The Tuskegee Syphilis Study: Medical Ethics & Race

The Tuskegee Syphilis Study was an ethically problematic, to say the least, medical research project conducted in Alabama. Officially titled “The Effects of Untreated Syphilis in the Negro Male,” this government-sponsored research project was conducted by the United States Public Health Service in Macon County, Alabama, between 1932 and 1972. For four decades, researchers observed the progression of untreated syphilis in approximately 399 African American men without their informed consent. Many of the men thought they were being treated for “bad blood,” which had a variety of connotations. They were not aware that they were being actively blocked from receiving effective treatment, even after penicillin became the recognized standard of care for syphilis in the 1940s. Rather than viewing the study as an isolated event, we’ll see how the Tuskegee study fits into a broader framework of American medical and disability history and racial discrimination.

Transcript for The Tuskegee Syphilis Study: Medical Ethics & Race

Written by Elizabeth Garner Masarik, PhD

Recorded by Averill Earls, PhD & Elizabeth Garner Masarik, PhD

I’m Elizabeth

And I’m Averill

And we are your historians for this episode of Dig.

Averill: We are so thankful for all of our Patreon supporters – especially our Auger and Excavator level patrons: Judy, Lisa, Karl, Karen, Jessy, Maria, Denise, Edward, Lauren, Colin, Susan, and Alissa! We can’t thank you enough. Listener, if you enjoy what we do here but aren’t yet a patron of this show, it’s easy: just go to patreon.com/digpodcast to learn more.

Elizabeth: As with all of our episodes, we rely on the scholarship of other historians and academics. This episode is primarily based on the scholarly work of Susan Reverby, Susan Lederer, James H. Jones, Christopher Crenner, and Alankaar Sharma, among others. Please visit digpodcast.org for a full transcript and bibliography for this and all of our episodes

Averill: In the early 20th century venereal diseases, particularly syphilis, were major public health concerns. Syphilis, caused by the bacterium Treponema pallidum, was widespread and devastating. We’ve talked a lot on the pod about syphilis and the social effects that the bacterial infection had on worldwide populations, which are linked on our website, digpodcast.org. Marissa also discusses syphilis in her latest episode, Crippling Contagion: A Long History of Epidemics and Mass-Dissabeling Events, so check out those resources for an indepth look at syphilis itself.

Elizabeth: For a general understanding of syphilis it is key to know that, if left untreated, the disease progresses through three stages. The first stage is when syphilis is most contagious and is characterized by a painless sore at the site of infection. During this stage it is most often spread by sexual contact but can also be spread to a fetus or an infant at birth through an infected mother or through an infected wet nurse. Infected fetuses can be stillborn or die shortly after birth, or if they survive they can develop blindness, deafness, physical abnormal teeth and nose formation, and neurological issues– these are part of the “long tail” of disability that Marissa’s episode explores.

Averill: During the second stage of a syphilis infection, an infected person may exhibit a rash, fever, swollen lymph nodes, or other aches and pains. This can happen several weeks to months after the initial infection. In the third stage, syphilis may go dormant and the individual may not exhibit any symptoms at all. This stage can last a lifetime with no adverse health effects.

Elizabeth: However, roughly 30 percent of untreated individuals may enter a tertiary stage that may cause damage to the brain (neurosyphilis), cardiovascular problems, or affect other areas of the body. During this late latency period the spirochetes (spi-ro-keets) of the bacterium can attach themselves to practically any internal organs.

Averill: Prior to the discovery of penicillin, treatment options were limited. Mercury treatments, which were both toxic and often ineffective, especially in advanced cases, led to the saying, “A night with Venus, a lifetime with Mercury.”^[1]By the early twentieth century, researchers developed a test to identify the bacterium, and arsenic-based and bismuth treatments were added to the treatment arsenal available to those with syphilis infections. Nevertheless, treatments could be painful and sometimes harmful to patients’ health and sometimes resulted in death.

