The Tuskegee Syphilis Experiment, commonly called The Tuskegee Study, was a peculiarly American tragedy, and it ultimately played a key role in creating the institutions and practices that today govern the use of human volunteers in U.S. biomedical research.1-3 From 1932 until 1972, the U.S. Public Health Service (PHS), aided and abetted by a number of partners, conducted a nontherapeutic study of the effects of untreated syphilis on more than 400 black men in Macon County, Alabama, in and around the county seat of Tuskegee. While PHS officers and other participating physicians performed a variety of tests and medical examinations on the men over the years, the Tuskegee Study in essence was a 40-year deathwatch. Only men with advanced cases of syphilis were selected for study, and the men were left largely untreated. Instead, the Tuskegee Study’s basic procedures called for periodic blood tests and routine autopsies to supplement the information obtained through regular clinical examinations. The fact that only men with advanced syphilis were selected for the study indicated that the PHS officers were eager to learn more about the serious complications that the disease inflicts on its victims. To comprehend the magnitude of the risks to the men from denying them adequate treatment, it is useful to know a few basic facts about the disease.
Syphilis is a highly contagious disease caused by the Treponema pallidum, a delicate bacterium that is microscopic in size and resembles a corkscrew in shape. The disease may be acquired or congenital. In acquired syphilis, the spirochete (as the Treponema pallidum is also called) enters the body through the skin or mucous membrane, usually during sexual intercourse, though infection may also occur from other forms of bodily contact, such as kissing. Congenital syphilis is transmitted to the fetus from the infected mother when the spirochete penetrates the placental barrier.
From the onset of infection, syphilis is a generalized disease involving tissues throughout the entire body. Once they wiggle their way through the skin or mucous membrane, the spirochetes enter the lymph capillaries where they are hurried along to the nearest lymph gland. There they multiply at a rapid rate and work their way into the bloodstream. Within days the spirochetes invade every part of the body.
Three stages mark the natural history of the disease: primary, secondary, and tertiary. The primary stage lasts from 10 to 60 days starting from the time of infection. During this first incubation period, the primary lesion of syphilis, the chancre, appears at the point of contact, usually on the genitals. The chancre, typically a slightly elevated, round ulcer, rarely causes personal discomfort and may be so small as to go unnoticed. If it does not become secondarily infected, the chancre will heal without treatment within a month or two, leaving a scar that persists for several months.
While the chancre is healing, the second stage begins. Within six weeks to six months, a rash appears, signaling the onset of secondary syphilis. The rash may resemble measles, chicken pox, or any number of skin eruptions, though occasionally it is so mild as to evade notice. Bones and joints often become painful, and circulatory disturbances, such as cardiac palpitations, may develop. Fever, indigestion, headaches, or other nonspecific symptoms may accompany the rash. In some cases skin lesions develop into moist ulcers teeming with spirochetes, a condition that is especially severe when the rash appears in the mouth and causes open sores that are viciously infectious. Scalp hair may drop out in patches, creating a “moth-eaten” appearance. The greatest proliferation and most widespread distribution of spirochetes throughout the body occur in secondary syphilis.
Secondary syphilis gives way in most cases, with or without treatment, to a period of latency that may last as little as a few weeks or as long as 30 years. As if by magic, all symptoms of the disease seem to disappear, and the syphilitic patient does not associate the disease’s early symptoms with the occasional skin infections, periodic chest pains, eye disorders, and vague discomforts that may follow. But the spirochetes do not vanish once the disease falls silent. They bore into the bone marrow, lymph glands, vital organs, and central nervous systems of their victims. In some cases the disease seems to follow a policy of peaceful coexistence, and its hosts are able to enjoy full and long lives. Even so, autopsies in such cases often reveal syphilitic lesions in vital organs as contributing causes of death. For many syphilitic patients, however, the disease remains latent only two or three years. Then the illusion of a truce is shattered by the appearance of signs and symptoms that denote tertiary syphilis, the disease’s final and most deadly stage.
It is during late syphilis, as the tertiary stage is also called, that the disease erupts into a merciless killer. Gummy or rubbery tumors (so-called gummas), the characteristic lesion of late syphilis, appear. They are the stigmata from the concentration of spirochetes in the body’s tissues, with deadly destruction of vital structures. The tumors often coalesce on the skin, forming large ulcers covered with crust consisting of several layers of exuded matter. Their assaults on bone structure produce deteriorations resembling osteomyelitis or bone tuberculosis. The small tumors may be absorbed, leaving slight scarred depressions, or they may cause wholesale destruction of the bone, such as the horrible mutilation that occurs when nasal and palate bones are eaten away. The liver may also be attacked; here the results are scarring and deformity of the organ that impede circulation from the intestines.
The cardiovascular and central nervous systems are frequent (and often fatal) targets of late syphilis. The tumors may attack the walls of the heart or the blood vessels. When the aorta is involved, the walls become weakened, scar tissue forms over the lesion, the artery dilates, and the valves of the heart no longer open and close properly. Instead, they start to leak. Then the stretching of the vessel walls often produces an aneurysm, a balloon-like bulge in the aorta. If the bulge bursts, the result is sudden death.
