Perspectives in Biology and Medicine

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 43 ¦ Number 1 ¦ Autumn 1999 THE SCIENTIFIC ENVIRONMENT OF THE TUSKEGEE STUDY OF SYPHILIS, 1920-1 960 THOMAS G. BENEDEK* and JONATHON ERLENt The "Tuskegee Study ofUntreated Syphilis" has been the source ofconsiderable controversy. Attacks on the study and its organizers became widespread beginning in 1973 and have focused largely on two issues: (1) penicillin should not have been withheld when it became available; (2) the study should not have been initiated because "informed consent" was not obtained from the prospective participants. Furthermore, since the study was conducted by white physicians on black subjects it has been perceived to have been blatantly racist. This negative publicity has been construed to have increased among African Americans a prevalent suspicion of the medical profession, and especially of governmentally subsidized medical research . Difficulties in addressing the current HIV/AIDS crisis among African Americans has been considered a major ramification of this lack of confidence [1, 2]. The present review seeks to place the Tuskegee Study, which was conducted from 1933 to 1972 by the Public Health Service (PHS), into its historical perspective. This requires: (1) appreciation of the perception that developed, beginning in the 1910s into the 1930s, that syphilis was a major public health problem in the United States, including the recognition of The authors would like to thank Carey Balaban, Ph.D., Professor of Otolaryngology and Neurobiology, University of Pittsburgh School of Medicine, and Paul Han, M.D., Assistant Professor ofMedicine, University ofPittsburgh School ofMedicine for their helpful comments during the preparation of this manuscript. * University ofPittsburgh School ofMedicine, Kaufmann Building, 3471 Fifth Avenue, Pittsburgh , PA 15213. fGraduate School of Public Health, University of Pittsburgh, 200 Scaife Hall, Pittsburgh, PA 15261.© 1999 by The University of Chicago. All rights reserved. 0031-5982/1999/4301-1124$01.00 Perspectives in Biology and Medicine, 43, 1 ¦ Autumn 1999 1 a race-related difference in its prevalence; (2) comprehension of the risks and potential benefits of the available treatments as perceived by physicians and a small fraction of the general population; and (3) understanding of the concern of medical experts that knowledge of the chronic course of syphilis was inadequate to reliably distinguish therapeutic effect after the initial phases of the disease from the variability of its chronic course. In any long-term investigation unforeseen events may intervene before its contemplated conclusion. The Tuskegee Study encountered two such events: the introduction of penicillin, which might prove to be far more effective than heretofore available medications, and formulation of the legal concept of "informed consent" to receive a particular treatment or to participate in a medical investigation. The Prevalence of Syphilis and Race-Related Findings of Its Manifestations In 1930 syphilis remained virtually unmentionable in public discourse, while it was recognized as a major but poorly quantified public health problem by segments of the medical profession. Statistical data were derived from clinic registrations and spot surveys of private physicians, but it was recognized that large numbers of cases were undiagnosed, and even if diagnosed , treated inadequately or not at all. It also was understood that syphilis was more prevalent in urban than in rural communities and, despite the fact that the black population was predominantly rural, its prevalence of syphilis was estimated to exceed that of the white population by 6 to 1 [3, p301]. Surgeon General Thomas Parran estimated in 1937 that more than 1.7 million cases "would be constantly under treatment if each continued until cured" [3, p56]. In 1916 a Texas physician concluded that although 25 to 30 percent of "apparently healthy adult negroes" had syphilis, "the occurrence of syphilis among white people of the same social class . . . would seem to be about the same as that among the negroes" [4] . Parran in 1937 echoed this point, stating: "Wherever education and living conditions among the negro race approximate that of the white race, the syphilis rate approximates that of the white" [3, pl77]. However, the victims rather than their poverty were more often blamed for the high prevalence of this disease in the black population. For example, one source declared the difference in rate of disease was "partly a reflection of the greater interest of...