Elizabeth: Researchers in the early twentieth century were desperate to stop the spread of the infection and to find better treatment options. Unfortunately, racist medical theories cast a pall over many medical studies conducted to abate syphilis and other infectious diseases. Many physicians and researchers subscribed to beliefs about inherent biological differences between races that went beyond skin color to include supposed differences in disease susceptibility, organ systems, and even neurological capacity. These beliefs were not marginal but were published in mainstream medical journals and taught in medical schools. Furthermore, this period was the height of the eugenics movement, which theorized that human traits could be improved through selective breeding and influenced many aspects of American public policy, from immigration to public health.

Averill: In the American medical community, dominated by white male physicians, there was a prevailing belief that syphilis manifested differently in Black bodies. Some physicians claimed that cardiovascular complications were more common in Black patients, while neurological complications were more prevalent in white patients—a phenomenon referred to as “the neurosyphilis paradox.” Dr. E.M. Hummel, for example, claimed that refinement of the brain predisposed white men to neurosyphilis, making it “the lot of the highly civilized white man,” while Black patients supposedly had more primitive nervous systems with greater resistance to such complications.^[2] This is not the case. Studies have shown that the bacteria that causes syphilis affects the brain and nervous system at the same rate across races, but in 1911, when Dr. Hummel made his proclamation, most doctors and scientists (who were white because people of color were not admitted to hospitals and training schools for the most part) adhered to the racist ideology that Black and Brown people were “primitive” in body and mind, compared to the white race.

Elizabeth: Furthermore, some physicians claimed venereal disease stemmed from the “immorality” of Black people. A Texas physician claimed in 1915, “it is appalling…the venereal infections among the nurses of our children, the cooks in our homes, the servants who drive our automobiles, wash our clothes and have dailey ingress into our homes.” Now to be clear, his outrage was over the purported “danger” that Black bodies had to white families. This was based on racist beliefs that Black people were more sexual than white. Another study looking at syphilis in primarily Black counties in Mississippi reported, “the rural negroes of Mississippi are unmoreal and prodigal…their prodigality is inordinate and their sex appetite is enormous.”^[3] Racist claims about Black people’s “immorality” further clouded clear understandings of the infection, its spread, and treatment options.

Averill: The United States Public Health Service, hereafter referred to as PHS, had its start in the late eighteenth century as the Marine Hospital Service. By 1912, the PHS had expanded into a corps of medical officers with the U.S. surgeon general at its helm and was involved with medical research, quarantine, and the control of infectious diseases, including syphilis. As Sarah discussed in her episode Sex & Soldiers, venereal disease among soldiers was a major issue in keeping a fighting force in shape. During World War I, Congress authorized $2 million dollars in 1918 to fund the PHS’s Venereal Disease Division and curb the spread of the infection in U.S. soldiers.

Elizabeth: After the war the PHS VD division turned its sights away from soldiers and toward curbing the spread of the infection in the general population. Primarily, doctors were not in agreement over how much treatment and which arsenicals and other metals would yield the best results for infected patients. According to historian Susan Reverby, “more than anything else, syphilologists wanted to understand the disease’s natural history and to determine how much treatment was really needed and for whom and when.”^[4]

Averill: However, without war funding the PHS needed money from private charities and organizations to continue its research and outreach programs. The PHS joined with the The Julius Rosenwald Fund, a philanthropic organization dedicated to improving opportunities for African Americans. Together the PHS and the Rosenwald Fund developed a program that would survey syphilis rates in six impoverished counties in the South but it would also include a treatment program for those testing positive for the infection. However, the study only focused on syphilis in Black people, even though Black and white people were living side-by-side and both races were susceptible to infection.

Elizabeth: Racist assumptions that racial biological differences affected the disease’s spread, as well as racist assumptions that Black people were more promiscuous than white, led the head of the PHS VD division Dr. Taliaferro Clark to pronounce “mass control of syphilis among rural Negroes in the South is both possible and practical, and offers a new and promising approach to the ultimate control of this disease in all classes of the population.”^[5]Socioeconomic inequalities shaped by racial discrimination greatly influenced the disease’s prevalence across the six counties, as many of the people infected with syphilis were sharecroppers with limited access to healthcare or treatment. However, researchers found the presumed biological racial differences and the opportunity to study the disease in what they considered a readily available population with a high disease rate, too good to pass up- despite the ethical implications.