The results of neurosyphilis are equally devastating. Syphilis spreads to the brain through the blood vessels, and while the disease can take several forms, the best known is paresis, a general softening of the brain that produces progressive paralysis and, eventually, insanity. Tabes dorsalis, another form of neurosyphilis, produces a stumbling, foot-slapping gait in its victims due to the destruction of nerve cells in the spinal cord. Syphilis can also attack the optic nerve, causing blindness, or can invade the eight cranial nerves, inflicting deafness. Since nerve cells lack regenerative power, all such damage is permanent.
<1>The Social Context
The germ that causes syphilis, the stages of the disease’s development, and the complications that can result from untreated syphilis were all known to medical science in 1932, the year the Tuskegee Study began. Indeed, among the many diseases that plagued mankind, syphilis was the most exhaustively studied, the most richly documented, the most elegantly described, and the best understood. So why would the U.S. PHS decide to launch a study of the effects of untreated syphilis in 1932, and why would PHS officials limit the study to black males?
The South in the 1930s was the section of the United States that most resembled the underdeveloped nations of the world. Its people, white and black, remained mostly rural; they were less well educated than other Americans; and they made decidedly less money.
As a group, black Americans in the South were among the poorest of the poor. Indeed, they were virtual paupers—chronically unemployed or underemployed, many living in shacks without benefit of sanitation, adequate diet, or the rudiments of hygiene. As a group, they did not enjoy good health. Many suffered from a host of diseases, including tuberculosis, syphilis, hookworm, pellagra, rickets, and rotting teeth, and their death rate far exceeded that of whites.
Despite their chronic need, few blacks received proper medical care. In fact, many blacks lived outside the world of modern medicine, going from cradle to grave without ever seeing a physician. There was a severe shortage of black physicians throughout the South, and many white physicians refused to treat black patients. In addition, there were only a handful of black hospitals in the South, and most white hospitals either denied blacks admission or assigned them to segregated wings that were often overcrowded and understaffed.
But poverty was as much to blame as racism for the medical neglect of black Americans during the 1930s. The United States was in the depths of a bleak economic depression, and blacks, always the last to be hired and the first to be fired, were especially hard hit by the collapse of the economy. Medical care in the United States was offered on a fee-for-service basis, and the truth was that many black Americans simply did not have the money to pay for health care.
<1>The Rise and Role of the PHS
During the Progressive Era, that period of social, economic, and political reform in the United States that began around 1890 and ended around 1920, the federal government took steps to ease the hardships on the poor, and part of these efforts centered on medical care. In 1912 the federal government united all its health related activities under the PHS. Over the next few decades, the PHS distinguished itself by launching attacks on hookworm, pellagra, and a host of other illnesses. In no field was the PHS more active than in its efforts to combat venereal diseases.
Health reformers knew that syphilis, in particular, was a killer, and that the disease was capable of inflicting blindness, deafness, and insanity on its victims. Furthermore, they regarded syphilis as a serious threat to the family because they associated it with prostitution and with loose morals in general, adding a moral dimension to their medical concerns.
Taking advantage of the emergency atmosphere of World War I, progressive reformers pushed through Congress in 1918 a bill to create a special Division of Venereal Diseases within the PHS. The PHS officers who worked in the VD Division called themselves “syphilis men,” so great was their personal identification with their vocations. They were crusaders, true believers. Safeguarding the public’s health was their mission and, as zealots, they had a tendency to overstate the challenges they confronted. Labeling syphilis “the great killer,” they proclaimed the gospels of prophylaxis, prompt diagnosis, and early treatment. To them syphilis was the most insidious of diseases, and they worked night and day to drive it from the land. The offensive they launched began with high hopes, and their initial successes were impressive. By 1919, they had established over 200 health clinics, which treated over 64,000 patients who otherwise could not have afforded health care.
To their credit, PHS officers did not ignore the health of black Americans. In the late 1920s, the PHS joined forces with the Rosenwald Fund, a private, philanthropic foundation in Chicago named in honor of its benefactor, Julius Rosenwald, who had made a fortune as one of the founders of Sears, Roebuck and Co. Together, the PHS and the Rosenwald Fund developed a syphilis control program for blacks in the South. In 1929, Michael M. Davis, the director of the Rosenwald Fund’s Medical Division, asked the PHS to assign one of its officers to the Fund in order to advise the Fund on health issues that would benefit blacks living in the South. Julius Rosenwald had a special interest in uplifting blacks, and he was eager to see his foundation’s medical division develop programs that would improve their health. In response, the PHS seconded a physician named Taliaferro Clark to the Rosenwald Fund, with instructions to provide advice and assistance in the Fund’s efforts to develop new programs to improve the health of blacks living in the South. Clark, who had served as the director of the PHS Division of Venereal Diseases, immediately recommended that the Rosenwald Fund develop a syphilis control program for blacks in the South.
Most white physicians believed the racial stereotypes that permeated white society, including the notion the blacks were libidinous creatures who could not control their sexual behavior. As a result, many white physicians assumed that blacks suffered a much higher infection rate than whites because blacks abandoned themselves to sexual promiscuity. And once infected, the argument held, blacks remained infected because they were too poor and too ignorant to seek medical care. In short, many physicians despaired of being able to treat syphilis in the black community, creating a powerful rationale for inactivity in the face of a health crisis that public health officials and private physicians alike agreed had reached epidemic portions.
