A court decision this week to leave Georgia's ex-President Mikheil Saakashvili in custody despite his worsening health has left his supporters in despair and others anticipating more tensions.

In a February 6 decision, the court denied the motion to defer Saakashvili's sentence or release him amid his deteriorating health. The government has been treating the ex-president's request as illegitimate, and the current president has ruled out pardoning him, leaving his family and political allies out of options on how to get him abroad for treatment. 

"I've basically got a death sentence and will stay in prison with all the lethal diseases and on a court verdict that nobody in the world except Russia recognizes," Saakashvili said in an English Facebook post in response to the ruling. "Putin promised to hang me 'by [my] balls' and looks like he is rendering [this] through his proxy Russian Oligarch Ivanishvili."

That was a reference to Bidzina Ivanishvili, the billionaire founder of the ruling Georgian Dream party, which ousted Saakashvili's government in 2012.

Saakashvili was arrested late in 2021 after he smuggled himself into the country following eight years of self-imposed exile, spent mostly in Ukraine. He had been convicted in absentia and sentenced to six years in prison on two abuse of power charges and is standing trial on two others; he separately faces charges for illegal border crossing.

Immediately after his arrest, Saakashvili went on a 50-day hunger strike that left him in poor health. He has been undergoing treatment in Tbilisi's Vivamedi hospital since last May.

Concerns started growing in late 2022 amid reports that he had lost more than 40 kilos while in custody at Vivamedi. Early in December, a group of independent doctors assembled by Georgia's public defender diagnosed Saakashvili with multiple physical and cognitive ailments, including cachexia, a syndrome associated with muscle loss. 

They said Saakashvili was suffering from an underlying syndrome which they could not diagnose given the limits of the Georgian healthcare system and warned that the damage could become irreversible in two to three months. Based on their report, Georgia's then-Public Defender Nino Lomjaria vouched for the deferral of his sentence on health grounds, and many hoped this would lead to his transfer abroad for treatment. 

Over the past few weeks, Saakashvili's allies have attributed his recent health deterioration to alleged heavy metal poisoning while in jail. Vivamedi's doctors, while confirming weight loss and expressing fears of a fatal outcome, have pointed at the patient's unwillingness to take food. 

But Tengiz Tsuladze, one of the doctors from the public defender’s group said during his February 1 court testimony that Saakashvili's condition was to blame for his low food intake. "Anorexia and cachexia cause nausea and loss of appetite. This cannot be controlled by the patient," he said.

His poor health and weight loss were further confirmed during two of his remote court appearances and in controversial video recordings from the hospital ward showing him in an emaciated state that drew shocked reactions from around the globe. 

But this did not seem to help his case. Fifteen hearings later, the court ruled against granting the deferral of his sentence, a decision many connect to the government's widely perceived influence over the judiciary. One of the critics of the court's decision was the largely figurehead president, Salome Zourabichvili. 

"With this decision, the Georgian people have been sentenced to be stuck in a closed circle and remain hostage to this situation," she said in a February 7 statement.

Zourabichvili said the Saakashvili issue was discrediting the country and diverting attention and resources from other pressing problems. Yet she ruled out pardoning the ex-president, arguing that would not grant him freedom as he is awaiting trial on three separate charges, and that he has not shown any remorse for the crimes he's been convicted of. (Some have criticized this stance, arguing that a pardon would at least pressure the court to release him from pre-trial custody). 

Desperate to save the ex-president, his family is considering taking the case to the European Court of Human Rights in Strasbourg. The United National Movement, the party Saakashvili founded, which is currently embroiled in a leadership crisis, announced another boycott of parliament sessions in response to the court ruling and pledged to hold permanent rallies across Georgia.

But only one other opposition party joined the boycott, and rallies seem unlikely to yield results given the poor track record of Georgia's many political protest campaigns in recent years.

The issue has attracted wide international attention. Concerns have been coming from Eastern European capitals, where governments have offered to assist with Saakashvili's transfer abroad for treatment. Particularly strident was Kyiv (Saakashvili is a Ukrainian citizen), with President Volodymyr Zelensky tweeting earlier this month that Saakashvili was "being slowly killed" and was being subjected to a "de facto public execution."

The EU Parliament has also been calling for his release on humanitarian grounds and as a means to reduce political polarization in Georgia. Reducing polarization is number one on the list of 12 priorities the EU told Georgia to address in order to be granted membership candidate status. 

EU and U.S. officials have repeatedly said they were watching the issue closely and that the government was responsible for Saakashvili's health and wellbeing.

The Georgian authorities, however, say it is Saakashvili's attempts to evade justice through self-harm and fakery that have brought about the current situation.

"The justice minister offered to invite any foreign doctor to come take care of the inmate. There was no reaction to that, right?" Irakli Kobakhidze, chairman of the ruling Georgian Dream party, told the Georgian Public Broadcaster on February 8, going on to sarcastically suggest that perhaps "it's Georgia's air that adversely affects his health."

Over the past few days, pro-government media have actively circulated a contract and a form recently uploaded by Akerman LLP, a U.S. law firm, in the U.S. Foreign Agent Registration Act register showing the firm was paid more than $900,000 by Saakashvili's family to receive legal representation, but also international political advocacy services and assistance to get expertise from U.S.-based doctors.

The contract shows that "the campaign concerning the release of Mikheil Saakashvili is fully dictated by political objectives, there is nothing medical in it," Kobakhidze said. "There is a single political objective – to free Mikheil Saakashvili so that unrest breaks out in the country, and the ultimate objective is [to open] a second front," he added, referring to the ruling party's conspiracy theory that the U.S. and the West seek to drag Georgian into the Ukraine war.