1. There is a debate, especially at Tuskegee University, over whether the study should be called the Tuskegee Study or the United States Public Health Service Study of Untreated Syphilis in the Male Negro at Tuskegee to mesh the researchers who did the study with its more formal title. Since it is primarily known as the Tuskegee Study, I use the term “Tuskegee” in quotes or just refer to it as the “study.”
2. Reverby, Susan M., Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill, 2009), 187–203.
3. There was also a debate well into the 1950s over whether penicillin should be given to those in the late latent stage of the disease. The standard of care was to decide this on an individual basis. This was not done in the study. The issue of whether any of the wives/sexual partners of the men were treated is still controversial. The now-available medical records (in the Southeast Regional National Archives in Morrow, Georgia) have the wives’ treatment status blacked out to protect their privacy, making it impossible to evaluate claims that there had been some treatment for wives found to be in the contagious stage. When the study ended, the PHS agreed to treat twenty-two wives, seventeen children, and two grandchildren who tested positive for syphilis. For more on how this was determined, see Reverby, Susan M., “The ‘Tuskegee’ Syphilis Study as a ‘Site of Memory,’” in The Search for the “Legacy” of the U.S. Public Health Syphilis Study at Tuskegee, ed. Katz, Ralph and Warren, Rueben (Lanham, Md., forthcoming).
4. Jones, James H., Bad Blood, rev. ed. (New York, 1993); Reverby, Susan M., ed., Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study (Chapel Hill, 2000); Reverby, Examining Tuskegee.
5. For more details and a timeline of the study, see http://www.examiningtuskegee.com. The study was not a secret. More than a dozen research articles were published about it in various medical journals.
6. Portelli, Alessandro, The Death of Luigi Trastulli and Other Stories (Albany, N.Y., 1990), 2.
7. Sociologist Tamotsu Shibutani, quoted in Whispers on the Color Line: Rumor and Race in America, ed. Turner, Patricia and Fine, Gary Alan (Berkeley and Los Angeles, 2004), 58–59.
8. The stereotype of black men as overly sexualized also needs to be confronted.
9. Reverby, Susan M., “More than Fact and Fiction: Cultural Memory and the Tuskegee Syphilis Study,” Hastings Center Report 31 (September–October 2001): 22–28.
10. For various versions of this argument, see Benedek, Thomas G. and Erlen, Jonathan, “The Scientific Environment of the Tuskegee Study of Syphilis, 1920–1960,” Perspectives in Biology and Medicine 45 (Autumn 1999): 1–30; Richard Shweder, “Tuskegee Re-Examined,” Spiked online, www.spiked-online.com, 8 January 2004; White, Robert W., “Unraveling the Tuskegee Study of Untreated Syphilis,” Archives of Internal Medicine 160 (13 March 2000): 585–98.
11. Sherwood, Joan, “Syphilization: Human Experimentation in the Search for a Syphilis Vaccine in the Nineteenth Century,” Journal of the History of Medicine 54 (July 1999): 364–86; and Lederer, Susan E., Subjected to Science: Human Experimentation in America Before the Second World War (Baltimore, 1995).
12. The records were donated to the University of Pittsburgh Archives Service Center in 1990, three years before Cutler appeared in the NOVA video “Deadly Deception.” The records are now closed and are being evaluated to see if they should become federal property. If so, they will be moved to the National Archives.
13. Cueto, Marcos, The Value of Health: A History of the Pan American Health Organization (Washington, D.C., 2007) argues that the immediate postwar era was a major point in “inter-American” public health exchanges; see also Pan American Bureau, Sanitary, The Pan American Sanitary Bureau: A History of Its Organization, Function, and Activities (Mexico City, 1946). On the expansion of social welfare during the liberalization of politics in Guatemala between World War II and before the CIA-backed coup in 1954, see Jonas, Susanne, The Battle for Guatemala: Rebels, Death Squads, and U.S. Power (Boulder, 1991), 21–40.