Armed with money from the Rosenwald Fund, the PHS devised a health study designed to establish the incidence of syphilis in blacks and to learn whether blacks could be treated successfully for syphilis if treatments programs were made available to them. To answer these questions, the PHS selected communities in six different southern states, each chosen because of the different demographic profiles it offered for representing a continuum of the living conditions and circumstances of blacks in the South. In each of the six communities, the PHS dispatched health professionals into the field to ascertain the incidence of syphilis by administering Wassermann tests to a representative sample of the local black residents and then to offer free treatment to those who tested positive and were found to be infected.
The results of this pilot program were at once informative and impressive. Based on the data from the six southern communities, the PHS learned that the rate of infection varied greatly from community to community, ranging from a low of roughly 7% in Albemarle County, Virginia, to a high of 36% in Macon County, Alabama. In large measure, PHS officers pointed to different socioeconomic conditions to explain the jarring variations they discovered among the communities. In communities where blacks enjoyed higher incomes, better housing, and affordable health care, the incidence of syphilis was relatively low, while blacks who suffered higher rates of infection were much more likely to live in communities where living wages, decent housing, and affordable health care were rare. In addition, the data from this pilot program demonstrated conclusively that black patients not only wanted medical treatment for syphilis but returned to the clinics in large numbers to complete the extended program of therapy required to cure the disease.
This program had to be abandoned, however, soon after the stock market collapse of 1929 forced the Rosenwald Fund to terminate its support, leaving the PHS without sufficient funds to follow up its syphilis control work among blacks in the South.
<1>The Tuskegee Syphilis Study
The PHS was reluctant to take leave of one of its pilot programs in particular, the one in Macon County, Alabama. Its county seat, Tuskegee, was the home of the Tuskegee Institute, the famed school founded by Booker T. Washington in 1882 to uplift blacks in the South. It was in and around Tuskegee that the PHS discovered an infection rate of 36%, the highest incidence in the six communities studied. In fact, despite the presence of the Tuskegee Institute, which boasted a well-equipped hospital that might have provided low cost health care to blacks in the region, Macon County was home to the worst poverty and the most sickly residents that the PHS uncovered anywhere in the South.
It was precisely this ready-made laboratory of human suffering that prompted the PHS to return to Macon County in 1932. Since the PHS could not afford to treat syphilis, Clark decided to document its damages on its victims by launching a scientific study of the effects of untreated syphilis on black males. (The reason he decided to limit the study to males was his belief that it was easier to get a reliable clinical history from males than it was from females because men were more likely to observe and remember the date of the appearance of the primary chancre, a crucial piece of data for pinpointing how long each person had suffered from the disease.) Many white Southerners, including many white physicians, believed that although syphilis was widespread among blacks, the disease did not harm them as severely as it did whites. PHS officials thought that this was nonsense because they knew that syphilis was a serious threat to the health of black Americans, and they intended to use the results of the study to pressure southern state legislatures into appropriating funds for syphilis control work among rural blacks. By denying the men treatment, the PHS intended to document the ravages of the disease in black people, build a case for treatment programs sponsored by state governments, and force state health officials to develop and fund treatment programs for Southern blacks modeled after the recently completed Rosenwald Fund syphilis control demonstrations. Here, the irony was palpable: By withholding treatment from the men in Tuskegee, the PHS hoped to secure treatment for blacks throughout the South.
Still, whatever social value might accrue from encouraging state legislatures to appropriate funds to diagnose and treat syphilis in their black citizens, the fact remains that these “hoped for” benefits in no way justified withholding treatment for a deadly disease from people who believed they were being helped.
There was another motive for the proposed study. For decades medical scientists and clinical physicians alike had accepted as an article of faith the notion that advanced syphilis affected whites and blacks differently. Blacks were believed to suffer a much higher incidence of cardiovascular syphilis, while whites were thought to suffer a higher incidence of brain damage and related neurological disease. The Oslo Study of untreated syphilis in a select group of Caucasians, a retrospective study that dated back to the 1890s, had provided medical science with a controlled experiment on whites, and the PHS officers wanted to develop comparable data on blacks. In other words, the Tuskegee Study was intended to provide a black counterpoint to the Oslo Study, supplying data that would permit scientists to test the notion that advanced syphilis affected blacks and whites differently. Here again, the social value of determining whether the disease affected the races differently must be weighed against the risks to the men from lack of treatment for a disease that medical authorities agreed was a killer.
In 1932, Clark dispatched two of his best officers from the Division of Venereal Disease, Oscar C. Wenger and Raymond Vonderlehr, to Alabama to conduct the study. As part of their preparations, Wenger and Vonderlehr briefed state health officials, the chief administrators and medical officials at the Tuskegee Institute, local doctors in the region, and other concerned parties on the proposed study and secured their full cooperation and support. In addition, they hired a black nurse, Eunice Rivers, to help with the study. Once these preparations were completed, the PHS officers went through Macon County and the surrounding counties with a Wassermann dragnet. Based on the test results of the men they examined, the PHS officers selected approximately 400 men who would serve as subjects in the study group. In 1933 and 1934, the PHS Officers selected an additional 200 men who were free of the disease to serve as controls.
From the outset, the Tuskegee Study was a nontherapeutic scientific experiment. It had nothing to do with treatment; its overriding purpose was to document the natural history of disease in black males. In order to secure their cooperation, Wenger and Vonderlehr told the local residents and the men who were selected for study that the PHS had returned to Macon County to resume the treatment program that had been started under the Rosenwald Fund syphilis control demonstrations. The PHS did not inform the men that they had syphilis. Instead, the men were told only that they had “bad blood,” a catch-all phrase that rural blacks used to describe a host of ailments. In short, the PHS did not obtain informed consent from the men in study. Rather, the PHS deceived them by withholding critical information about the nature of their illness and the true purpose of the study.
