syphilis experiment in us

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Tuskegee Experiment: The Infamous Syphilis Study

By: Elizabeth Nix

Updated: June 13, 2023 | Original: May 16, 2017

The Tuskegee experiment began in 1932, at a time when there was no known cure for syphilis, a contagious venereal disease. After being recruited by the promise of free medical care, 600 African American men in Macon County, Alabama were enrolled in the project, which aimed to study the full progression of the disease.

The participants were primarily sharecroppers, and many had never before visited a doctor. Doctors from the U.S. Public Health Service (PHS), which was running the study, informed the participants—399 men with latent syphilis and a control group of 201 others who were free of the disease—they were being treated for bad blood, a term commonly used in the area at the time to refer to a variety of ailments.

The men were monitored by health workers but only given placebos such as aspirin and mineral supplements, despite the fact that penicillin became the recommended treatment for syphilis in 1947, some 15 years into the study. PHS researchers convinced local physicians in Macon County not to treat the participants, and instead, research was done at the Tuskegee Institute. (Now called Tuskegee University, the school was founded in 1881 with Booker T. Washington as its first teacher.)

In order to track the disease’s full progression, researchers provided no effective care as the men died, went blind or insane or experienced other severe health problems due to their untreated syphilis.

In the mid-1960s, a PHS venereal disease investigator in San Francisco named Peter Buxton found out about the Tuskegee study and expressed his concerns to his superiors that it was unethical. In response, PHS officials formed a committee to review the study but ultimately opted to continue it—with the goal of tracking the participants until all had died, autopsies were performed and the project data could be analyzed.

Buxton then leaked the story to a reporter friend, who passed it on to a fellow reporter, Jean Heller of the Associated Press. Heller broke the story in July 1972, prompting public outrage and forcing the study to finally shut down.

By that time, 28 participants had perished from syphilis, 100 more had passed away from related complications, at least 40 spouses had been diagnosed with it and the disease had been passed to 19 children at birth.

In 1973, Congress held hearings on the Tuskegee experiments, and the following year the study’s surviving participants, along with the heirs of those who died, received a $10 million out-of-court settlement. Additionally, new guidelines were issued to protect human subjects in U.S. government-funded research projects.

As a result of the Tuskegee experiment, many African Americans developed a lingering, deep mistrust of public health officials and vaccines. In part to foster racial healing, President Bill Clinton issued a 1997 apology, stating, “The United States government did something that was wrong—deeply, profoundly, morally wrong… It is not only in remembering that shameful past that we can make amends and repair our nation, but it is in remembering that past that we can build a better present and a better future.”

During his apology, Clinton announced plans for the establishment of Tuskegee University’s National Center for Bioethics in Research and Health Care .

The final study participant passed away in 2004.

Tuskegee wasn't the first unethical syphilis study. In 2010, then- President Barack Obama and other federal officials apologized for another U.S.-sponsored experiment, conducted decades earlier in Guatemala. In that study, from 1946 to 1948, nearly 700 men and women—prisoners, soldiers and mental patients—were intentionally infected with syphilis (hundreds more people were exposed to other sexually transmitted diseases as part of the study) without their knowledge or consent.

The purpose of the study was to determine whether penicillin could prevent, not just cure, syphilis infection. Some of those who became infected never received medical treatment. The results of the study, which took place with the cooperation of Guatemalan government officials, were never published. The American public health researcher in charge of the project, Dr. John Cutler, went on to become a lead researcher in the Tuskegee experiments.

Following Cutler’s death in 2003, historian Susan Reverby uncovered the records of the Guatemala experiments while doing research related to the Tuskegee study. She shared her findings with U.S. government officials in 2010. Soon afterward, Secretary of State Hillary Clinton and Secretary of Health and Human Services Kathleen Sebelius issued an apology for the STD study and President Obama called the Guatemalan president to apologize for the experiments.