14. Ackerman, Jan, “Obituary: John Charles Cutler/Pioneer in Preventing Sexual Diseases,” Pittsburgh Post-Gazette, 12 February 2003, www.post-gazette.com. For more on Cutler’s career, see Reverby, Examining Tuskegee, 144–51.
15. Pubmed lists his name on fifty-eight articles published between 1946 and 1995.
16. “The Deadly Deception,” NOVA. Videotape, PBS. Directed by Denise DiIanni. Boston: WGBH Educational Foundation Films for the Humanities and Sciences, 1993.
17. After I gave a copy of this article pre-publication (see addendum) to Centers for Disease Control and Prevention officials, Dr. John Douglas was sent to look at the records in Pittsburgh. His report, “Findings from a CDC Report on the 1946–1948 U.S. Public Health Service Sexually Transmitted Disease (STD) Inoculation Study,” (http://www.hhs.gov/1946inoculationstudy/findings/html (accessed 11 October 2010), examined the medical records more closely. Dr. Douglas reports:
1. “In the series of syphilis studies, a total of 696 subjects or individual experiments … were exposed to infection (by sexual contact or inoculation). Of these, 427 (61%) were judged to be infected, of whom 369 (86%) received what was considered to be ‘adequate treatment’ with injections of penicillin (defined by the investigators as ≥ 3.4 million units.”
2. “In the series of gonorrhea studies, a total of 772 subjects of individual experiments … were exposed to infection (by sexual contact or inoculation). Of these, a summary report and experimental logs indicate that 234 (30%) were infected, 233 (99.5%) of whom were stated to have received treatment with injections of penicillin (300,000 units).”
3. In the “chancroid studies … a total of 142 subjects were exposed to infection by inoculation. Of these, a summary report and experimental logs indicate that 128 (97%) were infected, 129 (93%) of whom were stated to have received treatment with sulfathiazole (1 gram PO per day for 5 days).”
18. Tomes, Nancy, “Introduction: Imperial Medicine and Public Health,” in Colonial Crucible: Empire in the Making of the Modern American State, ed. McCoy, Alfred W. and Scarano, Francisco A. (Madison, 2009), 273–76.
19. Dowling, Harry F., Fighting Infection: Conquests of the Twentieth Century (Cambridge, Mass., 1977), 125–57; Parascandola, John, Sex, Sin, and Science (New York, 2008).
20. Quoted in Reverby, Examining Tuskegee, 139. The leftover questions about the biology of syphilis have resurfaced with those who think there is a connection between untreated syphilis and HIV/AIDS. See Coulter, Harris L., AIDS and Syphilis—The Hidden Link (Berkeley and Los Angeles, 1993); and Coleman Jones, “Challenging Dissident Dogma: The Role of Infectious Co-Factors in AIDS,” http://breakfornews.com/aidsmyth./news/000529syphilisdebate.htm (accessed 19 March 2010).
21. Cutler, John C., “Current Concepts of Prophylaxis,” Bulletin of the New York Academy of Medicine 52 (October 1976): 866–96. For the counterview to the position on prophylaxis taken by Cutler and the PHS, see Moore, Joseph Earle, The Modern Treatment of Syphilis, 2nd ed. (Springfield, Ill., 1943), 564–67. On tensions between the PHS doctors and Moore, see John F. Mahoney to John C. Cutler, 19 April 1948, Box 1, Folder 13, John C. Cutler Papers, University Archives, University of Pittsburgh, Pittsburgh, Pa. (hereafter, Cutler Papers).