Averill: When the Great Depression hit, the Rosenwald Fund was forced to withdraw its financial support, terminating the treatment program. However, the high prevalence of syphilis already documented in Macon County—estimated at about 35% of the adult population—caught the attention of PHS physicians. Rather than seeking alternative funding to continue treatment efforts, these doctors saw an opportunity to study the natural progression of untreated syphilis in a population they believed was unlikely –or more so– unable to access medical treatment because of their rural location and inability to pay for treatment.

Elizabeth: In 1930, Macon County, Alabama was a rural area where 82.4 percent of the population was Black and spread across 650 square miles. There was no public health hospital in the county. There were sixteen privately practicing doctors, of which only one was Black. Most Black residents in the county were poor and worked in farming as either landowners or sharecroppers. To gain credibility within the Black community and facilitate access to subjects, the PHS partnered with the Tuskegee Institute (now Tuskegee University). The Tuskegee Institute was founded in 1881 by Booker T. Washington. Since the turn of the century, Tuskegee acted as a training institute for Black doctors and nurses, although it was mostly reserved for the faculty, staff, and students of the historically Black college. By 1930, Tuskegee was home to a Veterans Affairs hospital that treated Black veterans.

Averill: In 1932, Dr. Clark, the director of the PHS VD division, along with colleagues Dr. Oliver Wenger and Dr. Raymond Vonderlehr, began their study, “The Effects of Untreated Syphilis in the Negro Male,” which has come to be known as the Tuskegee Study. The Tuskegee Institute provided their medical facilities for examinations and autopsies, and the participation of Black healthcare professionals helped lend legitimacy to the project within the community.

Elizabeth: Scholar Alankaar Sharma argues, “The Tuskegee Study was clearly premised on the belief that syphilis manifested differently in black men as compared to white men due to what it considered to be the fundamental differences between white and black bodies. This is evidenced in the fact that the study was conducted with an exclusive black sample as opposed to a multiracial sample. The organizers of the study were convinced that the existing medical knowledge about the treatment of syphilis was not applicable to black men, and believed that ‘blacks, promiscuous and lustful, would not seek or continue treatment.’”^[6]

Averill: Furthermore, the racialized concept of the “neurosyphilis paradox” shaped the white researchers thinking about the Tuskegee study, particularly because Dr. Joseph E. Moore, a leading syphilologist at Johns Hopkins Hospital, who developed theories about racial differences in neurosyphilis, was a key scientific advisor to the Tuskegee Study. Researchers were particularly interested in comparing their findings with data from a similar retrospective study conducted in Oslo, Norway, from 1891 to 1910 that had followed the progression of untreated syphilis in white men.

Elizabeth: The recruitment of subjects for the Tuskegee Study was unethical from the start. The researchers targeted rural Black men, many of whom had limited education and healthcare access. To encourage participation, the program offered multiple benefits including free health assessments, transportation services to and from medical facilities, a hot meal on days of medical evaluations, treatment at no cost for minor health concerns, and assurance that funeral allowances would be disbursed to family members after participants’ deaths.

Averill: In total, 399 men with latent syphilis enrolled in the study with an additional 201 men without syphilis recruited as a control group. However, these numbers are approximates as the study’s numbers fluctuate depending on the documents that are looked at. Published reports give numbers as high as 634 infected participants but the most commonly accepted number is 399. Most men were recruited by the PHS between 1932 to 1934.^[7]

Elizabeth: It’s important to point out that most subjects in this study were part of the earlier Rosenwald Fund study that had included treatment. However, in the Tuskegee study the patients were not informed that they were no longer being treated but were instead being studied. Proving this was not a general oversight, PHS officials passed out pink aspirin pills in prescription bottles and told patients they were being treated when in fact it was a ruse to cover up the fact that they were not receiving any kind of medical intervention to cure or control their syphilis.^[8] Furthermore, as in the Rosenwald study, patients might not be sure what they were being treated for because most doctors and patients referred to the disease as the patient’s “bad blood,” a colloquial term that could refer to various ailments, including syphilis, anemia, and fatigue. Some subjects believed they were being treated for rheumatism or stomach problems.