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Tuskegee syphilis study

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• Academia - The Tuskegee Syphilis Study: Some Ethical Reflections
• Encyclopedia of Alabama - Tuskegee Syphilis Study
• Centers for Disease Control and Prevention - The USPHS Untreated Syphilis Study at Tuskegee
• McGill University - Office for Science and Society - 40 Years of Human Experimentation in America: The Tuskegee Study
• JamesCook University Pressbooks - An Introduction to Research Methods for Undergraduate Health Profession Students - A Case Study – The Tuskegee Syphilis Experiment
• National Center for Biotechnology Information - PubMed Central - The Tuskegee syphilis study
• Tuskegee syphilis study - Student Encyclopedia (Ages 11 and up)

Tuskegee syphilis study , American medical research project that earned notoriety for its unethical experimentation on African American patients in the rural South .

The project, which was conducted by the U.S . Public Health Service (PHS) from 1932 to 1972, examined the natural course of untreated syphilis in African American men. The research was intended to test whether syphilis caused cardiovascular damage more often than neurological damage and to determine if the natural course of syphilis in black men was significantly different from that in whites. In order to recruit participants for its study, the PHS enlisted the support of the prestigious Tuskegee Institute (now Tuskegee University ), located in Macon county, Alabama . A group of 399 infected patients and 201 uninfected control patients were recruited for the program. The subjects were all impoverished sharecroppers from Macon county. The original study was scheduled to last only six to nine months.

The subjects were not told that they had syphilis or that the disease could be transmitted through sexual intercourse . Instead, they were told that they suffered from “bad blood,” a local term used to refer to a range of ills. Treatment was initially part of the study, and some patients were administered arsenic, bismuth, and mercury. But after the original study failed to produce any useful data, it was decided to follow the subjects until their deaths, and all treatment was halted. Penicillin was denied to the infected men after that drug became available in the mid-1940s, and it was still being withheld from them 25 years later, in direct violation of government legislation that mandated the treatment of venereal disease . It is estimated that more than 100 of the subjects died of tertiary syphilis .

The Tuskegee syphilis study finally came to an end in 1972 when the program and its unethical methods were exposed in the Washington Star . A class-action suit against the federal government was settled out of court for $10 million in 1974. That same year the U.S. Congress passed the National Research Act, requiring institutional review boards to approve all studies involving human subjects. In 1997 President Bill Clinton issued a formal apology for the study (see Sidebar: Presidential Apology for the Study at Tuskegee ).

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40 years of human experimentation in america: the tuskegee study.

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Starting in 1932, 600 African American men from Macon County, Alabama were enlisted to partake in a scientific experiment on syphilis. The “Tuskegee Study of Untreated Syphilis in the Negro Male,” was conducted by the United States Public Health Service (USPHS) and involved blood tests, x-rays, spinal taps and autopsies of the subjects.

The goal was to “observe the natural history of untreated syphilis” in black populations. But the subjects were unaware of this and were simply told they were receiving treatment for bad blood. Actually, they received no treatment at all. Even after penicillin was discovered as a safe and reliable cure for syphilis, the majority of men did not receive it.

To really understand the heinous nature of the Tuskegee Experiment requires some societal context, a lot of history, and a realization of just how many times government agencies were given a chance to stop this human experimentation but didn’t.

In 1865, the ratification of the Thirteenth Amendment of the U.S. Constitution formally ended the enslavement of black Americans. But by the early 20 th century, the cultural and medical landscape of the U.S. was still built upon and inundated with racist concepts. Social Darwinism was rising, predicated on the survival of the fittest, and “ scientific racism ” (a pseudoscientific practice of using science to reinforce racial biases) was common. Many white people already thought themselves superior to blacks and science and medicine was all too happy to reinforce this hierarchy.

Before the ending of slavery, scientific racism was used to justify the African slave trade. Scientists argued that African men were uniquely fit for enslavement due to their physical strength and simple minds. They argued that slaves possessed primitive nervous systems, so did not experience pain as white people did. Enslaved African Americans in the South were claimed to suffer from mental illness at rates lower than their free Northern counterparts (thereby proving that enslavement was good for them), and slaves who ran away were said to be suffering from their own mental illness known as drapetomania.

During and after the American Civil War, African Americans were argued to be a different species from white Americans, and mixed-race children were presumed prone to many medical issues. Doctors of the time testified that the emancipation of slaves had caused the “mental, moral and physical deterioration of the black population,” observing that “virtually free of disease as slaves, they were now overwhelmed by it.” Many believed that the African Americans were doomed to extinction, and arguments were made about their physiology being unsuited for the colder climates of America (thus they should be returned to Africa).