22. Inoculum was both cultured and taken from the penis of one infected man and put into the penis of another. See Mahoney, John F. et al. , “Experimental Gonococcic Urethritis in Human Volunteers,” American Journal of Syphilis, Gonorrhea, and Venereal Diseases 30 (January 1946): 1–39. For more on the policy debate over the Terre Haute research, see Marks, Harry M., The Progress of Experiment (New York, 1997), 100–105. On a revived interest in prison research, see Institute of Medicine, Ethical Considerations for Research Involving Prisoners (Washington, D.C., 2006); Lerner, Barron H., “Subjects or Objects? Prisoners and Human Experimentation,” New England Journal of Medicine 356 (3 May 2007): 1806–7.
23. Brand, Jeanne L., “The U.S. Public Health Service and International Health,” Bulletin of the History of Medicine 63 (Winter 1989): 582–83.
24. Hugh S. Cumming, who had been the surgeon general when the “Tuskegee” Study began, served as the director of the Pan American Sanitary Bureau from 1936 (when he left the PHS) to 1947. See Chester Williams, Ralph, The United States Public Health Service, 1798 to 1950 (Washington, D.C., 1951), 446.
25. Cueto, Marcos, “Introduction,” in Missionaries of Science: The Rockefeller Foundation and Latin America (Bloomington, 1994), xiii.
26. See Jonas, Battle for Guatemala; Kinzer, Stephen and Schlesinger, Stephen, Bitter Fruit: The Story of the American Coup in Guatemala (Cambridge, Mass., 1999); McBride, David, Missions for Science (New Brunswick, 2002).
27. Cheever Shattuck, George, “Syphilis and Yaws in Guatemala,” in A Medical Survey of the Republic of Guatemala, ed. Cheever Shattuck, George (Washington, D.C., 1938), 142. Shattuck also summarizes medical beliefs about racial differences in the virility and existence of syphilis. See “Appendix B, The Clinical Case of Syphilis in Various Races,”153–56; see also Cheever Shattuck, George, “Lesions of Syphilis in American Indians,” American Journal of Tropical Medicine 18 (1938): 577–86. On the use of race to matter and not matter, see Reverby, Examining Tuskegee. See also Frazier, Chester North and Hung-Chiung, Li, Racial Variations in Immunity to Syphilis: A Study of the Disease in the Chinese, White, and Negro Races (Chicago, 1948).
28. “Untitled Report,” 24 February 1954, Folder 1, Box 1, Cutler Papers.
29. Ibid., 2, and Sherwood, “Syphilization.”
30. On the search for a better prophylactic, see Arnold, R. C. and Cutler, John C., “Experimental Studies to Develop Local Prophylactic Agents Against Syphilis,” British Journal of Venereal Diseases 32 (1956): 34–36. For directions on how to use a World War II pro-kit if infection was suspected, see http://med-dept.com/vd.php (accessed 23 March 2010).
31. “Untitled Report,” 6.
32. Ibid., 7.
33. John C. Cutler to R. C. Arnold, 5 June 1947, Box 1, Folder 13, Cutler Papers. Unless otherwise noted, all correspondence is in this folder.
34. Elliott L. Harlow to John M. Mahoney, 30 June 1947.
35. Levitan, Sacha et al. , “Clinical and Serologic Studies with Reference to Syphilis in Guatemala, Central America,” American Journal of Syphilis, Gonorrhea, and Venereal Diseases 36 (July 1952): 379.
36. Cutler believed that widespread liver disease in Guatemala due to malnutrition might also affect the tests.
37. “Untitled Report,” 16.
38. Ibid., 5, and Levitan et al., “Clinical and Serologic Studies,” 379.
39. Levitan et al., “Clinical and Serologic Studies,” 387. They argued that “significantly higher percentages of positive and doubtful reactions were obtained from Kahn and Mazzini tests than with the Kolmer test and the VDRL slide test.” Today, syphilis serological diagnosis requires a reactive nontreponemal test confirmed with a treponemal test.
40. “Untitled Report,” 24.
41. Ibid., 25.
42. Ibid., 32.
43. For a discussion of the various strains of the disease used, see “Part II Final Syphilis Report,” p. 1-5, Box 1, Folder 2, Cutler Papers.