While the PHS had no intention of treating the men, J. N. Baker, the ranking state health officer, demanded as the price for the Alabama Health Department’s cooperation that the men in the study be given treatment—not enough to cure them, to be sure, but enough to render them noninfectious. Consequently, all of the men in the study received at least some treatment with arsphenamine by injection and mercury by inunction—the drugs and treatment methods of choice in the 1930s.
No one worried much at the time about the glaring contradiction of treating subjects in a study of untreated syphilis because the men did not receive enough treatment to cure them. Treatments against syphilis did exist at the time, although they were not as effective as current therapies. Any amount of treatment, however, was fatal to the scientific integrity of the experiment. Flawed beyond redemption, the Tuskegee Study had no scientific validity because it was hopelessly contaminated from the outset. In addition to being morally bankrupt, it was bad science.
The original plan called for the Tuskegee Study to last from six months to a year. After Vonderlehr started examining the men, however, he was fascinated by the high incidence of cardiovascular syphilis he believed he had discovered in the subjects. He urged Clark to extend the study for several more years so that science could learn more about the effects of untreated syphilis. Clark refused his request, explaining that the Division of Venereal Diseases did not have enough money to continue the study. Within the year, however, Clark retired and Vonderlehr succeeded him as the director of the Division. Vonderlehr’s promotion settled the matter. He decided to continue the Tuskegee Study, stipulating that its timeframe would be open-ended.
Vonderlehr’s decision to continue the study anticipated one of the most important reasons why the Tuskegee Study would last for 40 years. Over and over again during the next four decades, the PHS policy of promoting from within would bring to the directorship of the Division of Venereal Diseases officers who had worked in one capacity or another on the Tuskegee Study earlier in their careers. Often they had been sent to Tuskegee as young PHS recruits to sharpen their diagnostic skills by examining the men, and over the years they became not only knowledgeable about the study but comfortable with it. On those rare occasions when questions were asked regarding the study, these officers found it difficult to be objective. Time after time, they brushed aside scientific challenges and moral objections to continuing the study. In effect, they were co-opted by familiarity and they found it impossible to bring an unbiased assessment to the study.
The Tuskegee Study was not a difficult experiment to run. The PHS officers had only to monitor the progress of the disease in the subjects and perform autopsies on them when they died. To accomplish these tasks, the PHS sent teams of officers back to Tuskegee at regular intervals to perform what they called “annual round-ups.” Nurse Rivers was responsible for transporting the men in her automobile from their homes either to the Andrews Hospital on the campus of the Tuskegee Institute or to the nearby Veterans Hospital, the two facilities where most of the clinical examinations were performed. Men who were discovered to be in poor or declining health were followed closely until they died, at which time Nurse Rivers negotiated with their families to secure permission for doctors to perform autopsies.
The PHS offered the families of the deceased men a powerful incentive to allow the autopsies. Because most of these families did not have any kind of burial insurance, they were hard pressed to come up with the money for decent burials. The PHS offered the families burial stipends if they would consent to autopsies. Most did. To finance the burial stipends, the PHS turned directly to the Milbank Memorial Fund, a medical philanthropic foundation. Over the years, the Milbank Memorial Fund provided a series of grants to the PHS for the explicit purpose of providing burial stipends to the families that permitted autopsies.
Burial stipends were not the only incentives offered by the PHS. In order to make the men think they were being treated for their “bad blood,” Wenger, at the beginning of the study, started handing out pink-colored aspirin tablets to them. This “pink medicine,” as the doctors dubbed the aspirin, became an instant hit. Most of the men had never taken aspirin before and they marveled at how quickly it relieved their aches and pains. From then on, the “government doctors” routinely dispensed little bottles of “pink medicine” every time they examined the men. A few years later, the “government doctors” also started dispensing iron tonic to the men. It, too, became much in demand. Perhaps no better placebos could have been used.
It is striking how little the PHS offered the men. Indeed, it is difficult to imagine a risk-benefit ratio that was more lopsided. Small amounts of syphilis therapy at the beginning of the study, aspirin, iron tonics, and burial stipends were the only benefits the men received in the early years of the study. In the 1950s, the PHS sweetened the deal by giving the men official-looking certificates of appreciation and a dollar a year for every year they had remained in the study. Added together, the benefits can only be described as paltry. As a group, the men saw their life expectancy decline by 20%, and one estimate placed the number of men who died from complications from syphilis at 100, fully a quarter of the men with the disease. Meager as the benefits were, they had their intended effect. They kept the men in the study, illustrating to perfection two crucial factors that the PHS counted on to keep the study going: deception and inducements to the poor.
Originally, the Tuskegee Study was supposed to last for only six months to a year. But because there was no formal protocol at the beginning, the time frame proved to be remarkably elastic. As the years passed, it became open-ended, and PHS officials simply assumed that the study would continue until the last man had died. It was as though the PHS had converted Macon County and the surrounding areas into its own private laboratory—in effect, a “sick farm”—where diseased and dying subjects could be maintained without further treatment and herded together for inspection at the yearly roundups. One of the health officers who conducted an “annual roundup” even spoke of “corralling” the men, as though they were so many sheep or cattle. In truth, the Tuskegee Study made no emotional demands on the PHS officers who conducted it because the little contact they had with the subjects did not require them to develop person-to-person relationships. They never got to know the men as patients or as people.