Scientific and medical authorities of the late 19 th /early 20 th centuries held extremely harmful pseudoscientific ideas specifically about the sex drives and genitals of African Americans. It was widely believed that, while the brains of African Americans were under-evolved, their genitals were over-developed. Black men were seen to have an intrinsic perversion for white women, and all African Americans were seen as inherently immoral, with insatiable sexual appetites.

This all matters because it was with these understandings of race, sexuality and health that researchers undertook the Tuskegee study. They believed, largely due to their fundamentally flawed scientific understandings of race, that black people were extremely prone to sexually transmitted infections (like syphilis). Low birth rates and high miscarriage rates were universally blamed on STIs.

They also believed that all black people, regardless of their education, background, economic or personal situations, could not be convinced to get treatment for syphilis. Thus, the USPHS could justify the Tuskegee study, calling it a “study in nature” rather than an experiment, meant to simply observe the natural progression of syphilis within a community that wouldn’t seek treatment.

The USPHS set their study in Macon County due to estimates that 35% of its population was infected with syphilis. In 1932, the initial patients between the ages of 25 and 60 were recruited under the guise of receiving free medical care for “bad blood,” a colloquial term encompassing anemia, syphilis, fatigue and other conditions. Told that the treatment would last only six months, they received physical examinations, x-rays, spinal taps, and when they died, autopsies.

Researchers faced a lack of participants due to fears that the physical examinations were actually for the purpose of recruiting them to the military. To assuage these fears, doctors began examining women and children as well. Men diagnosed with syphilis who were of the appropriate age were recruited for the study, while others received proper treatments for their syphilis (at the time these were commonly mercury - or arsenic -containing medicines).

In 1933, researchers decided to continue the study long term. They recruited 200+ control patients who did not have syphilis (simply switching them to the syphilis-positive group if at any time they developed it). They also began giving all patients ineffective medicines ( ointments or capsules with too small doses of neoarsphenamine or mercury) to further their belief that they were being treated.

As time progressed, however, patients began to stop attending their appointments. To greater incentivize them to remain a part of the study, the USPHS hired a nurse named Eunice Rivers to drive them to and from their appointments, provide them with hot meals and deliver their medicines, services especially valuable to subjects during the Great Depression. In an effort to ensure the autopsies of their test subjects, the researchers also began covering patient’s funeral expenses.

Multiple times throughout the experiment researchers actively worked to ensure that their subjects did not receive treatment for syphilis. In 1934 they provided doctors in Macon County with lists of their subjects and asked them not to treat them. In 1940 they did the same with the Alabama Health Department. In 1941 many of the men were drafted and had their syphilis uncovered by the entrance medical exam, so the researchers had the men removed from the army, rather than let their syphilis be treated.

It was in these moments that the Tuskegee study’s true nature became clear. Rather than simply observing and documenting the natural progression of syphilis in the community as had been planned, the researchers intervened: first by telling the participants that they were being treated (a lie), and then again by preventing their participants from seeking treatment that could save their lives. Thus, the original basis for the study--that the people of Macon County would likely not seek treatment and thus could be observed as their syphilis progressed--became a self-fulfilling prophecy.

The Henderson Act was passed in 1943, requiring tests and treatments for venereal diseases to be publicly funded, and by 1947, penicillin had become the standard treatment for syphilis , prompting the USPHS to open several Rapid Treatment Centers specifically to treat syphilis with penicillin. All the while they were actively preventing 399 men from receiving the same treatments.

By 1952, however, about 30% of the participants had received penicillin anyway, despite the researchers’ best efforts. Regardless, the USPHS argued that their participants wouldn’t seek penicillin or stick to the prescribed treatment plans. They claimed that their participants, all black men, were too “stoic” to visit a doctor. In truth these men thought they were already being treated, so why would they seek out further treatment?

The researchers’ tune changed again as time went on. In 1965, they argued that it was too late to give the subjects penicillin, as their syphilis had progressed too far for the drug to help. While a convenient justification for their continuation of the study, penicillin is (and was) recommended for all stages of syphilis and could have stopped the disease’s progression in the patients.

