(8-86)
United States Department of the Interior
National Park Service
National Register of Historic Places
Continuation Sheet
Section number / E / Page / 1 / U.S. Public Health Service Syphilis Study, Macon County, AL, 1932-1973Introduction
One of the most infamous incidents in the medical history of the United States is the study of syphilis, sponsored by the U. S. Public Health Service (USPHS) in Macon County, Alabama, from 1932 to 1973. It is often called “The Tuskegee Study” because the MaconCounty seat is Tuskegee and a former hospital at Tuskegee Institute (now university) and the Veterans’ Hospital at Tuskegee were used for some of the medical procedures.
What happened, and did not happen, in Macon County, Alabama, during the syphilis study is of national significance in the history of medicine in the United States. “The Tuskegee Study” holds a central place in our understanding of twentieth-century medicine, science, race, and research,” point out scholars Allan M. Brandt and Larry R. Churchill. They emphasize that since “researchers and writers, ethicists and activists have repeatedly turned their attention to the Tuskegee Study in the last quarter-century. . . the study has become more than an important and tragic episode in the ongoing history of human subjects research.” In fact, Brandt and Churchill conclude that “the study reels with significance for the most central questions of contemporary medicine and society.”[1]
“The Tuskegee syphilis study,” according to public health scholars Amy L. Fairchild and Ronald Bayer, “has come to symbolize the most egregious abuse of authority on the part of medical researchers.”[2] A multi-disciplinary group of scholars agreed. In 2005, they reviewed the international history of human experimentation in the mid-twentieth century and concluded that the USPHS syphilis study was “one of the most notorious cases of government-sponsored research in American history.”[3] Historian James H. Jones, in a new edition of his authoritative study, Bad Blood: the Tuskegee Syphilis Experiment (1993), argued that “the Tuskegee Study has much to teach us about racism in the United States and the social warrant of medicine in people’s lives.”[4] “For more than a quarter century now,” historian Susan M. Reverby wrote at the end of the century, “the images conjured up by the words ‘Tuskegee Syphilis Study’ or ‘bad blood’ have haunted our cultural landscape.”[5]
The cultural landscape of the approximately 623 victims (adding together the actual study subjects with the “control” group) of the USPHS study, however, remains undocumented and unassessed. The places where the men gathered, where they were tested, and where the majority of them are buried remain in the cultural landscape of Macon County, Alabama. Finding those places and assessing their association with the USPHS study, as well as their role and function within the rural communities of MaconCounty, are the goals of this report. It is the unknown side of the “Tuskegee Study.” A part of American as well as medical history, this landscape needs to be understood. As Angel David Nieves has recently emphasized, “the physical, social, and intellectual spaces created by African Americans will offer us new forms of historical evidence, methodologies, and analyses.”[6]
I. Origins of the Study, 1929-1932
The U.S. Public Heath Service Study began at a time when some medical professionals and public officials were trying to provide more health services for underserved African Americans, especially in the rural South. In 1929 the Julius Rosenwald Fund (JRF) collaborated with the U. S. Public Health Service to make possible better rural health programs for African Americans. The JRF had earlier sponsored a USPHS survey of syphilis in Mississippi, so the federal agency proposed that the Fund help to extend this survey across the region. In November 1929, the Fund approved $50,000 for pilot projects during 1930 in six southern counties, including Macon County, Alabama. In May 1930, Dr. H. L. Harris, Jr., of the JRF visited MaconCounty and reviewed the process and progress of the demonstration project that was providing treatment for syphilis and yielding positive results. He returned in the fall and recommended the implementation of a comprehensive health plan. But as the Great Depression sunk deeper roots, there was not enough money to implement this recommendation for a real public health program for rural communities.[7]
Lack of funding unfortunately meant that officials lost an opportunity to build upon a program that had gained considerable local support. FiskUniversity sociologist Charles S. Johnson wrote in 1934 that African Americans in MaconCounty responded positively to the JRF demonstration project. Johnson also noted that some of the tests and shots were administered at the recently constructed Rosenwald schools of the county. Johnson further emphasized that the 1930 project involved much more than testing and gathering data. He reported:
Some 7,500 blood examinations and 3,200 urine analyses were made on those under treatment, and a total of 2,042 prescriptions dispensed during the first year. Apart from this, however, 3,500 typhoid inoculations were given, and 600 children immunized against diphtheria, and 200 vaccinated against smallpox. This altogether, with the Red Cross distribution of seeds for gardens and yeast to be used in combating pellagra, constituted one of the most intense concentrations upon a reconstructive health campaign of any rural section in the South.[8]
By the time Johnson wrote his report, however, federal medical professionals had already re-instituted a study of untreated late latent syphilis in MaconCounty in the late summer and fall of 1932. Initially the USPHS study of 1932 was designed as a short-term (six months) follow-up to the earlier Rosenwald Demonstration Project although it did not reach the same people in MaconCounty who had been in the Rosenwald project. Dr. Raymond A. Vonderlehr, the USPHS Passed Assistant Surgeon, came to Tuskegee to identify the sample of subjects and later the control subjects to be examined in the project. Dr. Vonderlehr wanted to focus on African American males between the ages of 25 and 60. (Women were never a focus in the study even though the agency understood that untreated, or undertreated, men would continue to pass syphilis to their wives and girlfriends). Vonderlehr soon encountered resistance from the African American communities, as they were convinced that his call for men only over the age of 25 meant that the program was really for military draft physicals. Due to an initial low response, the agency had no choice but to test large numbers of men and women to allay local fears. Since the federal officials earlier had agreed with the Macon County Board of Health’s request to treat individuals not within the survey parameters, the 1932 survey soon took more time and cost much more money than the agency had predicted.[9]
The USPHS turned to Tuskegee Institute and the Veterans’ AdministrationHospital at Tuskegee for assistance with the study. Given segregation in the hospitals of the Jim Crow South and the lack of facilities in MaconCounty, the USPHS had little choice in medical facilities. Tuskegee Institute officials agreed to cooperate with USPHS in carrying out the initial study in MaconCounty. On September 17, 1932, the director of the institute’s AndrewHospital, Dr. Eugene H. Dibble, Jr., had asked institute president Dr. R. R. Moton to support the USPHS. “While this would not bring any additional compensation to our hospital,” admitted Dibble, “it would certainly not cost us any more and would offer very valuable training for our students as well as for the Internes [sic]. As Dr. [Taliaferro] Clark said, our own hospital and Tuskegee Institute would get credit for this piece of research work. He also predicts that the result of this study will be sought after the world over.”[10] Dr. Moton also heard from the U.S. Surgeon General himself, Dr. Hugh Smith Cumming, who urged the Tuskegee president to cooperate with a project that “offers an unparalleled opportunity for carrying on this piece of scientific research which probably cannot be duplicated anywhere else in the world.”[11] Tuskegee Institute provided facilities; control over the study, and decisions on its funding, rested with the U.S. Public Health Service.
Local African American professionals were needed to make the study work. The USPHS hired former Tuskegee nurse Eunice Rivers to be the key community contact person. She was well known to the African American communities of MaconCounty, starting with her involvement in the TuskegeeMovableSchool project in 1923. She knew the roads to the local communities and where to meet with the research subjects. Rivers took subjects to medical offices at Tuskegee Institute and at the nearby VeteransAdministrationHospital. She served as the liaison between the patients and the medical professionals from 1932 until her retirement in April 1970, almost the entire length of the study. Dr. Jesse Peters, of the Veterans’ AdministrationHospital, carried out the x-rays and autopsies of the subjects.
After testing a much larger group than initially planned, the USPHS in 1932 did identify a group of subjects, approximately 400 men, that in its mind had received no or limited and ineffective treatment. The first group of men under the USPHS study received a complete examination, including x-rays and spinal taps (both of the latter procedures were firsts for the great majority of the men). In this initial study, the USPHS had no plans to offer any medical treatment for latent syphilis, which was assumed to be non-contagious, nor did they inform the patients of the nature of the study. When the agency wrote the subjects of the forthcoming spinal tap procedure, they did so in misleading terminology while stating that the procedure was part of a treatment process:
Some time ago you were given a thorough examination and since that time we hope you have gotten a great deal of treatment for bad blood. You will now be given your last chance to get a second examination. The examination is a very special one and after it is finished you will be given a special treatment if it is believed you are in a condition to stand it.