Instead, the PHS officers behaved like absentee landlords, issuing orders from afar, demanding strict accountings for day-to-day affairs, and appearing in Tuskegee only when needed. From their standpoint, the operation of their sick farm in Alabama was ideal. They were free to analyze data and to write scientific papers about the effects of untreated syphilis in black males; a few weeks of frantic work each year during the roundups was all they had to do in Alabama. Time, disease, and Nurse Rivers took care of the rest.
<1>Potential Challenges to the Tuskegee Study
During the first few years of the experiment, there was no real danger that the men would receive medical treatment; poverty and ignorance decreed that they would remain untreated. That situation changed dramatically in 1937. In that year, the Rosenwald Fund decided to renew its support of syphilis control programs in the South and sent a black physician, William B. Perry of the Harvard School of Public Health, to Macon County. Fearing that the resumption of treatment activities might endanger the experiment and aware that Perry badly needed help, Vonderlehr shrewdly arranged to have Nurse Rivers assigned as his assistant. Perry agreed to cooperate fully with the experiment by not treating any of the subjects. Nurse Rivers worked closely with him to make certain that none of the subjects, all of whom she knew by name and on sight, received treatment.
While withholding treatment from the subjects had always been standard operating procedure, this episode marked a sea change. Before the study began, the men were in no real danger of being treated because they were too poor and too ignorant to seek medical care. In a sense, then, all the Tuskegee Study did was to take a de facto situation and place it under a microscope so that science could compile data from the men’s plights. By denying the subjects in the study therapy when treatment became widely available in the late 1930s and early 1940s, however, the PHS actually prevented the men from benefiting from therapy that they otherwise would have received.
Nor was this the only time when the PHS took steps to deny the men treatment. Until World War II erupted, Nurse Rivers, with the aid of local and state health authorities, had successfully cut the men off from treatment programs, but the war created a situation in which representatives of the lay public were making certain that syphilitic men in Macon County received treatment. Approximately 250 of the syphilitic subjects were under 45 years of age (the cut-off age for the draft) in 1941, and they became “1-A” registrants, the group first in line for induction into the armed services. Once their physical examinations revealed syphilis, the men in the study started receiving letters from their local draft boards ordering them to take treatment. To prevent them from being treated and from being inducted into the armed services, the PHS intervened with the local drafts and obtained deferments for all of the men in the study. Thanks to the PHS intervention, a significant number of the subjects were denied treatment once again, for the PHS had no intention of losing men from the study. If the men were to be placed in harm’s way, the PHS meant for them to do so as “soldiers of science,” not as soldiers who fought the nation’s enemies on foreign battlefields.
Preventing the men from receiving treatment had always been a violation of Alabama’s public health statutes requiring public reporting and prompt treatment of venereal disease cases. In 1943 these regulations were superseded by the Henderson Act, an extremely stringent public health law inspired by the wartime emergency. The law pertained to tuberculosis as well as venereal diseases and required state and local health officials to test everyone in the state between the ages of 14 and 50 and to treat those who were found to be infected. Under the auspices of the law, health officials conducted the largest state-level testing and treatment program in the history of the nation. But just as the men in the Tuskegee Study were cut off from earlier treatment programs, the Henderson Act was never applied to them. State and local health officials deferred to the PHS policy of keeping the men untreated and continued to cooperate with the study.
Two developments associated with World War II might have impinged on the study, but did not do so. The first was the discovery of penicillin and the drug’s mass production during the last part of the war. Yet penicillin did not produce any soul searching or second thoughts within the PHS. It was withheld for the same reason that other drugs had been denied to the men from the beginning of the experiment: Treatment would have ended the Tuskegee Study. In the view of the PHS, the men were subjects, not patients; clinical material, not sick people.
The other development associated with World War II that might have given the PHS officers pause was the Nuremberg trials and the Nuremberg Code, the 10 basic conclusions or principles on human experimentation that emerged from the trials. (see Chapter 12) The PHS officers associated with the Tuskegee Study during and immediately after World War II saw no connection whatsoever between the atrocities committed by Nazi scientists and their own actions in the Tuskegee Study. Indeed, there is no evidence that the Tuskegee Study was ever discussed in light of the Nuremberg Code.
And yet there was a similarity between the Nazi experiments and the Tuskegee Study, one which transcended their racist and medical natures. Just as the chain of command within the military hierarchy of Nazi Germany blunted individual responsibility and failed to frame moral issues, the Tuskegee Study’s firm entrenchment within the PHS bureaucracy reduced the sense of personal responsibility and ethical concerns. Like the Nazi doctors who pleaded that they were simply following orders, the PHS officers, state health officials, the medical staff of the Tuskegee Institute, and the staff from the Veterans Hospital in Tuskegee all felt that they were simply doing their jobs. Some spoke of merely “following orders,” while other insisted that they had worked to advance science.