In 1947 the Nuremberg code was written, and in 1964 the World Health Organization published their Declaration of Helsinki . Both aimed to protect humans from experimentation, but despite this, the Centers for Disease Control (which had taken over from the USPHS in controlling the study) actively decided to continue the study as late as 1969.

It wasn’t until a whistleblower, Peter Buxtun, leaked information about the study to the New York Times and the paper published it on the front page on November 16 th , 1972, that the Tuskegee study finally ended. By this time only 74 of the test subjects were still alive. 128 patients had died of syphilis or its complications, 40 of their wives had been infected, and 19 of their children had acquired congenital syphilis.

There was mass public outrage, and the National Association for the Advancement of Colored People launched a class action lawsuit against the USPHS. It settled the suit two years later for 10 million dollars and agreed to pay the medical treatments of all surviving participants and infected family members, the last of whom died in 2009.

Largely in response to the Tuskegee study, Congress passed the National Research Act in 1974, and the Office for Human Research Protections was established within the USPHS. Obtaining informed consent from all study participants became required for all research on humans, with this process overseen by Institutional Review Boards (IRBs) within academia and hospitals.

The Tuskegee study has had lasting effects on America . It’s estimated that the life expectancy of black men fell by up to 1.4 years when the study’s details came to light. Many also blame the study for impacting the willingness of black individuals to willingly participate in medical research today.

We know all about evil Nazis who experimented on prisoners. We condemn the scientists in Marvel movies who carry out tests on prisoners of war. But we’d do well to remember that America has also used its own people as lab rats . Yet to this day, no one has been prosecuted for their role in dooming 399 men to syphilis.

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About the USPHS Syphilis Study

Where the Study Took Place

The study took place in Macon County, Alabama, the county seat of Tuskegee referred to as the "Black Belt" because of its rich soil and vast number of black sharecroppers who were the economic backbone of the region. The research itself took place on the campus of Tuskegee Institute.

What it Was Designed to Find Out

The intent of the study was to record the natural history of syphilis in Black people. The study was called the "Tuskegee Study of Untreated Syphilis in the Negro Male." When the study was initiated there were no proven treatments for the disease. Researchers told the men participating in the study that they were to be treated for "bad blood." This term was used locally by people to describe a host of diagnosable ailments including but not limited to anemia, fatigue, and syphilis.

Who Were the Participants

 A total of 600 men were enrolled in the study. Of this group 399, who had syphilis were a part of the experimental group and 201 were control subjects. Most of the men were poor and illiterate sharecroppers from the county.

What the Men Received in Exchange for Participation

The men were offered what most Negroes could only dream of in terms of medical care and survivors insurance. They were enticed and enrolled in the study with incentives including: medical exams, rides to and from the clinics, meals on examination days, free treatment for minor ailments and guarantees that provisions would be made after their deaths in terms of burial stipends paid to their survivors.

Treatment Withheld

There were no proven treatments for syphilis when the study began. When penicillin became the standard treatment for the disease in 1947 the medicine was withheld as a part of the treatment for both the experimental group and control group.

How/Why the Study Ended

On July 25, 1972 Jean Heller of the Associated Press broke the story that appeared simultaneously both in New York and Washington, that there had been a 40-year nontherapeutic experiment called "a study" on the effects of untreated syphilis on Black men in the rural south.

Between the start of the study in 1932 and 1947, the date when penicillin was determined as a cure for the disease, dozens of men had died and their wives, children and untold number of others had been infected. This set into motion international public outcry and a series of actions initiated by U.S. federal agencies. The Assistant Secretary for Health and Scientific Affairs appointed an Ad Hoc Advisory Panel, comprised of nine members from the fields of health administration, medicine, law, religion, education, etc. to review the study.

While the panel concluded that the men participated in the study freely, agreeing to the examinations and treatments, there was evidence that scientific research protocol routinely applied to human subjects was either ignored or deeply flawed to ensure the safety and well-being of the men involved. Specifically, the men were never told about or offered the research procedure called informed consent. Researchers had not informed the men of the actual name of the study, i.e. "Tuskegee Study of Untreated Syphilis in the Negro Male," its purpose, and potential consequences of the treatment or non-treatment that they would receive during the study. The men never knew of the debilitating and life threatening consequences of the treatments they were to receive, the impact on their wives, girlfriends, and children they may have conceived once involved in the research. The panel also concluded that there were no choices given to the participants to quit the study when penicillin became available as a treatment and cure for syphilis.