REMEMBER THIS IS YOUR LAST CHANCE FOR SPECIAL FREE TREATMENT. BE SURE TO MEET THE NURSE.[12]
II. The Syphilis Study in its Formative Years, 1933-1947
In the spring of 1933, Dr. Raymond A. Vonderlehr wrote his superior, Dr. Taliaferro Clark, who had authored the Rosenwald Fund report of 1930, and was the chief of the USPHS Venereal Disease Division:
At the end of this project we shall have a considerable number of cases presenting various complications of syphilis who have received only mercury and may still be considered untreated in the modern sense of therapy. Should these cases be followed over a period of from five to ten years many interesting facts could be learned regarding the course of complications [from] untreated syphilis. The longevity of these syphilitics could be ascertained, and if properly administered I believe that necropsies could be arranged through the hospital at the [Tuskegee] Institute with the cooperation of the National Institute of Health. A part time social worker should be able to see the cases as often as necessary and the whole scheme could be supervised by one of our officers occasionally. Undoubtedly other interesting points for study could be worked out should this follow-up work be considered seriously. I realize, of course, the difficulties in the way of the projection of such a plan in view of the unsettled conditions and the urgent need for economy. However, it seems a pity to me to lose such an unusual opportunity.[13]
Dr. Vonderlehr had good reason to think that Dr. Clark would agree that the unusual opportunity should not be missed. The three key federal officials who instituted the Tuskegee study and guided it during its formative years were Dr. Hugh Smith Cumming, the U.S. Surgeon General; Dr. Clark, and Dr. Vonderlehr,. All three medical professionals had taken degrees at the University of Virginia, which according to historians Paul Lombardo and Gregory Dorr “was an epicenter of eugenical thought, closely linked with the national eugenics movement and with the Virginia antimiscegenation movement and tied to the state mental health professionals who promoted eugenic sterilization.”[14] Professional, institutional, and personal “links between the PHS and the University of Virginia’s medical school imbued PHS officers in the Division of Venereal Diseases with a professional outlook born of a common institutional heritage.”[15] This proved especially true once Vonderlehr succeeded Clark as Chief of the Venereal Diseases Division in June 1933. Sociologist Susan E. Bell pointed out that “over the next four decades the head of the Division of Venereal Disease (VD) is usually recruited from a man who has worked on the Tuskegee Syphilis Study.”[16]
Thus, “race-conscious ideology profoundly influenced the intellectual and organizational origins” of the USPHS syphilis study in MaconCounty. Dr. Vonderlehr in particular wanted “to prove the biological basis of racial difference by documenting race-linked pathology, consistent with prevailing eugenic theory.”[17] His USPHS colleagues agreed that the project—studying untreated late latent syphilis in a large sample of rural African Americans--had too much potential to end. Treatment was far from their minds but not all subjects had symptoms and many received some treatment from aspirin, protiodide (used for syphilis), iron, and placebos. They were not informed as to the nature of the study, its purpose, or its dangers. Since now the project was viewed as a long-term study, rather than a short-term review, Vonderlehr instituted a group of just over 200 men as a control sample.
The new USPHS procedures underscored how the study was now a case of human experimentation that ended with the subject’s death. Historian James Jones called the study “a nontherapeutic experiment, aimed at compiling data on the effects of the spontaneous evolution of syphilis on black males.”[18] Medical historian Susan Lederer concluded, chillingly, “the investigators who staffed the study over four decades regarded their African American subjects neither as patients, nor as experimental subjects, but as cadavers, who had been identified while still alive.”[19] Her judgment is confirmed by a July 1933 letter where Dr. O. C. Wenger of the USPHS told Vonderlehr: “we have no further interest in these patients until they die.”[20]
The USPHS hierarchy pursued autopsies of the subjects as a key part of the project. The officials understood that autopsies would be controversial among any southern rural community. Wenger told Vonderlehr: “if the colored population becomes aware that accepting free hospital care means a post-mortem, every darkey will leave MaconCounty.”[21] They took steps to secure the involvement of Tuskegee officials in the autopsies, made sure that local MaconCounty doctors understood the importance of autopsies, and found that Nurse Rivers was a crucial person to develop trust with the subject’s families and convince them to proceed with autopsies. Surgeon General Dr. Cummings wrote Dr. R. R. Moton at Tuskegee Institute: “Since clinical observations are not considered final in the medical world, it is our desire to continue observation on the cases selected for the recent study and if possible to bring a percentage of these cases to autopsy so that pathological confirmation may be made of the disease processes.”[22] USPHS medical professionals also convinced Tuskegee Institute to house terminally-ill patients at the institute hospital, making the possibility of autopsy more certain. Dr. Jerome Peters of the VeteransAdministrationHospital at Tuskegee conducted the autopsies, with the funding for the procedures coming from the Milbank Memorial Fund, starting in 1935. Families who participated received $50 as a burial stipend.
Nurse Rivers recalled “when I went to, to confirm autopsy I had to explain to them [the subject’s families] what the procedures were. I had to guarantee them that they would not mar that body. They didn’t want the public to know that we had cut that body, the family didn’t. OK. I had to make Dr. Peters promise that we would not mar that body where it would be exposed. And he wouldn’t.”[23] Even so, some families refused to agree with autopsies no matter what Rivers promised and she was unable to secure the necessary permissions.
Dr. Vonderlehr published the first professional paper from the project in a 1936 issue of Venereal Disease Information. And the project continued to adapt to a changing medical climate. In 1937 the Julius Rosenwald Fund revived its efforts to treat venereal diseases in the rural South. The JRF sent Dr. William B. Perry, an African American physician from the School of Public Health at HarvardUniversity, to MaconCounty to establish a syphilis control project. The USPHS arranged to have Nurse Rivers assigned as Perry’s assistant, meaning that in the months of the JRF program, Rivers had an opportunity to screen patients and to ensure that subjects from the USPHS syphilis study remained untreated, although it is unclear whether she took steps to keep men and their spouses from treatment. Vonderlehr took similar steps when the new U.S. Surgeon General, Thomas Parran, launched a major federal program to eradicate venereal diseases. In the spring of 1939, the USPHS detailed staff and loaned one of its mobile units to the Macon County Health Department for the syphilis treatment. Again, Nurse Rivers received the assignment of being the project assistant. She and various federal medical professionals used the car and the mobile unit to conduct tests “on site” at various locations in the county.[24]