go down in the record books. Much of what has transpired at GTMO since December 2001 has required innovation from the forces charged with the detainee mission; nowhere is this more evident than in military medicine and public health. While a fleet hospital would be dispatched to GTMO for treating detainees, it would not be ready before the first detainees arrived. Additionally, the influx of detainees was projected to swell the base population to 5,000 - more than double what the hospital was accustomed to dealing with.

"When we understood that our naval hospital would be taking care of dangerous people, I sent personnel to Puerto Rico to see how the federal prison there provides health care," says Capt. Albert J. Shimkus Jr., commanding officer of the U.S. Naval Hospital at GTMO. "We literally had no experience in providing care to a dangerous population."

Another aspect of the looming mission was how to deal with critically injured detainees. As head of a small community hospital with fewer than 25 beds and a staff of 160, Shimkus normally would medevac patients to the mainland when they required a greater level of care than the base hospital could provide. With the detainees, that would not be an option except in the most extraordinary cases.

An intensive care unit was created for the worst cases among the detainees. As wave after wave of detainees arrived, usually in groups of 30 so as not to overwhelm security forces, the extent of medical needs became clear. "Many of these individuals came in with horrific wounds - some requiring amputation. There was frostbite, tuberculosis (tb), malaria, even fungal pneumonia," Lehnert recounts. A few were underweight and malnourished, but as Shimkus says, "The detainees are survivors."

In accordance with standard medical practice, the hospital would perform no procedure or operation without the consent of the patient. Surgical procedures have included amputations, the removal of an eye, and extensive debriding and dressing of wounds, but on at least one occasion, consent was withheld for needed surgery.

Specialists are not on staff but are flown in from the mainland for a day of surgery, then flown back out.

Malaria and TB, diseases now seldom seen in the Western hemisphere, became pivotal concerns for Shimkus. "Forty percent of the population in Afghanistan has malaria. Malaria has been eradicated from Cuba for 50 years. We needed infectious-disease specialists to advise us, because we didn't want to reintroduce malaria or tb into Cuba," he explains. The base consulted with the Centers for Disease Control in Atlanta and the Armed Forces Medical Intelligence Center at Fort Detrick, Md., and Shimkus' staff went through special classes on identifying the symptoms of these diseases. The base also embarked on a robust program to eradicate mosquitoes, whose bite can transfer malaria. The camp is sprayed at dawn and sunset to kill the insects. The detainees receive antimalaria pills, and their orange uniforms are treated with antimosquito repellant. Among the arriving detainees, at least four cases of malaria and active tb have been confirmed and treated.

With 33 nationalities represented among the more than 300 detainees, there are major translation issues for the medical personnel and the security forces. Because interpreters are in high demand and not always available, Shimkus and Capt. Pat Alford, usn, commander of the fleet hospital put up near the coastline, have had to devise novel ways to communicate with their patients. "You can ask simple questions in English, 'Are you in pain? Are you hungry, thirsty?' and with gestures and facial expression ascertain if they are," Alford explains. The medical staff also uses flash cards with English and Afghan phrases. According to Alford, "Many of the detainees are sophisticated individuals and even speak some English or have a rudimentary understanding of it."

As the buildup continued, the presence of Alford's newly erected fleet hospital marked the Navy's first use of the modular medical unit. Originally designed as a 500-bed expeditionary facility, it was reduced in size to meet the needs at GTMO. The series of hospital tents were joined at 90 degree angles and could be expanded or reduced to provide room for the necessary security provisions and personnel.

All of the incoming medical staff had to learn about providing care for patients who were under guard and considered dangerous - while functioning in a fleet hospital setting that had never been deployed before. The challenges were substantial, but many detainees have thanked the medical staff. "They recognize it's the best medical care they've ever received and that we are doing things that are helpful. By and large, they have been cooperative," Shimkus observes.

While Shimkus and Alford were concerned with both treating the detainees and keeping their diseases from reaching the general population, Buehn and Lehnert also faced a two-sided issue: The detainees had to be incarcerated, but they also needed to be protected from external attack. Lehnert explains, "We're concerned about someone trying to get them out, and we're also concerned that we may have someone in here who knows a great deal more than we have determined, and for that reason, there may even be an effort to silence that person. So in that respect we are defending the detainees as much as the troops and family members here."

The family members on base fell into two categories, according to Buehn - those who were afraid they would be evacuated and those who were afraid they wouldn't be. Buehn had to reassure both groups and keep the base, with its small-town friendliness, scout troops, and soccer practices, running smoothly while a buildup was doubling the requirements for food, housing, and security.

Antiterrorism force protection exercises have become commonplace at GTMO, Buehn says. The exercises keep people on their toes and highlight any command and control "seams" that may need to be tweaked to keep base security tight. Roadblocks and id card checks are among the few obvious changes.

Security was beefed up on the water also. "I needed a mobile, inshore, undersea warfare unit to give me eyes and ears for looking into the water," Lehnert explains. "Also, there was need for an interdiction capability on the water, as well as port security, and the Coast Guard provides that with six 22-foot Boston Whalers. The Army provides internal security at Camp X-Ray and other locations.

"We have a high number of reservists here, because the Army has a large population of its military policemen in the reserves," Lehnert continues. The perimeter security for the fence line that demarcates the base from Cuba always has been assigned to Marines, many of whom are reservists. Also, active duty Marines were brought in to handle perimeter security around Camp X-Ray and other assigned areas.

Offering medical aid to those responsible for the carnage of Sept. 11 could have been difficult for the GTMO staff. "But," says Shimkus, "All of our uniformed people on this island have stepped up to the task. Certainly many personnel have feelings about ... providing care to people who are part of an organization that has done great harm to us. It can cause some emotional and intellectual turmoil." He called in the Department of Defense "Sprint Team," which responds to catastrophic events and helps with coping skills and emotional healing.

The medical and security staff assigned to this mission also faced a significant cultural question. "We made a decision early on that all our military women would continue to function in their normal roles," Alford says. The fleet hospital setup includes a pre-identified staff, and many are female corpsmen, nurses, administrators, and physicians. "[The detainees'] culture doesn't have females dealing with medical issues for men, but the detainees have accepted that we do, and it's become a nonissue."

While the ultimate fate of the detainees remains problematic, the temporary facilities at Camp X-Ray were always just that - temporary. The detainees now have been moved into more permanent facilities at the new Camp Delta; each cell includes a bed, sink, and toilet.

And as events continue to unfold, certainly the wisdom of having a voluntary military force is being underscored. High standards of professional excellence - even in the very face of the enemy - are hallmarks of a force committed to carrying out the national will, whether that force is participating in combat in Afghanistan or guarding and treating detainees in Cuba.