Black professionals in and around Tuskegee showed no more concern for the men than did the white doctors and health officials who launched and sustained the experiment. Over the decades, a procession of black doctors, health officials, educators, and nurses all lent their support, knowing full well the details of the study and its goals. Robert Russa Moton, who succeeded Booker T. Washington as the principal of the Tuskegee Institute; Eugene Dibble, the head of the Andrews Hospital at the Tuskegee Institute; William B. Perry, who conducted the second Rosenwald Fund syphilis treatment program in Macon County; Jerome J. Peters, who performed many of the autopsies at the Veterans Hospital in Tuskegee, all cooperated with the Tuskegee Study. Indeed, they and other black professionals lent a powerful element of biracial support to the Tuskegee Study. For at every stage of the study, the black professionals worked side-by-side with their white counterparts, and their very presence served to reassure the subjects that they were being helped by their participation in the Tuskegee Study. Indeed, it seems doubtful that the Tuskegee Study could have kept going without the black professionals. Yet as a group, they went largely unnoticed by the later pundits who saw the experiment as a simple morality play that cast white people in the familiar role of exploiters and oppressors of black people. It was far easier to keep things simple than to explore class divisions, based largely on education and income, within the black community, or to ponder how those same class divisions and professional identities could ally black professionals with white professionals.
<1>Exposing the Tuskegee Study
Despite its powerful element of biracial support, the Tuskegee Study was a bellwether for race relations in the United States. Only 35 miles from Tuskegee, Rosa Parks and Martin Luther King were launching historic protests against racial injustice in the United States..
At one level, the civil rights movement made it difficult for the PHS to conduct business as usual with regard to the Tuskegee Study. Previously, PHS officers had always published their scientific reports on the experiment like scientists who had nothing to hide. By the 1960s and early 1970s, however, the self-confidence of their predecessors had been replaced by self-consciousness. For beneath the façade of “business as usual” there was a growing uneasiness, a perception that things had changed. It was not that the PHS officers had come to the conclusion that the Tuskegee Study was morally wrong. Rather, they feared dire consequences if the experiment became known. In other words, they regarded the Tuskegee Study as a potential public relations disaster waiting to happen. The day had passed when medical researchers could ignore the public’s concern over the protection of human subjects, and they knew it. They understood, at least at some level, that race added a volatile issue.
In the years following the appearance of the Nuremberg Code and the Declaration of Helsinki (see Chapter 13), pressure gradually grew within the United States for the government to regulate human experimentation. In 1966, the Surgeon General’s office issued Policy and Procedure Order Number 129, outlining the PHS’s first guidelines on grants for clinical research and training. The guidelines established a system of peer review conducted by a standing panel of colleagues at an investigator’s institution. Members of the committee had the responsibility of reviewing all proposals from their institution and submitting an “assurance of compliance” to the PHS.
Significantly, none of the guidelines contained provisions that applied to the PHS’ own research programs. And nothing in the guidelines—except, of course, their spirit—obliged the PHS to meet the same standards as its grantees. Thus, none of the PHS health officers connected with the Tuskegee Study felt bound by these guidelines, and none expressed any ethical concern about the experiment in the light of these guidelines.
Peter Buxtun was different. He thought the Tuskegee Study was a moral disaster, and he said as much to anyone within the PHS who would listen. In the mid-1960s, Buxtun, a psychiatric social worker by training, was employed by the PHS at the Hunt Street Clinic in San Francisco, California, where he worked as a venereal disease interviewer and investigator. Buxtun learned about the Tuskegee Study from discussions with co-workers, and he researched the topic for a short paper he was required to prepare as part of his training. Disturbed by what he learned from his research, Buxtun launched a one-man crusade within the PHS to protest the bankrupt morality of the Tuskegee Study. He wrote letters, met with officials, and did everything in his power to persuade them to end the study.
As a result of Buxtun’s protests, the PHS conducted a full-scale review of the Tuskegee Study in 1969. The review was held at the Communicable Disease Center (now the Centers for Disease Control and Prevention, or CDC) in Atlanta, Georgia, and the committee consisted of several high ranking PHS officials, three medical professors, the state health officer of Alabama, and a senior representative of the Milbank Memorial Fund, the philanthropic foundation that had provided the money to pay small stipends to cover the burial expenses of deceased subjects in exchange for their families’ permission to perform autopsies. No one with training in medical ethics was invited to the meeting, none of the participants was black, and at no point during the discussions did anyone mention the PHS’ own guidelines on human experimentation or those of other federal agencies. Equally noteworthy, all the members of the committee except one had been directly involved with the Tuskegee Study in one capacity or another in the past. And precisely because all of them but one had been implicated by familiarity, it was difficult for them to bring an objective, fresh perspective to their task. Instead, as group, they were hostages of the same attitudes and values that had allowed them to work on the study for years.
During the course of the review, the committee members discussed whether to stop the study and offer the surviving subjects treatment. In the end, however, they decided to continue the study and recommended steps to improve it scientifically. In addition, they concluded that it would be an excellent idea to seek some type of “informed consent” for the study. Following a discussion, they agreed that the subjects were incapable of giving “informed consent” due to their meager educations and advanced ages. In place of the subjects, the committee members recommended that the PHS consult with state health authorities and the members of the local medical societies in and around Tuskegee, explain the study to these officials, and seek their cooperation and approval—obtaining, as it were, a kind of “surrogate informed consent” from the local medical establishment.
