“They injected him every fortnight to a month. They never told him why.” A Guatemalan local shares the story of his father, a soldier in the Guatemalan army who unknowingly participated in the Guatemala syphilis experiments (The Frightening Legacy of US Syphilis Experiments in Guatemala 2011). These experiments took place from 1946 to 1948 and intentionally exposed 1308 Guatemalans to syphilis and other sexually transmitted diseases (Ethically Impossible 2011, 33). Around 4,000 others were involved in the study through diagnostic testing (Ethically Impossible 2011, 33).
Afterwards, patients were supposed to be treated with penicillin, but not all of them were adequately cared for. The impact of these unethical experiments are still felt today by those affected and their descendants. This chapter in history serves to demonstrate how twisted science can be in the name of medical progress. The researchers behind these experiments desired to learn more about STD prevention and cures but took advantage of the Guatemalan locals, using them as a means to an end. Although the scientists are culpable, so too are the institutions and government forces that allowed such an event to happen. I offer an analysis of this story and its underlying causes.
Before launching into the story, let us step back and examine the events that led to the experiments in Guatemala from 1946-48. The context is crucial to understanding the whole story and the underlying factors behind the decisions made in Guatemala. Without the complete picture, we may make unfounded assumptions about the scientists and other parties involved.
From 1943-44, researchers from the United States Public Health Service performed a set of gonorrhea experiments in Terra Haute Prison in Indiana (Ethically Impossible 2011, 13). These experiments were similar to the onesin Guatemala in terms of study design, research goals, and scientists. The researchers wanted to find an STD prophylaxis – something that would prevent STDs post exposure. They planned to induce gonorrhea in participants and treat the disease using two experimental chemical compounds (Ethically Impossible 2010, 15).
Their research was wholeheartedly endorsed by the US Army and Navy.Dr. Ross McIntire, Surgeon General of the US Navy, was quoted saying, “The incidence of gonorrhea in the armed forces and the lost manpower resulting therefrom constitutes a problem of major military importance” (Ethically Impossible 2010, 15).
The Terra Haute Prison experiments demonstrate several important factors. First, the researchers understood the importance of recruiting volunteers only. They created a waiver form describing the procedures that would be performed and the risks involved; in addition, the officer in charge had to agree to the outlined terms before the inmate was allowed to waive liability (Ethically Impossible 2010, 15).
Thus the researchers, many of whom would later be involved in the Guatemala experiments, understood the concept of informed consent and were aware of the public backlash that might result if informed consent was not given in such an intentionally dangerous experiment. Second, the experiment deliberately used prisoners – a vulnerable population — as participants for several reasons. Not only were the inmates were sexually isolated and under medical supervision, but they also were willing volunteers, hoping to help the war effort through their participation (Ethically Impossible 2011, 16-17). Many of these factors, present in Terra Haute, would be missing in Guatemala.
Dr. John Mahoney led the Terra Haute Prison experiment, supervising Dr. John Cutler and another junior doctor (Ethically Impossible 2011, 20). They started trying to induce different strains of gonorrhea in participants through a variety of methods, but none were effective. Dr. Mahoney was concerned the experiment was not going to work, but the committee overseeing the project advised him to continue the research because “the opportunity for a study of experimental gonococcal infectionin human volunteers…is unlikely to rise again unless under the impetus of a future war” (Ethically Impossible 2010, 21).
In other words, this experiment was a golden opportunity that would be difficult to replicate in the future, both by finding willing participants and obtaining approval and funding. The researchers labored for another few months but were still unable to find a consistent infection strategy for inducing gonorrhea. The experiment was discontinued, but a concluding note mentioned two strategies left untested – “the intraurethral inoculation of pus taken directly from the cervix or urethra of infected females or by the natural method of infection – sexual intercourse” (Ethically Impossible 2010, 22). Ultimately these two methods would be tested in Guatemala.