Averill: The study focused exclusively on male subjects, reflecting particular assumptions about Black masculinity and promiscuity that influenced how the researchers viewed and treated the Tuskegee subjects. Though focused on male subjects, the Tuskegee Study profoundly affected women and families as well. Wives and sexual partners of the participants were not informed of the men’s condition, leaving them vulnerable to infection. Many women contracted syphilis from their unknowing husbands, and some passed congenital syphilis to their children.

Elizabeth: Eunice Rivers, an African American nurse, began working with the Tuskegee study and played a crucial role in maintaining contact with the subjects over the four decades of the study. Nurse Rivers built relationships with the men and their families, gained their trust, and ensured their continued participation through regular check-ups and home visits. She also arranged transportation to examinations, and provided minor medical care. Her presence helped ensure participants’ continued involvement and also highlights the complex ethical dilemmas faced by minority healthcare workers in a segregated system. Different historical interpretations have portrayed Nurse Rivers variously as a willing collaborator, a well-intentioned but compromised professional with limited power to challenge authority, or a trapped intermediary trying to provide what care she could within a racist system.

A medical professional examines the arm of a man as part of a health assessment, set in a rural outdoor environment. — *PHS employee taking a blood sample*

Averill: By 1936, the researchers decided to follow the men until death, extending what had been planned as a short-term study into a longitudinal observation spanning decades. Also, in addition to blood testing, PHS researchers began performing painful and risky spinal taps, which were described to the subjects as “special treatments” rather than diagnostic procedures. One study participant recounted how painful the spinal taps could be. Charlie Pollard remembered, “I laid in bed a whole week” after the procedure. Another man told PHS officials that “the fellow before him died on table- needle broke,” after getting the spinal tap.^[9] Many Tuskegee patients had bad memories of the spinal taps.

Elizabeth: PHS doctors Vonderlehr, Clark, Wenger, and Heller coauthored a paper about the study in 1936 and presented their findings at a meeting of the American Medical Association. The study did not make it clear that the patients being studied were also being denied treatment. Furthermore, the paper undermined the neurosyphilis paradox by showing that 7.8 percent of the men with syphilis had documented evidence of neurosyphilis and 18.3 percent had reactive spinal fluid. This meant that over 20% of the Tuskegee Study participants showed evidence of neurosyphilis. However, the lively discussion that followed cast doubt on the idea that neurosyphilis could affect Black men in equal numbers to white, with almost all of the physicians in attendance dismissing the neurosyphilis as resulting from malaria or even “racial influence.”^[10] The paper and following discussion encouraged more treatment for syphilis, but not on the Black men that the Tuskegee Study was following.

Averill: The ethical violations of the study became even more egregious after 1943, when penicillin was demonstrated to be an effective cure for syphilis and became widely available for treatment. Despite this medical breakthrough, the researchers made a deliberate decision to continue the Tuskegee study without offering penicillin to the infected men. By this point, the research had shifted from observing what was considered inevitable due to lack of effective treatment options to deliberately ensuring that men remained diseased when a cure was available in order to study the long-term effects of the disease on the human body.