The committee’s recommendation settled the fate of the Tuskegee Study, at least for the time being. It would continue. All of the committee members were physicians, and they approached the experiment as a medical matter. And once a medical judgment had been made against treating the men, the members of the committee saw no point in stopping the study. As a group, they did not perceive a conflict between their own scientific interests in continuing the experiment and attempting to decide what was best for the subjects. As physicians and men of science, they felt fully capable of deciding both. In their professional judgment, the Tuskegee Study was important to science, and they agreed that much remained to be learned from its continuation. Therefore, they decided to follow the men until the last subject had died and all the data had been analyzed and reported in scientific articles.
The members of the committee obviously felt comfortable deciding the fate of the men as a group, without bothering to examining a single subject. For while they expressed concern for the men and discussed whether any might benefit from treatment, they did not recommend that the PHS monitor the men and care for their well-being.
The PHS paid more attention to building alliances with medical groups in Alabama than it did to the subjects. In 1970, the PHS followed up on its plans to meet with state and county health officials in Alabama and with the membership of the local medical societies in and around Tuskegee. During those conferences the PHS officials reviewed the history of the Tuskegee Study, outlined their plans for continuing the study, asked for suggestions, and requested the cooperation of the health officials and private physicians with whom they met. In each instance, the PHS officials were pushing against an open door. Not only did the state health authorities and the local doctors fail to question or criticize the experiment, they offered to help in any way they could. Their response was all the more noteworthy for the fact that the Macon County Medical Society included many black physicians among its members. Thus, from beginning to end, the Tuskegee Study enjoyed the support of white and black doctors and health officials alike.
<1>The Final Disclosure of Tuskegee
Had the PHS been left to its own devices, there is no doubt that the Tuskegee Study would have continued until the last subject had died, all the data had been analyzed, and the final article had been published. Instead, Peter Buxtun suddenly reappeared on the scene. Aided by the press, he moved with dispatch and purpose to end the experiment. Buxtun had resigned from the PHS in 1967 to attend law school, and during his years as a law student, he had attempted to interest several different law professors in the Tuskegee Study, all to no avail. After finishing law school, he finally told his story early in 1972 to someone who was willing to do something more than listen politely—Edith Lederer, a longtime friend who worked as an international affairs reporter for the Associated Press. After Buxtun showed her published articles and copies of his correspondence with PHS officials regarding the experiment, Lederer forwarded these materials to her superiors at the Associated Press, asking to be assigned to the story. Instead, the Associated Press gave the story to a highly regarded young reporter named Jean Heller, largely because she was based in Washington, D.C., and was familiar with government agencies.
A little digging on Heller’s part uncovered additional medical articles on the experiment, but her best source proved to be the officials at the CDC. Heller recalls that in numerous telephone interviews, she received straightforward, matter-of-fact answers to her questions—however sensitive or potentially damaging to the PHS. Spokesmen there even provided estimates of the number of men who had died from the various complications of late syphilis, placing the figure between 28 and 100.
True to their goal of pursuing the study until the last subject had died, PHS officers were still conducting the experiment when Heller broke the story on July 25, 1972. In a series of hard-hitting articles that followed in rapid succession, Heller did a brilliant job of laying out the bare facts of the study. Her articles were only the beginning. All across the country television news shows and newspapers bombarded the public with facts and commentary on the Tuskegee Study. At first PHS officials tried to defend the experiment, but public outrage quickly silenced them, and the PHS officials announced that they had given orders for the experiment to be ended—effective immediately.
Suddenly, the 40-year deathwatch was over, but the fallout from the experiment continued unabated. In the wake of the experiment’s abrupt ending, Fred Gray, a black attorney and civil rights leader in Tuskegee, brought a class action lawsuit on behalf of the Tuskegee Study’s surviving subjects and the estates of the deceased subjects. Rather than go to trial, the government settled the case. As part of the out-of-court settlement, the surviving subjects were finally treated with penicillin for syphilis. In addition, the men and the families of the deceased subjects received small cash payments.
In 1973, Senator Edward Kennedy of Massachusetts held hearings on the Tuskegee Study and other human experiments, and the next year the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created the explore the full range of issues involved in the use of humans in biomedical research. In response to the public uproar and the National Commission’s recommendations, the government issued new guidelines for research projects that used federal funds in the United States. Drafted for the explicit purpose of protecting human subjects in scientific and medical experiments, these guidelines established and strengthened Institutional Review Boards in universities and hospitals throughout the United States. (see Chapter 14)
<1>The Tuskegee Legacy
But the Tuskegee Study’s troubled legacy did not end there. No scientific experiment in history inflicted more damage on the collective psyche of black Americans than the Tuskegee Study. In the years after the experiment’s disclosure, news of the tragedy spread in the black community. In addition to what they read in newspapers and magazines or heard on the radio and television, many blacks learned about the study by word of mouth, replete with the sorts of embellishments and distortions that usually attend oral traditions. Many blacks and whites were told that the federal government deliberately inoculated black sharecroppers with syphilis, while others were given to understand that the experiment was conducted on black prisoners.
Despite such errors, most black Americans got the gist of the story right: they understood that for 40 years, an agency of the federal government had withheld treatment from men with syphilis so science could learn what the disease, if left untreated, would do to people. Many of the men, the black public learned, had died from syphilis, while others had gone blind or insane. Confronted with the experiment’s moral bankruptcy, many blacks lost faith in the government and in the medical establishment and no longer trusted health officials who spoke to them on matters of public concern.