The Tuskegee Syphilis Study was another important development in medical research at the time. Beginning in 1932 and lasting until the 1970s, these experiments observed the course of untreated syphilis in black males in Macon County, Alabama (Brandt 1978, 21). Despite the development of STD treatments during this period, the participants were not offered treatment (Reverby 2011, 7). Rather, the researchers wanted to study the effects of syphilis as it progressed; treatment would have been detrimental to the study (Brandt 1978, 21).
Racism played an integral role in this decision. The researchers believed “syphilis in the negro is in many respects almost a different disease from syphilis in the white” (Brandt 1978, 23). Blacks were considered naturally more promiscuous than whites, so treatment was deemed pointless: blacks would not seek or be able to continue treatment, nor would they understand what they were told (Brandt 1978, 23). Participants were deceived into thinking they were receiving “special treatments” whereas they were offered no treatment at all (Brandt 1978, 24).
In fact, they were given fake drugs and ointments as incentives, and their bodies were used for experimentation (Brandt 1978, 24). The Tuskegee experiments highlight the use of deception andthe practice of taking advantage of less informed populationsin STD research. These elementsare found in Guatemala and several parallels will be discussed later.
Before moving on to the Guatemala experiments, let us consider several other important factors that led to its conception and implementation. First, Dr. Mahoney, a leading expert in venereal disease, discovered in 1943 that penicillin was an effective cure to syphilis (Spector- Bagdady and Lombardo 2013, 702). Despite this useful discovery, Dr. Mahoney also wanted to find a way to prevent STDs before they occurred; penicillin functioned as a cure only after theinfection was already in place (Spector-Bagdady and Lombardo 2013, 702). In addition, penicillin dosage and its range of treatable diseases was not understood well. The focus on penicillin would become part of the experimental design in Guatemala.
Another contributing factor to the Guatemala experiments was the relative freedom of scientific research at the time. In January of 1946, a new branch of the NIH was established. This structure, known as the Division of Research Grants, was headed by Dr. Van Slyke, a mandedicated to making scientific research less burdensome (Spector-Bagdady and Lombardo 2013, 700). His organization awarded research grants that gave recipients “complete freedom to conduct projects in whatever ways they choose” (Spector-Bagdady and Lombardo 2013, 700).
In fact, progress reports were required annually rather than monthlyso that scientists could focus on their research rather than the onerous task of filling out paperwork (Spector-Bagdady and Lombardo 2013, 700). On top of that, researchers did not have to follow a pre-conceived plan or outlined budget, but rather were given freedom to pursue whatever leads their research took them (Spector-Bagdady and Lombardo 2013, 701).
Although the lack of rules may seem startling to us today, at the time Dr. Van Slyke believed in the integrity of scientists. He trusted his system dealt with “men of ‘high ethical purposes and completely good morals”” and would allow for the most rapid scientific progress (Spector-Bagdady and Lombardo 2013, 700-701). His vision was adopted by the NIH and was implemented in time for the Guatemalan experiment to be approved. These were the conditions under which the Guatemala syphilis studies were conceived and carried out.
Guatemala Syphilis Experiments (1946-48)
The experiments were headed by 31-year-old Dr. John Cutler, an American scientist dedicated to researching and finding cures for venereal diseases (Reverby 2011, 9). He was involved in the Terra Haute Prison experiment and would go on to be an active member in the Tuskegee Syphilis study that lasted from the 1930s to the 1970s (Reverby 2011, 9).Dr. Cutler’s direct superior and the principal investigator of the study was Dr. John Mahoney, who was also involved in the Terra Haute experiment (Reverby 2011, 9). Both of these doctors would go on to have distinguished careers in public health. On the Guatemalan end was Dr. Juan Funes, the leading STD specialist in Guatemala. He had trained with the US Public Health Service for a year and thus was seen as a suitable leader for the study (Reverby 2011, 11).
The goals and design of the experiments were similar to those in the Terra Haute prison. Cutler and his colleagues wanted to learn what methods would cause syphilis and other STDs and what methods would cure them (Reverby 2011, 9). The first step involved establishing infection in research subjects through two main methods – “normal” transmission through infectious prostitutes and inoculums made from infected tissue injected or applied directly to genitalia (Reverby 2011, 9).