Elizabeth: Not only did the researchers withhold treatment, but they actively worked to prevent the participants from obtaining treatment elsewhere. When the U.S. military began drafting men for World War II and requiring treatment for those found to have syphilis, the PHS provided the draft boards with a list of study participants to ensure they would be exempted from this treatment requirement. Similarly, when mobile “bad blood” treatment clinics came to Macon County, study participants were discouraged from accessing them.^[11]

Averill: During WWII the PHS set up a “Rapid Treatment Center” near Birmingham, Alabama at the Army Air Force Base, which is about 130 miles away from Tuskegee. They began a massive 42-day venereal disease control campaign. More than 500,000 pieces of literature were distributed on base and in the surrounding area, urging Black and white people to get tested and treated for all venereal diseases. Treatment included penicillin for those who tested positive for syphilis. Yet, participants in the Tuskegee study were prevented from going. Pollard testified that he was told he wasn’t allowed to go to the Birmingham center for treatment “because I was in this study [so] I could not go.”^[12]

Elizabeth: Herman Shaw gave a more detailed description of his denial of treatment:

In the late 1940’s- I do not remember the exact date- they sent me to Birmingham. We left about 2 o’clock and we got to Birmingham before dark. They gave us our supper and put us to bed. The next morning they gave us breakfast. I saw a nurse roaming through the crowd. She said she had been worried all night. She said that she had been looking for a man that was not supposed to be here and his name is Herman Shaw. Naturally I stood up. She said come here. She said, “what are you doing here?” I said, “I do not know, they sent me here.” They got me on a bus and sent me back home.^[13]

Averill: It’s not clear who sent him to Birmingham in the first place and the interviewer at the time did not ask Mr. Shaw that clarifying question. However, there was an Alabama state law passed in 1943 that required state residents to get a blood test for syphilis. It’s possible Mr. Shaw was tested near his home and then sent to Birmingham for treatment but officials with the Tuskegee Study intervened before he could receive a cure. So they weren’t just discouraging the Tuskegee patients from getting penicillin, they were actively prohibiting it.

Elizabeth: The Centers for Disease Control (CDC), first named the Communicable Disease Center, was established in 1946 and absorbed the PHS VD Division in the 1950s, taking over the Tuskegee study. In 1969, when internal concerns were raised about the ethics of the Tuskegee study, the CDC convened an expert panel to decide whether it should continue the study. Only one person on the panel, Dr. Gene Stollerman, and the only person who was not previously familiar with the study, raised concerns and voted that it should be dismantled. The rest of the panel voted to continue the study, and it continued.^[14]

Averill: The Tuskegee Study might have continued indefinitely had it not been for a CDC venereal disease investigator named Peter Buxtun. After learning about the study in 1966, Buxtun repeatedly raised concerns internally about its ethical impropriety. When his objections were dismissed, he eventually leaked information about the study to Associated Press reporter Jean Heller in 1972. On July 25, 1972, Heller’s front-page story in the Washington Star sent shockwaves through American society. The headline read, “Syphilis Victims in U.S. Study Went Untreated for 40 Years.” The New York Times picked up the story the following day and published it on their front page as well. Public outrage was swift and intense, with particular criticism focused on the fact that the study had continued long after penicillin became available as a cure.

Elizabeth: Under intense media scrutiny and public pressure, the Assistant Secretary for Health and Scientific Affairs appointed an Ad Hoc Advisory Panel to review the study. The panel concluded that the study was “ethically unjustified” and determined that penicillin should have been provided to the participants when it became available in the 1940s. The Tuskegee Study was immediately terminated, and surviving participants were finally offered treatment.

Averill: The effects of untreated syphilis on the study subjects was sometimes devastating. Many developed serious complications including cardiovascular problems, neurological damage, blindness, and mental illness. The medical records and reports from the study show that the men with untreated syphilis had worse health outcomes than those in the control group. Charts showed the younger study participants had a 17 percent shorter life expectancy than those who were not infected.^[15]

Elizabeth: However, as historian Susan Reverby shows, the medical records, study reports, and death certificates are unclear and it is impossible to tell exactly how many of the men in the study died directly from their syphilis and how many died “with syphilis.” Initial reports stated that 28-100 of the men died as a direct result of untreated syphilis, but changes in the way cause of death was recorded over the years make it difficult to tell. Furthermore, not all of the men in the study were autopsied. Nurse Rivers attempted to keep track of all of the participants but wasn’t always successful as people moved out of the county.