44. “Untitled Report,” 48. See also instructions from R. C. Arnold to John C. Cutler, 21 July 1947. On the history of various kinds of inoculation techniques, see Magnuson, Harold J. et al. , “Inoculation Syphilis in Human Volunteers,” Medicine 35 (February 1956): 33–82. On the difference with gonorrhea inoculation, see Mahoney et al., “Experimental Gonococcic Urethritis in Human Volunteers.” Cutler was a co-author on both of these articles. Prison studies seem to use the term “human volunteers” in their titles.
45. Cutler to Mahoney, 27 December 1947.
46. I did not tally up all these numbers. I am grateful to Dr. John Douglas of the CDC for this information in his report. See note 17.
47. Cutler to Arnold, 5 June 1947.
48. Cutler to Arnold, 27 June 1947.
49. Benison, Saul, Tom Rivers: Reflections on a Life in Medicine and Science, An Oral History Memoir prepared by Saul Benison (Cambridge, 1967), 187.
50. John C. Cutler, “An Experimental Resurvey of the Basic Factors Concerned in Prophylaxis in Syphilis,” unpublished typescript, Box 1, Folder 9, Cutler Papers.
51. “Part III Final Syphilis Report,” p. 25, Box 1, Folder 3, Cutler Papers.
52. “Untitled Report,” 34–39; see also note 17.
53. Brandt, Allan M., No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880 (New York, 1987, 1993). By 1950, the VDRL stopped all research on chemical prophylaxis. See Cutler, John C., “Current Concepts of Prophylaxis,” Bulletin of the New York Academy of Medicine 52 (October 1976): 886–96.
54. Mahoney to Cutler, 18 November 1946; Cutler to Mahoney, 30 November 1946; Mahoney to Cutler, 18 December 1946.
55. Cutler to Mahoney, 18 September 1947.
56. Lederer, Subjected to Science, 82–87, on Hideyo Noguchi’s controversial syphilis experiments at the Rockefeller Institute in New York in 1911.
57. John F. Mahoney to John C. Cutler, 15 October 1946.
58. Mahoney to Cutler, 5 May 1947. Eagle was then working at the National Cancer Institute and this may have been part of a turf battle with the PHS. There is no evidence that Eagle ever participated in the Guatemala work.
59. Mahoney to Cutler, 11 August 1987. Mahoney concluded: “It is becoming obvious also that experimental infection cannot be produced with sufficient frequency to assure an adequate background for the study of prophylaxis.”
60. Mahoney to Cutler, 8 September 1947.
61. Niemela, Jussi, “What Puts the ‘Yuck’ in the ‘Yuck Factor,” Bioethics, online 25 February 2010, www3.interscience.wiley.com (accessed 25 March 2010).
62. R. C. Arnold to Cutler, 19 April 1948, Box 1, Folder 17, Cutler Papers.
63. The National Research Council, established in 1916, oversees scientific research policy for the U.S. government and had a subcommittee of the Committee on Medical Research during World War II that specifically focused on venereal disease research. See Marks, Progress of Experiment, 100–105.
64. G. Robert Coatney to Cutler, 17 February 1947, Box 1, Folder 17, Cutler Papers.
65. Cutler to Mahoney, 17 May 1947, Box 1, Folder 11, Cutler Papers.
66. Mahoney to Cutler, 30 June 1947. The Doctors’ Trial at Nuremberg was taking place between 9 December 1946 and 20 August 1947, although neither Mahoney nor Cutler mentioned it in their correspondence.
