Infectious and Epidemic Disease in History

Department of History
University of California, Irvine
 Instructor:    Dr. Barbara J. Becker

Lecture 10.  Tuskegee.

Syphilis and the Ethics of Scientific Research

Nineteenth century:

  • social hygiene movement in US
    • provide medical treatment for poor
    • combat prostitution, homosexuality, self-pollution, venereal disease (VD)
The Fatal Consequences of Masturbation

(illustrations from one of many popular pamphlets on the subject)

He was young, handsome--his mother's pride and joy...

But he corrupted himself and soon became old before his time...

His eyes lose their sparkle...

his teeth fall out and...

he becomes prematurely BALD!!!

He vomits blood... 

becomes covered with hideous pustules...

languishes as fever consumes him and...

dies a horrible death at age 17 [!]


Syphilis in the Twentieth Century:  Many Questions, Few Answers
  Eric Hoffman (1868-1959) [shown above] and
Fritz Schaudinn (1871-1906) [below] ...
...isolate and identify syphilis's infecting agent, Treponema pallidum.

August von Wassermann (1866-1925)...
...develops diagnostic blood test for presence of antibodies to the spirochete.

Paul Erlich (1854-1915)...
...creates salvarsan
  • 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
Routine examination of US military recruits reveals alarmingly high level of venereal infection (not necessarily in the new recruits pictured here!!)
Congress creates Division of Venereal Diseases (DVD) in the US Public Health Service (PHS)
  • provides ample budget to help states develop and maintain prophylaxis and treatment programs
  • 44 states organize bureaus for VD control
by 1919
64,000+ persons are receiving health care who otherwise could not have afforded it
Johns Hopkins University study of 1800+ syphilitics suggests racial differences in effects of the disease:
  • bone and cardiovascular syphilis more common in blacks than whites
  • higher incidences of neurological damage in whites than blacks
  The Hopkins study reinforced longheld views of many in the medical establishment concerning racial differences in the relative incidence of syphilis:
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)
Public sense of urgency regarding VD declines.

Federal government stops funding VD work.

  Financial support sought from the Rosenwald Fund (est. 1917)  

Julius Rosenwald (1862-1932)
philanthropist and president of Sears, Roebuck and Co.

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 
Questions that needed answers:
  • 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?
Retrospective Norwegian syphilis case study published:
  • 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
Project participants:
  • many had never seen a physician 
  • did not know the word "syphilis"

How could researchers communicate with participants?
gain their confidence?


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


  • 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 
Rosenwald Fund withdraws support--

"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
Research questions that a more extensive study could answer:

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?

  Taliaferro Clark saw opportunity for PHS-sponsored prospective study of untreated syphilis:
  • follow up on patients
  • conduct complete examinations
  • test for complications of syphilis
  • compare results with retrospective 1929 Norwegian study

Dr. Raymond Vonderlehr...
(specialty:  cardiovascular syphilis)
selected to direct PHS-sponsored syphilis study--
  • 616 men (412 syphilitics; 204 controls) 
Experiment to last six months to a year

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
Supposed to mark end of PHS study

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)
Eunice Rivers
PHS nurse
  • 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)

In 1928, Alexander Fleming (1881-1955)...
...had discovered the antibiotic properties of the penicillium mold:

Penicillium notatum


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

...begin landmark experiments that demonstrate penicillin's capacity to combat bacterial disease in humans.

John Heller, director of DVD...
...decides not to administer penicillin to study subjects.
Nuremberg Code
  • 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
PHS launches first full-scale review of the syphilis study.

Senior officials unanimously recommend syphilis study go forward.

Focus of syphilis study shifts to problems of aging and heart disease in study participants.
Dr. Irwin Schatz:  first medical professional to formally object to syphilis study on moral grounds.
Peter Buxtun, VD investigator for PHS, questions morality of the syphilis study.

Writes letter to DVD

Buxton writes second letter
PHS convenes Blue Ribbon Panel to review syphilis study.

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

Washington Star reporter, Jean Heller, writes article critical of syphilis study.

Peter Buxton...
...testifies at a Congressional hearing.
Congress passes legislation creating the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 

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

Three guiding principles of the Belmont Report

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 
Commission publishes "Ethical Principles and Guidelines for the Protection of Human Subjects of Research," also known as-- 

"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.

Postscript.... New discoveries of questionable research practices in the past:  Syphilis studies in Guatemala
Go to:
  • "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;
  • The Belmont Report (1979), by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research;
  • 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.
Weekly Readings
Lecture Notes