Averill: Even if there was an autopsy performed, the results were not always clear. For example, one individual died “from syphilis” at age 52. When he entered the study in 1932 he was already 27 years out from his initial infection. His autopsy showed “marked arteriosclerosis, hypertension…and syphilitic involvement of all his arteries.” Yet when the tissue sample was sent to the National Institute of Health, researchers there determined there were “no microscopic findings in this case particularly indicative of syphilis.”^[16] So, these are obviously unclear results and just further puts into perspective the egregiousness of the study as there were really no real controls or parameters set out to actually measure the progression of syphilis.

Elizabeth: In fact, a researcher as early as 1938 pointed this out to PHS officials. Syphilologist Austin V. Deibert was brought on to the study to assist with the program but when he began looking at the published results and the medical records of the patients he realized that some of the untreated patients had in fact received rudimentary treatments while others in the control group had developed evidence of syphilitic infection. Instead of demanding a stop to the study, he suggested that the syphilitic patients should be broken into two groups, those with truly untreated syphilis and those that had had a modicum of treatment but not enough for complete medical intervention. Deibert’s findings should have raised a red flag, but didn’t, further evidence of the disregard for the Black men that they were studying.

Averill: Deibert’s critique foreshadowed the impossibility of conducting the study in any kind of scientific matter, ethics aside. For example, some of the participants in the syphilitic group did receive treatment and penicillin. Mr. Shaw got penicillin in the 1950s after being hospitalized for pneumonia. There were other patients that did end up getting treatment at the Birmingham Rapid Treatment Center or at the local health department. These treatments more than likely happened because the Tuskegee Study wasn’t able to proactively stop them.^[17] So although it’s great that some of the patients in the study did get some treatment, even in a roundabout way, it points to the egregiousness of the study. Not only was it simply racist, it was also really sloppy.

Elizabeth: Many of the men in the study lived with the stigma of “bad blood” without fully understanding or knowing they had a sexually transmitted infection that could be passed to their wives and children. The PHS was not methodical about checking wives for infection, although if wives and children did test positive, Nurse Rivers maintained that they were always treated by the V.D. Control program in Macon, County. The study did not make any effort to track down sexual partners of the men who were not wives. After the study ended the government admitted that “there is ample proof that a sizeable percentage of wives became infected after their husbands entered the study.”^[18]

Averill: Beyond the physical suffering, subjects experienced social and psychological harm. The mental burden of declining health without explanation or effective intervention cannot be overstated. As Reverby notes, the medical reports and records show that the men in the study often reported they suffered from “misery,” which seems to refer to the men’s “aches, pains, and ills.” One man said that he had “a terrible misery in my throat. I was sorry for the time to come to drink water it hurt me so bad.”^[19] So obviously this man was explaining a sore throat but by calling the hurt a “misery” it perhaps speaks to the larger implications of living with a lifelong infection.

Elizabeth: The public outcry over the Tuskegee Study prompted congressional hearings led by Senator Edward Kennedy, focusing on human experimentation and protections for research subjects. These hearings revealed that the Tuskegee Study was not an isolated incident but rather indicative of broader problems in the oversight of human research.

A group of six African American men standing in front of a building with a sign that reads 'DAVISVILLE,' accompanied by a white dog. — *Group of men in Untreated Syphilis Study at Tuskegee*

Averill: As a result, Congress passed the National Research Act of 1974, which established requirements for informed consent in human research and mandated the creation of Institutional Review Boards (IRBs) to review and approve research involving human subjects. The Act also created federal commissions to bring together experts from a number of fields to consider the ethical issues posed by human experimentation.

Elizabeth: Additionally, the Act created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which later produced the Belmont Report in 1979. This landmark document established three fundamental ethical principles for research involving human subjects: respect for persons, beneficence, and justice. These principles still guide American research today.

