COMMENTARY Unraveling the Tuskegee Study of Untreated Syphilis ODAY WE repeatedly and public health in relation to and/ that contributed to the genesis of the hear about the or concurrent with the TSUS. This in- TSUS will be briefly described. Tuskegee Study of cludesactivitiesbythegovernmentand In the early 1930s, the Rosen- Untreated Syphilis nongovernment entities. If Americans wald Memorial Fund, a Chicago- (TSUS) in the media. do not understand the historical con- based philanthropic foundation, TThe TSUS was the 1932 through text and the successes and failures of undertook what had not been per- 1972 US Public Health Service past public health policy and medical formed before in America—a study (USPHS) study involving approxi- practices,wemayrepeatsimilarerrors. of the prevalence of syphilis among mately 400 African American men A historically correct, empiri- African Americans. The study was with syphilis who were found un- cally based analysis of the TSUS is performed with the cooperation of treated in rural Alabama and were ob- presented in this article. This is im- the USPHS. The purpose of the study served to autopsy. As a control, there portant given the impact that pre- was to determine the practicability was also a comparable group of 200 vious interpretations (ie, racism, and effectiveness of measures for African American men without syphi- genocide, and conspiracy) of the mass control of syphilis. Macon lis who were observed to autopsy.1 TSUS have had on present-day re- County, Alabama, was one of 6 ru- The TSUS is a topic the domain search, medical practice, and race re- ral counties chosen for study; the of which includes not only medicine lations. Four areas that begin to pro- other counties were Albermarle and research but also the social and vide clarity and specificity in County, Virginia; Pitt County, North political sciences. In the popular press understanding the TSUS are the foci Carolina; Bolivar County, Missis- and medical literature, it is linked to of this article: (1) the public health sippi; Tipton County, Tennessee; and discussions about maternal-infant context, (2) the age of the 400 male Glynn County, Georgia. Macon transmission of human immunodefi- syphilitic participants, (3) the pub- County was included because of its ciency virus (HIV) trials in develop- lication of articles about the TSUS proximity to the Tuskegee Institute ing countries,2 the cold-virus trials,3 by the American Medical Associa- and its hospital, the John A. Andrew andallegedCIAdistributionofcocaine tion (AMA), and (4) the public re- Hospital, and the Tuskegee Veter- in Los Angeles, Calif.4,5 The myths in- lations context as interpreted by me- ans Administration Hospital—both clude many scenarios, ie, that the 400 dia and historiographers. These African American–run institutions. men in the study were infected with discussions will emphasize the his- The county and state health depart- syphilis by the government, that no torical perspective with respect to the ments were also cooperative.9 African Americans knew about the standards of medical practice and The Rosenwald Study was the study until the study was exposed in public health at the beginning and first successful attempt to control ve- 1972, and that none of the men re- during the first 20 years of the study. nereal disease in rural areas. The ceived penicillin.5,6 Sir William Osler techniques developed from this his- hascalledsyphilis,initslatestage,“the A PUBLIC HEALTH PROBLEM toric project were adopted by the great imitator” because it could simu- USPHS as a model for venereal dis- late or complicate practically every Former Surgeon General Thomas ease control nationwide. Although condition known to internal medi- Parran (1936-1948) provided the the treatment given was not exten- cine.7 And so has the TSUS, at this late following definition of a public sive enough to cure all patients, the stage, become “the great imitator.” It health problem: USPHS physicians were able to ren- has been used to exemplify and vali- der most of the cases noninfec- date government mistrust and con- whenever a disease is so widespread in tious.10,11 Because of the different so- a population, so serious in its effects, so spiracies, primarily those against Af- costly in its treatment, that the individual cioeconomic conditions in the 6 rican Americans. unaided cannot cope with it himself.8 counties, the USPHS also, with re- Absent from current discussions gard to syphilis, learned that fac- are the historical policies, programs, With this definition in mind, tors such as social and economic and procedures surrounding syphilis the immediate prior research events conditions had a more important im- ARCH INTERN MED/ VOL 160, MAR 13, 2000 WWW.ARCHINTERNMED.COM 585 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 pact on disease prevalence than whose objectives were seemingly to evaluate and required consider- race.12 Dr Taliaferro Clark, consult- positive.5,17-20 In the Rosenwald able time (ie, 10-20 