The Tuskegee Syphilis Study. Fred Gray

in a testing program the PHS had just completed in Bolivar County, Mississippi. Approximately a fourth of the two thousand African Americans employed there by the Delta Pine and Land Company were infected.

      Davis agreed to pay for a one-year program of treatments, provided that at least one African American nurse would be hired for the project. Thus the PHS was able to make a demonstration treatment program out of its survey project in Mississippi. The success of this effort led PHS officials to ask the Rosenwald Fund to help set up similar projects in other states. The Fund’s directors subsequently appropriated fifty thousand dollars to be spent during 1930 for syphilis treatment demonstrations in six counties in Alabama, Virginia, Tennessee, Mississippi, North Carolina, and Georgia. The Alabama project was to be in Macon County.

      Meanwhile, medical interest in syphilis in the early decades of the twentieth century was not limited to the South or even to the United States. Syphilis had been a serious health problem around the world for centuries. There was considerable research on syphilis throughout the world in the late nineteenth and early twentieth century as medical and scientific technology improved. The discovery of the causes and sometimes the cures of other diseases led medical professionals to hope a cure could be found for syphilis, too. The spirochete that actually causes the disease was isolated by two German scientists in 1905, and the Wasserman blood tests for detection of syphilis came along two years later. However, it would be another thirty-five years before the discovery of penicillin produced a reliable, effective cure.

      During our legal investigation of the Tuskegee experiment, we found a document, “An Introduction to the Tuskegee Study,” written in 1964 by R. A. Vonderlehr, M.D., for a venereal disease conference. This paper discusses some of the early research, beginning with a Norwegian study of 2,200 syphilis patients between 1891 and 1910. At the time, the only known treatment involved injections of arsenic-type drugs, which was not always effective and often caused serious side effects. The doctor doing the Norwegian study believed the patient’s own immune system would be more effective. So he hospitalized these patients until their lesions healed but he did not treat them. Then, in 1928, the original doctor’s assistant, Dr. E. Bruusgaard, reported on the fate of these patients during the fifteen to forty years since they had been infected. He found that of every “hundred patients with untreated syphilis, ten would develop neurosyphilis, thirteen cardiovascular syphilis, and twelve benign late syphilis, but that sixty-four would pass through life apparently unharmed. Furthermore, in twenty-eight of the sixty-four, ‘spontaneous cure’ would occur.”

      According to Vonderlehr, Bruusgaard’s findings were considered suspect for various reasons of methodology, principally that he had obtained follow-up information on only 22 percent of the original 2,200 patients. Nevertheless, his report was received with great interest by syphilis specialists around the globe. During the years 1928-1930, the Health Section of the League of Nations—the forerunner of today’s United Nations—conducted a survey, out of which a group of leading syphilologists of the day standardized a procedure for the treatment of early syphilis in the United States. Vonderlehr described both that treatment and the beginnings of the Tuskegee Syphilis Study:

      In general, this [standardized procedure] consisted of weekly injections of an arsenical and bismuth administered in alternating courses for a period of 70 weeks. For comparative purposes in evaluating the efficacy of this treatment, a group of untreated syphilitics was desirable. Although the Bruusgaard study had just been published, these data did not seem applicable to the situation in the United States. A large percentage of our infected population was Negro and with even our limited knowledge of that time we were aware that in this group syphilis more frequently attacks the cardiovascular than the central nervous system. We were also aware that although cardiovascular conditions could easily be detected their etiology could rarely be determined prior to autopsy.

      Between 1929 and 1931 the Public Health Service in cooperation with local health departments and the Julius Rosenwald Fund had surveyed six rural areas in the South. The highest prevalence of syphilis (398 per 1,000) was found in Macon County, Alabama. Of the 1400 cases admitted to treatment during the survey, only 33 had ever had previous antisyphilitic therapy and the average for these 33 was less than 5 arsenical injections.

      The large number of syphilis cases in Macon County, and the fact so few of the cases had received any treatment, was to play a crucial role in the creation of the Tuskegee Syphilis Study.

      The Rosenwald/Public Health Service projects during 1930–31 were almost too successful. Approximately forty thousand persons were tested for syphilis in the six counties surveyed, and 25 percent were found to be infected. The infection rates ranged from a low of 7 percent in Albemarle County, Virginia, to a high of 36 percent in Macon County. Everyone involved realized they had documented a problem of enormous dimensions, and solving it would take both public money and public resolve. However, as the Great Depression deepened, there was less rather than more money available from both government and philanthropy to address the problem. The Rosenwald Fund directors, hamstrung by the declining value of the Fund’s assets in the stock market, voted in the Spring of 1932 to end the syphilis treatment program.

      However, as Dr. Vonderlehr indicates above, even if no funding was available for an ongoing treatment program, the very fact that there was so much untreated syphilis in Macon County offered the opportunity for a study of a different sort.

      The idea for an observation study of the effects of untreated syphilis in Macon County may have originated with Dr. Taliaferro Clark, who was responsible for writing the report summarizing the Rosenwald surveys, or it may have come from some of the young white doctors who had worked on the project in Macon County. In any case, Dr. Clark became the high-level advocate necessary to create the Tuskegee Study of Untreated Syphilis in the Negro Male.

      All the ingredients were there. The county had a high African American population (82 percent). The Rosenwald demonstration programs had shown the residents of Macon County to have the highest incidence of syphilis among the six counties surveyed in 1930–31. Virtually none of the cases of syphilis among the rural population had been treated. Thus, case acquisition, which required mass screening, could be done most cheaply here. In Tuskegee Institute’s John A. Andrew Memorial Hospital, there was a facility where physical examinations, X-rays, and spinal taps could be made. PHS officials felt that the African American medical professionals associated with the Andrew Hospital were already known in the community and would help to reassure the African American subjects of the observation.

      If there were no funds to treat the syphilis problem in Macon County, at least a scientific experiment might be a way to learn something from it, Dr. Clark reasoned. The study he proposed was not originally planned as a long-term observation of syphilitics. Clark’s original design was for an observation project of only six to eight months. The goal was to assess the extent of medical deterioration, correlated against the duration of infection, among a group of untreated syphilitics. That group was to be located by mass screening a larger population using Wassermann tests. Like many public health surveys it was not single-purposed. Instead, the information gained would have helped answer a number of open questions of great interest. First, studies by American’s leading syphilologist, Dr. J. E. Moore of Johns Hopkins, had shown that 80 percent of syphilitics would suffer active late lesions. However, the Bruusgaard study cited by Vonderlehr indicated that only 37 percent of those infected had developed active late lesions. Those patients had been left untreated by a doctor who doubted the efficacy of heavy metal treatments. If Bruusgaard was right, a 37 percent complication rate was interesting and might warrant questioning the benefit as opposed to the risk, of then current arsenical treatments.

      Second, the venereal disease professionals of that era, like many medical researchers before and since, believed that government at all levels, and the public, misunderstood how important and deserving of support was their research. Reticence about discussing sexual matters, coupled with the high incidence of venereal disease among the poor, accounted for public indifference to what the doctors deemed, properly, one of the nation’s major public health problems. If the true extent of the damage syphilis causes could be shown, the money for public health treatment efforts might materialize despite the Depression’s onset. Third, poorly done studies of syphilis in African Americans showed the disease led to different complications than for Caucasians: African Americans endured