Averill: It would take another twenty-five years for the United States government to formally apologize for the Tuskegee Study. On May 16, 1997, President Bill Clinton held a White House ceremony where he apologized to the surviving participants and their families on behalf of the United States government.

Elizabeth: During the apology, President Clinton acknowledged the racist underpinnings of the study and its profound betrayal of trust: “The United States government did something that was wrong—deeply, profoundly, morally wrong. It was an outrage to our commitment to integrity and equality for all our citizens… To the survivors, to the wives and family members, the children and the grandchildren, I say what you know: No power on Earth can give you back the lives lost, the pain suffered, the years of internal torment and anguish. What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look you in the eye and finally say on behalf of the American people, what the United States government did was shameful, and I am sorry.”

Averill: As part of reparations, the government established the Tuskegee Health Benefit Program to provide lifetime medical benefits to surviving participants and later extended these benefits to wives, widows, and children infected through congenital transmission. The government also committed funds to establish a bioethics center at Tuskegee University to ensure that similar ethical violations would not recur.

Elizabeth: The Tuskegee Study has had lasting impacts on trust in medical institutions, particularly among African Americans. Research has consistently shown that knowledge of the study contributes to mistrust of medical research and healthcare providers within Black communities. This mistrust has manifested in lower participation rates in clinical trials, skepticism about public health initiatives, and delays in seeking medical care.

Averill: Furthermore, the study’s legacy is frequently cited as a contributor to health disparities and as an explanation for vaccine hesitancy. African Americans continue to experience higher rates of many diseases, lower quality of care, and shorter life expectancies compared to white Americans. Black pain levels are chronically taken less seriously in emergency rooms and outcomes for Black patients undergoing surgery are worse than those for white patients. While these disparities have complex causes—including white racism, socioeconomic factors, environmental exposures, and access barriers—the legacy of medical racism exemplified by Tuskegee remains relevant to understanding them.

Elizabeth: But things didn’t have to be this way. While the Tuskegee Study was unfolding, another initiative addressing syphilis in Black Americans took a different approach. The Negro Project of the American Social Hygiene Association (also known as the Negro Venereal Disease Education Project), was launched by the American Social Hygiene Association (ASHA) in the early 1940s. Unlike the Tuskegee Study, the Negro Project aimed at reducing the prevalence of venereal diseases among African Americans through education, awareness, and treatment.

Averill: The Negro Project explicitly rejected the notion that racial susceptibility to syphilis was innate or biological. Project officials maintained that syphilis was a racialized disease, meaning that the socioeconomic barriers that prevented most African Americans from accessing basic care in the United States made them more susceptible to venereal diseases such as syphilis. The study concluded that “the possibility of developing cardiovascular syphilis is increased by hard labor and by lack of treatment or inadequate treatment… As the work of Negroes is usually arduous and as medical care for Negroes is all too frequently inadequate or absent, syphilis in this group is especially disastrous.”^[20]

Elizabeth: This was different from the racist discourse underpinning the Tuskegee Study. Sharma maintains:

the Tuskegee study approached syphilis in black men through the discourse of diseased race. Within the framework of this discourse, black men were inferior people who had brought the disease upon themselves due to their uncontrolled lust and promiscuity, and could not be helped medically because treatment would either not work for them, or they would not seek or continue treatment. They did not have the capacity to participate in interventions aimed at them. Their sexuality was not just unhealthy but also dangerous, and therefore needed to be harnessed through symbolic castrations. In a nutshell, their race was diseased.^[21]

Averill: Similarly, greater attention to the roles of Black physicians, researchers, and community members has complicated the historical narrative. Scholars have documented how some African American physicians, like those at the Tuskegee VA Hospital, were developing progressive approaches to treating neurosyphilis in Black patients during the same period that the PHS was withholding treatment in the Tuskegee Study.