These methods were specifically untested in Terra Haute due to ethical concerns (Ethically Impossible 2011, 22).After determining what caused infection, the researchers would attempt to cure the disease using penicillin or a chemical wash called the orvus-mapharsen prophylaxis (Ethically Impossible 2011, 29). At the time, pilot studies with penicillin and chemical washes had been performed on rabbits and small groups of humans with promising results, but further testing was needed before their effectiveness could be determined and publicized (CDC Report 2010, 5).
Guatemala was selected as the area of interest for several reasons. First, commercial sex work was legalized in Guatemala. Therefore studying STD infection through the “natural” mode of transmission would have been possible in Guatemala (CDC Report 2010, 6-7).Such a feat would not have been possiblein the United States, where prostitution was outlawed.
Also, Guatemala was a country in Central America, somewhere out of public sight. The previous Terra Haute experiment in Indiana had generated some negative public scrutiny, and the PHS was looking to conduct research where they would not be bothered (Ethically Impossible 2011, 17- 18). The relative lack of oversight meant researchers were free to pursue less savory avenues of research without penalty. In addition, the Guatemalan officials were quite willing to let US researchers conduct experiments in Guatemala. There already existed a relationship between the two countries, as the United States was sending medical provisions and helping Guatemala develop its public health system (Ethically Impossible 2011, 29).
The United States continued its show of goodwill by offering STD treatment to several hundred members of the Guatemalan army in 1946 (Ethically Impossible 2011, 33). Guatemalan officials were appreciative of these efforts and thus were eager to develop closer ties with the United States. They saw Cutler’s research as a possible opportunity to improve their own public health system. Finally, the supposed lack of syphilis in Guatemala made the locals desirable test subjects (Reverby 2011, 11). Because the research was designed to introduce syphilis and then treat it, patients without prior exposure to the disease would eliminate confounding variables.
Dr. Cutler began his research in the Guatemalan penitentiary. Prostitutes were hired to service the prisoners; some prostitutes were already positive for syphilis and other STDs while “uninfected prostitutes had inoculums of the diseases placed on their cervixes before the sexual visits began” (Reverby 2011, 12). No evidence of patient consent or knowledge of experimental details was documented (CDC Report 2010, 8). We can conclude the inmates and the prostitutes were unaware of the experiments they were involved in.
The researchers ran into two problemsalmost immediately. First, blood tests showed too many positives for syphilis before sexual exposure even began (Reverby 2011, 13). This was a huge problem -the goal of the experiment was to find uninfected men and infect them, and the Guatemalan population was specifically chosen because of its supposed lack of syphilis. Because the participants displayed no clinical symptoms of syphilis, Cutler and his colleagues suspected the blood tests were at fault. They tried to draw 10 cc of blood on a weekly or biweekly basis to analyze their tests, but the inmates were highly resistant to blood withdrawals (Reverby 2011, 13).
Cutler called them “ignorant and superstitious” because they thought blood withdrawals weakened their bodies, despite the iron pills they received to replace the blood loss (Reverby 2011, 13). Another problem they encountered at the penitentiary was reminiscent of Terra Haute: not enough men were contracting syphilis (Reverby 2011, 13). In other words, the normal mode of transmission did not appear to be effective in transmitting syphilis. As a result of these unexpected complications, Cutler moved on another method – direct inoculation.
The intentional exposure experiments began in Guatemala’s mental hospital in February 1947 (Spector-Bagdady and Lombardo 2013, 704). To ensure the cooperation of the administrative staff, Cutler offered supplies – the place was underfunded and overcrowded and desperately needed anti-convulsant drugs (Reverby 2011, 14). Cutler also provided a refrigerator, motion picture projector, silverware, and more (Reverby 2011, 14). The funds came out of the budget line originally dedicated to paying volunteers (CDC Report 2010, 9). Such a discrepancy would not be permitted today, yet the freedom of scientific research at the time allowed Cutler to change his plans without requesting approval.
