His eyes lose their sparkle...

his teeth fall out and...

he becomes prematurely BALD!!!

becomes covered with hideous pustules...

languishes as fever consumes him and...

dies a horrible death at age 17 [!]

• arsenic compound (arsphenamine) -- a "magic bullet"
• initially believed that single injection could cure syphilis in a week
• later found to be a less efficacious and far riskier treatment

• provides ample budget to help states develop and maintain prophylaxis and treatment programs

• 44 states organize bureaus for VD control

• bone and cardiovascular syphilis more common in blacks than whites

• higher incidences of neurological damage in whites than blacks

The prophylaxis of syphilis in the negro is especially difficult, for it is impossible to persuade the poor variety of negro that sexual gratification is wrong, even when he is in the actively infectious stage [of syphilis].

H. H. Hazen
"Syphilis in the American Negro"
Journal of the American Medical Assocation (1914)

From our knowledge of the negro, we should be inclined to the opinion that a chance for an education or even its acquisition does not materially influence his well known sexual promiscuity.

Louis Wender
"The Role of Syphilis in the Insane Negro"
New York Medical Journal (1916)

Federal government stops funding VD work.

targets of Rosenwald's philanthropic efforts were inspired by life and work of Booker T. Washington

promoted community-based projects aimed at improving welfare of black Americans

before 1928, built 5300+ schools for blacks in the rural South

Rosenwald Fund initiated medical service program:

• Dr. Michael Davis, director
• aggressive innovator
• leader in community medicine
• committed to 
• health of rural blacks 
• improving race relations
• securing wider opportunities for blacks 

• Are there real and measurable racial differences in incidence and effects of syphilis?

• Are available remedies worse than the disease???

• How can numbers of new cases of syphilis be reduced?

• review of 2000 untreated Caucasian syphilitics who had been examined in Oslo clinic between 1891 and 1910

Rosenwald Fund, in collaboration with Surgeon General and PHS, appropriates $10,000/site in seed money for one-year study of syphilis and its control:

Dr. Taliaferro Clark
PHS advisor to Rosenwald Fund-sponsored syphilis study

• five rural counties included
• principal aims: 
• determine incidence of syphilis in the local population
• train physicians and nurses in its treatment 
• plan:
• conduct blood test survey
• identify study subjects
• provide one-year treatment program
• arsphenamine
• bismuth
• mercury

• many had never seen a physician 
• did not know the word "syphilis"

How could researchers communicate with participants?
gain their confidence?

Communication:

• use familiar term "bad blood" as synonym for syphilis 

Confidence:

• Tuskegee Institute and John A. Andrew Memorial Hospital
• institutional support and oversight
• staffed and administered entirely by black physicians and nurses
• Local physicians
• provide training in VD treatments 
• distribute antisyphilitic drugs
• promote use of state diagnostic lab facilities 

"There is bound to be danger that the impression will be given that syphilis in the South is a Negro problem rather than one of both races."

• public relations concerns
• survey revealed that 36% of Macon County blacks had syphilis -- far higher than national rate

• syphilis not the only health problem in area
• population needed comprehensive health and social welfare program to combat TB, malnutrition, pellagra....

• program had probably accomplished all that could be expected given treatments then available

• Depression
• widespread financial stress
• local and state authorities unable to meet their financial commitment

Is monitored, but untreated, syphilis as bad as the toxic cures currently available?

Is syphilis truly different between blacks and whites in terms of involvement of cardiovascular vs. nervous system?

• follow up on patients

• conduct complete examinations

• test for complications of syphilis

• compare results with retrospective 1929 Norwegian study

• 616 men (412 syphilitics; 204 controls) 

Anyone found to be infected would be treated

Obtained the cooperation of

• Alabama State Board of Health
• Macon County Health Department
• Tuskegee Institute
• Macon County private physicians

Vonderlehr appointed head of DVD

Gave greenlight to continuing project for another 5-10 years

Participants offered:

• free blood tests
• medical treatment
• burial costs ($500)

• served as nurse and (more importantly) as community/medical staff liaison

• helped obtain and maintain cooperation of local physicians

• obtained permission from participants for autopsies ($50 payment)

Howard Florey (1898-1968) and
Ernst Chain (1906-1979)...

• drafted in wake of outrage over Nazi atrocities by international panel of experts on medical research, human rights, and ethics

• urged researchers to obtain voluntary consent of human subjects

• urged researchers to weigh anticipated potential humanitarian benefits of proposed experiment against risks to the participant

• served as model for public and private research and professional organizations that conduct research involving human subjects

Senior officials unanimously recommend syphilis study go forward.

Writes letter to DVD

Panel recommends study leaders turn their attention to obtaining patient consent.

Commissioners include prominent experts and scholars in the fields of medicine, psychology, civil rights, the law, ethics and religion.

Respect for Persons

• research subjects should be treated as autonomous agents
• persons with diminished autonomy are entitled to protection

• research should do no intentional harm

• research should maximize possible benefits and minimize possible harms, both to individuals involved and to society at large 

• attention must be paid to equitable distribution within human society of benefits and burdens of research involving human subjects

• participants should not be inequitably selected from groups unlikely to benefit from the work 

"The Belmont Report" 

• ethical framework for exploring issues associated with use of human beings as research subjects

• more comprehensive than Nuremberg Code

• defines boundary between accepted therapeutic practice and experimental research

the Nation apologizes.

• History 135F Home Page

• "Syphilis Victims in U.S. Study Went Untreated for 40 Years" (July 26, 1972), by Jean Heller;

• "Survivor of '32 Syphilis Study Recalls a Diagnosis" (July 27, 1972), by James T. Wooten;

• "All in the Name of Science" (July 30, 1972), by Jane E. Brody;

• The Belmont Report (1979), by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research;

• Final Report of the Tuskegee Syphilis Study Legacy Committee (1996);

• Presidential Apology (1997), to African-American participants in the "Tuskegee Study of Untreated Syphilis in the Negro Male"; and

• "U.S. Apologizes for Syphilis Tests in Guatemala" (October 1, 2010), by Donald G. McNeil, Jr. with contributions from Elisabeth Malkin.