Elizabeth: To fully understand the ethical failures of the Tuskegee Study, it is important to contextualize it within the ethical standards of medical research at the time. While the formal codification of research ethics was less developed in 1932 than it is today, several fundamental principles were already recognized in the medical community. By the early 20th century, there was growing recognition of the need for informed consent in experimental procedures. As historian Susan Lederer notes, “In the early twentieth century, some researchers were very sensitive to the ethical issues posed by human experimentation. When the U.S. Army expedition to study yellow fever in Cuba wanted to test whether mosquitoes transmit the disease, surgeon Walter Reed was concerned about the safety of the men who participated… To ensure that participants recognized some of the risks, Reed introduced written contracts between the participants and the researchers. These contracts (which were also available in Spanish for non-English speaking participants) identified the risk of disease and death and specified the compensation the subject would receive for participation. Although some researchers adopted Reed’s innovation, most did not.”^[22]

Averill: So obviously informed consent did exist during the time of the Tuskegee Study. However, there were no hard and fast informed consent rules or other ethical guardrails put in place by either the U.S. government or other governing bodies like the American Medical Association.

Elizabeth: Furthermore, the Tuskegee Study took place during a period that also saw the horrific medical experiments conducted by Nazi physicians. The Nuremberg Trials of 1946-1947, which prosecuted these Nazi doctors, resulted in the creation of the Nuremberg Code—the first international document to explicitly outline ethical principles for human experimentation.

Averill: The timing is significant: while the Nuremberg Code was established in 1947, explicitly requiring voluntary consent from research subjects, the Tuskegee Study continued for another 25 years in direct violation of these principles. American medical researchers and officials, some of whom had participated in the Nuremberg Doctors’ Trial as expert witnesses or consultants, failed to apply these same ethical standards to research conducted within the United States- or more explicitly– on Black men in the United States.

Elizabeth: The Tuskegee Syphilis Study emerged as part of a series of controversial medical experiments that gained public attention in the twentieth century. These included the Willowbrook State School research where children with disabilities were deliberately exposed to hepatitis, and the Brooklyn Jewish Chronic Disease Hospital case where elderly patients unknowingly received injections of live cancer cells. Similarly concerning was the case of Henrietta Lacks, whose cancer cells were harvested without her knowledge or consent in 1951, creating the immortal HeLa cell line that revolutionized medical research while raising profound questions about patient autonomy, informed consent, and the exploitation of marginalized communities in scientific advancement.

Averill: The longevity of the Tuskegee Study required the complicity of numerous individuals and institutions over four decades. Beyond the PHS researchers who designed and conducted the study, several other entities played roles in its continuation. The Tuskegee Institute provided facilities and lent institutional credibility to the project and local Black physicians referred patients and sometimes participated in examinations. Also, the American Medical Association was aware of publications about the Tuskegee study and some of the ethical issues as well as disparities in having any semblance of a control group, yet raised no objections to the study. Furthermore, peer reviewed medical journals published results from the study without questioning its ethics. Numerous American physicians and researchers were consulted throughout the forty years of the study, yet none raised alarms strong enough to make the study stop.

Elizabeth: The Tuskegee Study affected hundreds of men directly and thousands of family members across four decades. The research prioritized scientific discovery over human rights, allowing racial biases to compromise ethical standards. Its exposure, however, sparked important reforms in research protocols and oversight. The public response and the government’s later apology reflected a societal rejection of scientific advancement at the expense of human dignity. Yet the U.S. medical system is still racially biased and health outcomes for the wealthy and white are much better than for the poor or people of color, no matter their socioeconomic status. The legacy of Tuskegee now functions both as a cautionary tale about medical dehumanization and as a catalyst for creating more equitable healthcare systems.

References

Brandt, Allan M. “Racism and Research: The Case of the Tuskegee Syphilis Study.” The Hastings Center Report, , Vol. 8, No. 6 (Dec., 1978), pp. 21-29.

Crenner, Christopher. “The Tuskegee Syphilis Study and the Scientific Concept of Racial Nervous Resistance.” Journal of the History of Medicine and Allied Sciences, Vol. 67, No. 2 (APRIL 2012), pp. 244-280.

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