67. Mahoney to Cutler, 8 September 1947, Box 1, Folder 13, Cutler Papers.
68. Arnold to Cutler, 30 July 1947, Box 1, Folder 11, Cutler Papers.
69. Levitan, Sacha et al. , “Clinical and Serologic Studies with Reference to Syphilis in Guatemala Central America I,” American Journal of Syphilis, Gonorrhea, and Venereal Diseases 36 (July 1952): 379–87; John C. Cutler et al., “Studies on the Comparative Behavior of Various Serologic Tests for Syphilis II,”ibid. 36 (November 1952): 533–44; Joseph Portnoy et al., “Clinical and Serologic Studies with Reference to Syphilis in Guatemala, Central American III,”ibid. 36 (November 1952): 566–70.
70. Funes, Juan et al. , “Serologic and Clinical Studies in Syphilis in Guatemala, Central America, II,” Boletín de la Oficina Sanitaria Panamericana 34 (January 1953): 14–18.
71. Magnuson et al., “Inoculation Syphilis.” One of the other physicians on this project was Sidney Olansky, who had directed the work in Tuskegee in the 1950s. For more on Olansky and Cutler, see Reverby, Examining Tuskegee.
72. See Anderson, Warwick, “Pacific Crossings: Imperial Logics in United States’ Public Health Programs,” in Colonial Crucible, ed. McCoy, and Scarano, , 277–87.
73. There is a huge bioethics and policy debate on this issue. See, for example, Hawkins, Jennifer S. and Emanuel, Ezekiel J., eds., Exploitation and Developing Countries: The Ethics of Clinical Research (Princeton, 2008); Macklin, Ruth, Double Standards in Medical Research in Developing Countries (Cambridge, 2004); and Reverby, Examining Tuskegee, 228–30.
74. The issue of human-subject protection is even more relevant now as the percentage of foreign trials for drugs in the United States has become more common. See Harris, Gardiner, “Concern over Foreign Trials for Drugs Sold in U.S.” New York Times, 21 June 2010, A14; Petryna, Adriana, When Experiments Travel: Clinical Trials and the Global Search for Human Subjects (Princeton, 2009).
75. For more details, see Reverby, Susan M., “After the Media Frenzy: Preventing Another ‘Guatemala,’” Bioethics Forum: A Service of the Hastings Center, 6 October 2010, http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4919&blogid=140 (accessed 6 October 2010).
76. John M. Douglas, “Full Centers for Disease Control and Prevention Report on the 1946–1948 U.S. Public Health Service Sexually Transmitted Disease (STD) Inoculation Study,” http://www.hhs.gov/1946inoculationstudy (accessed 15 October 2010).
77. “Joint Statement by Secretaries Clinton and Sebelius on a 1946–1948 Study,” http://www.hhs.gov/1946inoculationstudy (accessed 15 October 2010).
78. “Read-out of the President’s Call with Guatemalan President Colom,” http://www.hhs.gov/1946inoculationstudy (accessed 15 October 2010).
79. Frieden, Thomas R. and Collins, Francis S., “Intentional Infection of Vulnerable Populations in 1946–1948,” Journal of the American Medical Association, published online 11 October 2010. doi:10.1001/jama.2010.1554 and http://www.hhs.gov/1946inoculationstudy.
I am grateful to Marianne Kasica at the University of Pittsburgh Archives for her assistance in doing what archivists are supposed to do: make the papers in their archives available to legitimate researchers. Thank you to Zachary Schrag for his editing, encouragement, and questions, as well as those of my colleagues who heard this paper when I first presented it at the annual meeting of the American Association for the History of Medicine in May 2010. I also appreciate the comments of former CDC director Dr. David Sencer, who did not know the details of this study, which did not take place on his watch. Without his concern, connections, and respect for the importance of history, knowledge of this study might never have garnered such an extraordinary response. Dr. John Douglas of the CDC did an amazing report on short notice that confirmed my work and provided the clear statistics on the subjects. I am grateful to the U.S. government officials who saw the wrongs here and stepped forward to acknowledge them. I appreciate all those who took the time to think about this, to communicate their concern publicly and privately, and to be part of the continued struggle for the balance of human rights and medical progress.
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