Reviewing the results of the research the panel concluded that the study was "ethically unjustified." The panel articulated all of the above findings in October of 1972 and then one month later the Assistant Secretary for Health and Scientific Affairs officially declared the end of the Tuskegee Study.

Class-Action Suit

In the summer of 1973, Attorney Fred Gray filed a class-action suit on behalf of the men in the study, their wives, children and families. It ended a settlement giving more than $9 million to the study participants.

The Role of the US Public Health Service

In the beginning of the 20th Century, the U.S. Public Health Service (PHS) was entrusted with the responsibility to monitor, identify trends in the heath of the citizenry, and develop interventions to treat disease, ailments and negative trends adversely impacting the health and wellness of Americans. It was organized into sections and divisions including one devoted to venereal diseases. All sections of the PHS conducted scientific research involving human beings. The research standards were for their times adequate, by comparison to today's standards dramatically different and influenced by the professional and personal biases of the people leading the PHS. Scientists believed that few people outside of the scientific community could comprehend the complexities of research from the nature of the scientific experiments to the consent involved in becoming a research subject. These sentiments were particularly true about the poor and uneducated Black community.

The PHS began working with Tuskegee Institute in 1932 to study hundreds of black men with syphilis from Macon County, Alabama.

Compensation for Participants

As part of the class-action suit settlement, the U.S. government promised to provide a range of free services to the survivors of the study, their wives, widows, and children. All living participants became immediately entitled to free medical and burial services. These services were provided by the Tuskegee Health Benefit Program, which was and continues to be administered by the Centers for Disease Control and Prevention in their National Center for HIV, STD and TB Prevention.

1996 Tuskegee Legacy Committee

In February of 1994 at the Claude Moore Health Sciences Library in Charlottesville, VA, a symposium was held entitled "Doing Bad in the Name of Good?: The Tuskegee Syphilis Study and Its Legacy." Resulting from this gathering was the creation of the Tuskegee Syphilis Study Legacy Committee which met for the first time in January 18th & 19th of 1996.  The committee had two goals; (1) to persuade President Clinton to apologize on behalf of the government for the atrocities of the study and (2) to develop a strategy to address the damages of the study to the psyche of African-Americans and others about the ethical behavior of government-led research; rebuilding the reputation of Tuskegee through public education about the study, developing a clearinghouse on the ethics of scientific research and scholarship and assembling training programs for health care providers. After intensive discussions, the Committee's final report in May of 1996 urged President Clinton to apologize for the emotional, medical, research and psychological damage of the study. On May 16th at a White House ceremony attended by the men, members of the Legacy Committee and others representing the medical and research communities, the apology was delivered to the surviving participants of the study and families of the deceased.

What Newly Digitized Records Reveal About the Tuskegee Syphilis Study

The archival trove chronicles the extreme measures administrators took to ensure Black sharecroppers did not receive treatment for the venereal disease

Caitjan Gainty, The Conversation

In 1972, a whistleblower revealed that the United States Public Health Service (USPHS) had withheld syphilis treatment from hundreds of Black men as part of a 40-year study observing the natural course of the disease. The experiment’s subjects—the majority of whom were sharecroppers from rural Alabama—believed they were undergoing treatment for “bad blood,” a colloquial name then used for a host of conditions, including venereal diseases. Instead, they received placebos and inadequate medical care, even after penicillin emerged as an effective, readily available treatment for syphilis in the mid-1940s.

The Tuskegee syphilis study , as the experiment is often called today, began in 1932 with the recruitment of 600 Black men, 399 with syphilis and 201 without, to serve as the control group. Initially intended to run for six months, the study continued for decades. Unwitting participants lured in by the promise of free medical care, hot meals and burial insurance returned regularly for aspirin, tonics, blood draws and the occasional spinal tap. But none of these treatments does any good for syphilis, and 128 of the men ultimately died of the disease or complications related to it.