years) to deter- ant to the Rosenwald Memorial Study, treatment consisted of 8 or 9 mine the outcome. Specifically, the Fund and one of the USPHS offic- doses of an arsenical, which was less question arose whether clinical and ers who initiated the TSUS, stated than the adequate treatment of 20 serological evaluations were as accu- that “syphilis is not peculiarly a ra- doses and far short of the defini- rate as autopsy examinations in de- cial disease, but is also influenced in tively curative treatment of 70 termining the presence or absence of large measure by environment and doses.21 disease.16 In fact, Dr Felix Under- social standards.”13,14 Dr Charles Johnson, a rural so- wood, a Mississippi public health of- Macon County, the poorest of ciologist from Fisk University, Nash- ficial, after listening to the presenta- the 6 counties, had the highest syphi- ville, Tenn, wrote a classic book tion of an article on the Rosenwald lis prevalence rate—approximately about the people of Macon County Study, contemplated whether syphi- 40%. Clark surmised that the high who the Rosenwald Memorial Fund lis was a major public health prob- prevalence rate was a result of the surveyed. In his book Shadow of the lem in African Americans. He ques- low rate of previous antisyphilitic Plantation, Johnson commented that tioned whether syphilis caused treatment (33 treated out of 1200 se- the physicians noted the large num- damage that resulted in loss of time ropositives [3%]), ie, treatment while ber of positive Wassermann test re- from work and decreased work effi- the patient was infectious.15 Evi- sults (ie, seropositive for syphilis) cacy as well as neurological and car- dence from Albermarle and Pitt among elderly men and women. On diovascular disease. It appeared to counties, which had the lowest examination of these people, the Underwood that since there was such prevalence rates (10% and 13%, re- physicians expected to find more a low percentage of African Ameri- spectively), supported this view. Al- than a positive blood test result (eg, cans receiving treatment, “either though the treatment that was re- evidence of syphilitic destruction). syphilis is not causing the negro of ceived by the residents in Albermarle They further noted that the peak the South much discomfort, or the and Pitt counties seemed inad- positive Wassermann test result rate medical practitioners of the respec- equate, Maxcy and Brumfield,16 was in the group aged 25 to 29 years tive states are not diagnosing 95 per medical faculty members at the Uni- for men and 20 to 24 years for wom- cent of the syphilis” in these states.22 versity of Virginia, believed it may en.9 Subsequent to these peaks, there However, the USPHS officers be- have been sufficient to render early was a decrease in the percentage of lieved that the TSUS “should for- cases noninfectious, thereby halt- positive serological results with ad- ever dispel the rather general belief ing the spread of syphilis. The dif- vancing age that was more abrupt that syphilis is a disease of small con- ferences between residents in Alber- and marked than anticipated. Data sequence to the Negro.”23 marle and Pitt counties and Macon from the other 5 rural counties sup- The results of the Rosenwald County were a function of access to ported this pattern of the “disease” Study and the debate over the re- social, economic, and educational becoming asymptomatic and dem- sults and about whether syphilis opportunities.16 Parran’s definition onstrating serologically negative test caused damage in African Ameri- of a public health problem fit syphi- results later in the life of an un- cans may have contributed to the sci- lis in the population of poor black treated patient—characteristics pre- entific thought that led to the TSUS. sharecroppers in Macon County in viously described in the Oslo Study, The specific precursors seemingly the early 1930s. Clearly, according a retrospective study of untreated were to observe patients with un- to Clark, “the extensive prevalence primary and secondary syphilis. The treated latent syphilis to autopsy and of syphilis” in Macon County con- physicians ruled out a treatment ef- verify the presence or absence of stituted “a public health problem of fect, death, and incapacitation by syphilitic destructive lesions. No prime importance.”13 neurologic or cardiovascular syphi- other prospective study of this type The findings from the Rosen- lis as causes for the decreasing per- had ever been performed. Based on wald Study and the decision to treat centage of positive serological re- the prior experimental data avail- patients to render them noninfec- sults with age.16 able from the Rosenwald Study, the tious were presented and recorded Public health officials were con- risk to the men did not appear to ex- at a constituent meeting of the 1932 cerned about whether clinical and se- ceed the importance of the informa- Annual Convention of the Na- rological evaluations could serve as tion that could be derived.