In addition, the fact that he worked with the staff rather than the participants showed disrespect for the participants and a devalued sense of their lives (Nelson 2012, 104). The participants, paid in cigarettes, were not told the reasons for injection nor the risks associated with the experiments (CDC Report 2010, 9). Effectively they were considered less important than the American participants in Terra Haute, who in contrast gave full consent and were provided knowledge of the experiment in addition to being offered $100 and a letter of recommendation to the parole board (Ethically Impossible 2011, 20).
Dozens of intentional exposure experiments were performed in the asylum and on soldiers (CDC Report 2010, 9). In particular, 712 subjects were exposed to infectious syphilitic material that caused infection rates estimated as high as 62%, andsimilar experiments were performed with gonorrhea and chancroid (CDC Report 2010, 11-13). Again, participants were left in the dark. They were identified only by name and gender, and they were not provided with knowledge of the experiment, nor was it possible to obtainconsent from many of them given the advanced stages of their mental conditions (CDC Report 2010, 11).
Despite Cutler’s disregard for the participants, the inoculum infection strategy proved relatively effective, and so he proceeded to the next stage. The treatment section was conducted messily, so the effectiveness of the treatments are unclear. An estimated 21% of the patients were transferred, freed, or somehow left the institution after inoculation, so they were unable to receive treatment(CDC Report 2010, 18). If the participants were in a normal mental state and had known what they were injected with, there is a very good chance they would have asked for treatment.
Additionally, only 67% of the remaining participants were treated with adequate doses of penicillin (CDC Report 2010, 19). Even then, the timing of the treatment was inconsistent – some patients were exposed to the diseases for months before receiving treatment, causing irreparable harm to their bodies (CDC Report 2010, 19). The poor execution of this section of the study led to 71 documented deaths and unnecessary pain and suffering (Nelson 2012, 105). The subjects unwittingly participated in these experiments and weretreated with neitherrespect nor care.
Cutler’s experiments continued into 1948. During this time he also performed experiments on children residing in Guatemala’s National Orphanage (Reverby 2011, 13-14). The children were used merely to study the blood tests, which were displaying an unusually high number of false positives; no STDs were administered (Reverby 2011, 13). The serology tests on these children showed results similar to prior experiments. It was clear the tests were unreliable, but before further research could be conducted, funding for the experiments ran out in June 1948.
Cutler asked Mahoney, his supervisor, to seek additional funding, but Dr. Mahoney was not enthusiastic about the idea, saying additional funding would require a progress report, which they might be unable to provide at the time (Ethically Impossible 2011, 71). This suggests the results from the experiment were inconclusive. Indeed, the data from the Guatemala experiments were never published (CDC Report 2010, 22). In late 1948, Dr. Cutler packed his bags and left Guatemala. There is evidence that some serological testing and clinical observations continued up until 1953, but for all intents and purposes, the experiments ended in 1948.
The experiments in Guatemala demonstrated an egregious disregard for the well-being of the participants. Almost all of the participants came from underserved populations – prisoners, mental patients, children, and soldiers. There is a clear consensus now and in the 1940s that certain populations deserve special attention in research because they may be unable to assess the risks posed in experiments (Ethically Impossible 2011, 93) and because they may be willing to take more risks than regular subjects (Nelson 2012, 104).
The researchers in Guatemala deliberately took advantage of those vulnerabilities. Participants were not provided knowledge about the experiment and its associated risks, and in many cases consent was unable to be requested. The researchers understood the concept of providing informed consent, given their carefully designed Terra Haute experiment, but in Guatemala theseexpectations were not met. Compounding the vulnerability of the underserved populations was the poverty of Guatemala relative to the United States.
Today, Guatemala suffers from a poverty rate of 53.7%, and conditions were even worse in the 1940s (Rodriguez and Garcia 2013, 2122). Guatemalan officials had little choice but to cooperate with US researchers because they saw the United States as a source of guidance and financial support (Ethically Impossible 2011, 103). A refusal may have led to discontinuation of aid, which Guatemala needed to sustain and improve its health system. Thus the US Public Health Service took advantage not only of Guatemala’s people, but the country itself.