This problem came into stark relief when the HIV epidemic struck the United States. Predisposed to distrust health authorities, many black Americans believed the rumors that circulated in the black community charging that HIV was a man-made virus created to perpetrate genocide on African-Americans. Although these charges had no scientific basis, many of the people who heard them believed that they were true. And many of these same people did not believe the government’s official explanations and theories about the causes of HIV. Suspicious and mistrustful of the government’s reports on HIV, they felt deeply alienated from the experts who purported to have their best interests at heart.
Not surprisingly, then, many health officials encountered opposition when they tried to study HIV in black communities. In 1988, federal health authorities were forced to abandon a planned study of HIV infections in the District of Columbia. As designed, the scrapped project proposed to ask the residents of a black neighborhood to submit to household blood tests and complete a questionnaire to determine the feasibility of a national survey to gather data on the incidence of HIV. According to the New York Times, city officials “expressed concern that Washington’s black community was being used as a ‘guinea pig’ in a project that would stigmatize the city and its minority communities.”4 The meaning of this and similar episodes across the country was clear: the legacy of the Tuskegee Study was hampering the government’s efforts to control HIV in the black community.
In an effort to address this problem, President William J. Clinton held a public ceremony at the White House on May 16, 1997 and officially apologized for the Tuskegee Study. Speaking to the handful of Tuskegee Study survivors who had been brought to the White House at government expense to hear the apology—and speaking, by extension, to the nation—Clinton delivered an apology that constituted a masterly performance of the politics of symbolism. Aware that blacks have long placed great faith in symbols to express their hopes that they would one day enjoy true freedom and equality in the “land of the free,” Clinton used the moral authority of his office to attempt to make amends for the Tuskegee Study and to begin the healing process within the black community.
Despite Clinton’s best efforts, however, the Tuskegee Study remains today what it has been ever since the public became aware of it in 1972: a symbol of research malfeasance in which virtually every principle underlying the ethical treatment of human subjects of research was violated.
This essay is based on my book, Bad Blood: The Tuskegee Syphilis Experiment, expanded edition. New York, N.Y.: The Free Press, 1993 .
1. James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, expanded edition. New York, N.Y.: The Free Press, 1993 .
2. Susan M. Reverby, editor. Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study. Chapel Hill, N.C.: University of North Carolina Press, 2000.
3. Fred D. Gray. The Tuskegee Syphilis Study: The Real Story and Beyond. Montgomery, Ala.: NewSouth Books, 1998.
4. Boffey PM. U.S. drops AIDS study in community protests. The New York Times 1988;Aug. 17;Sect.A:14.
Figure 8.1. Tuskegee Syphilis Study Timeline
The Rosenwald Fund, a private philanthropic foundation, appropriates $50,000 to finance syphilis control demonstrations by the U.S. Public Health Service (PHS) with African Americans in six different communities in six different southern states, one of which is the town of Tuskegee, the county seat of Macon County, Ala.
The PHS begins its syphilis control demonstrations in Tuskegee and other communities in the South.
The PHS returns to Tuskegee, where it previously uncovered an infection rate of 35% among those tested, to study the effects of untreated syphilis in a select group of African American males. The men are not told the purpose of the study nor the effects of syphilis on human beings.
Spinal taps are performed on the subjects of the study without the procedure or its effects being explained to them.
Taliaferro Clark, who originated the study, retires from the PHS. Raymond Vonderlehr, who is intent on continuing the study, succeeds him.
Nov. 1933 –
PHS officers return to Tuskegee and add a group of approximately 200 African American men to serve as controls for the study, again without explaining the study to them.
The Milbank Memorial Fund, another private philanthropic foundation, gives the PHS a grant of $500 to pay burial stipends to the men as an incentive for them and their families to consent to autopsies on the men when they die. The grant is extended in subsequent years.
The PHS sends mobile units into Macon County to treat people for syphilis, but treatment is withheld from the men in the study.
The PHS intervenes with the local draft boards in and around Macon County to secure deferments for the men in the study in order to prevent them from receiving treatment from the armed services upon induction into military service.
The PHS starts treating patients who have syphilis with penicillin in several medical centers in the United States.
The Nuremberg Code is articulated to protect human subjects from unethical and illegal medical experiments and studies.
The PHS attempts to improve its record-keeping and diagnostic standards for the study.
The PHS distributes certificates of appreciation and small cash payments to the men in the study.
The Declaration of Helsinki, which stipulates that researchers must obtain informed consent from their subjects, is issued by the World Medical Association.
Peter Buxtun, a PHS employee in San Francisco, Calif., raises strong moral objections to the Tuskegee Study.
The PHS convenes a blue-ribbon panel to review the Tuskegee Study, and the panel recommends that the study be continued, with one panelist in dissent.
Peter Buxtun tells a newspaper reporter about the Tuskegee Study and the press breaks the story.
In response to public outrage, the Department of Health, Education and Welfare (HEW) appoints a panel to investigate the Tuskegee Study.
The U.S. Senate holds hearings on human experimentation; the Tuskegee Study is given prominent attention.
HEW officially ends the Tuskegee Study by authorizing treatment for the survivors.
Attorney Fred Gray files a $1.8 billion class action lawsuit against the United States, HEW, the State of Alabama, the State Board of Health of Alabama, and the Milbank Fund, as well as certain individuals in their private capacity.
A settlement is reached in the lawsuit.
The U.S. government agrees to treat the wives and children of the men in the Tuskegee Study.
President Bill Clinton apologizes for the Tuskegee Study.