Race played an important role in medical research at the time, although it was not explicitly discussed in Cutler’s documents. Most doctors at the time believed different races experienced syphilis and other STDs in different ways (Ethically Impossible 2011, 72). In fact, they concluded the “clinical lesions of syphilis found in the Central American Indian…are different from those found in the white European” (Ethically Impossible 2011, 73). Sexual promiscuity was noted as a cause (Ethically Impossible 2011, 73), but this biological reductionism excludes social and cultural factors that may have contributed to the difference (Epstein 2007, 229).
For example, the poverty and lack of infrastructure for proper sanitation in Guatemala may have led to varying syphilis symptoms, not necessarily race. In addition, race was used as a justification for withholding information about the experiment. A member of Dr. Cutler’s team said “he need not explain the experiments at all to the ‘Indians’ in the Penitentiary ‘as they are only confused by explanations and knowing what is happening”” (Ethically Impossible 2011, 74). A similar justification was used in the Tuskegee Syphilis study (Brandt 1978, 23), highlighting the divisive role of race in medical research at the time.
The depth of deception in the Guatemala experiments highlights its unethical nature. Not only did the researchers hide information from their participants, they also hid information from their supporters s and funders in the United States(Ethically Impossible 2011, 78). In 1947, Dr. Cutler wrote Dr. Mahoney: “It is imperative that the least possible be known and said about this project, for a few words to the wrong person here, or even at home, might wreck it or parts of it” (Ethically Impossible 2011, 78). Mahoney agreed, and Cutler began sending monthly progress reports to Mahoney directly rather than to the entire committee (Ethically Impossible 2011, 78).
Clearly they were aware of the linesthey had crossed. This constant secrecy may have contributed to the haphazard design of the experiment and its lack of conclusive results. Too afraid to poke their heads out, they missed opportunities for guidance. However, the scientists themselves may not be entirely at fault. They too were the victims of the scientific freedom granted by the NIH-without the checks imposed by a strict funding committee, Cutler and his team were not required to followa strict plan. Their research progressed messily and did not accomplish its goals. Thus the Guatemala syphilis experiments serve as a reminder of the necessity of regulations in protectingvulnerable populations.
Cutler held on to his research documents until his retirement in 1990. At that point, the documents were placed in the archives at the University of Pittsburgh and were left untouched until historian Susan Reverby accidentally unearthed them while studying Cutler’s Tuskegee records (Reverby 2012, 494). Upon her disclosure of this secret to the White House, the horrifying story of the Guatemala syphilis experiments exploded in the media. President Barack Obama and other US officials formally apologized to the president of Guatemala in October 2010 (Reverby 2012, 494). In return, the Guatemalan government filed a class-action lawsuit against the US government.
Despite USacknowledgement, no mention of compensation to the victims or to the Guatemalan government has been discussed (Rodriguez and Garcia 2013, 2122). In the case of Tuskegee, a parallel study, the Tuskegee Health Benefit Program was created to provide reparation to the victims and their families (Cohen and Adashi 2012, e5). No such program exists for Guatemala, possibly because of its relatively recent discovery or its remoteness from the American sphere of life.
Whatever happens in the future, it is critical that we view this event in history from the broadest lens possible, for that is how we can learn the most. Terry Collingsworth, a human rights lawyer involved in the class-action suit, calls Cutler “an evil man” (The Frightening Legacy of US Syphilis Experiments in Guatemala 2011), but putting the full blame on Cutler reduces this complexevent to an issue of right and wrong. We can agree that Cutler and his team performed unethical experiments, but they were offered that opportunity by the NIH in the shadow of the war effort. They performedrisky science in hopes of learning about STD transmission and prevention – a commendable goal. The most important lesson to take away from this event is that medical research and ethics go hand-in-hand.