When news of the study broke, Chuck Stone , a journalist and former Tuskegee Airman , responded with an impassioned editorial, writing, “It either takes a tough constitution or a rancid morality to sit quietly by and watch 200 men die without doing anything about it. I call it genocide. Have you got a better name for it?”

Historians have had decades to pore over the study’s archives. Now, the National Library of Medicine has made a collection of those documents available for public viewing online . Anyone with an internet connection can read the primary source material—hundreds of pages of administrative records, letters and meeting minutes.

No one would expect the portrait this collection paints to be pretty or redemptive. Indeed, the study has gone down in the annals of American history as one of the most notorious, but by no means only, examples of medicine at its most prejudicial, virulent and unethical. Even with this knowledge, it is galling to read about the lengths USPHS doctors went to to ensure their patients were denied treatment.

Immobile and malleable

A 1948 history of the study makes it clear that the choice to set the experiment in the Deep South was deliberate. As the paper notes, the study followed a broader survey of syphilis in the still deeply segregated region. Sponsored by the Julius Rosenwald Fund , this earlier program aimed to assess the prevalence of the disease in several Southern counties and make sensible plans for its treatment—a starkly different goal than the Tuskegee experiment. The USPHS drew on this data to identify Macon County, Alabama, the surveyed area with the highest prevalence rate of syphilis, as the right place for a new study. Macon County also had high poverty rates and low education rates, ensuring the experiment’s subjects would be both immobile and malleable.

Another contributing factor was the presence of the venerable Tuskegee University, a historically Black college then known as the Tuskegee Institute, which had the facilities necessary to carry out the autopsies and lab work the study required.

Always a hurdle was a 1927 Alabama state statute that required medical personnel to report and treat all cases of syphilis. But enforcement of this statute was so lax that the experiment could have continued unimpeded had it not been for the 1942 draft, which led the local Selective Service Board to unmask the syphilitic status of the study’s subjects. The board’s charge was to evaluate individuals for military service, a process that required testing for venereal diseases and mandatory treatment for those affected.

R.A. Vonderlehr, the assistant surgeon general and one of the originators of the study, jumped into action to prevent the subjects from receiving treatment. He wrote urgently to local health officer Murray Smith, asking him to pull some strings to get the study subjects exempted.

“I would suggest that you confer with the chairman of the local Selective Service Board,” Vonderlehr wrote. “I believe he is an old friend of yours, and I would inform him of all the circumstances connected with the study. It is entirely probable that … he will cooperate with you in the completion of the investigation.”

Smith made good use of his social connections, managing to get the 256 remaining syphilitic subjects exempted from treatment. Likewise, when the same matter reached D.G. Gill, director of the Alabama Department of Health’s Bureau of Preventable Diseases, he requested Vonderlehr’s advice on whether to “make an exception of these few individuals” to avoid “encroaching on some of your study material.”

Effective treatment denied

Even in the postwar period, when penicillin became widely available, replacing the arguably ineffective and dangerous arsenic-based syphilis treatments that had preceded it, the study ploughed ahead , still more committed to documenting the disease than treating its sufferers. There was nothing unwitting about this denial of treatment.

Indeed, the archive shows that subjects were explicitly and repeatedly lied to for decades so they wouldn’t seek treatment for syphilis on their own. Even the form letters they received bore the hallmarks of a scam. They were invited to a “special examination” with government doctors waiting to give them “special attention” to “find out how you have been feeling and whether the treatment has improved your health.” Some of these notes were signed by Smith, who was designated just below his signature as a “special expert” to the USPHS.

And then there were the spinal taps , which were widely hated by the study subjects for the severe headaches they caused and because the men worried the procedure “robbed [them] of their procreative powers (regardless of the fact that I claim it stimulates them),” wrote physician Austin V. Deibert in a 1939 letter to Vonderlehr. 

Deibert told Vonderlehr the USPHS might have to  cancel the spinal taps  for the sake of the study’s continuation. “All in all and with no attempt at humor,” he said, he was the one with the real “headache.”

Neither World War II nor the early civil rights movement seemed to move the subsequent generations of study staff and administrators. The study was widely known in medical circles, thanks to the dozen or so articles on its findings published in prominent journals. Though outsiders started criticizing the experiment in the 1950s and ’60s, these dissenting voices were few and far between.

The first confirmed critique of the study from outside the USPHS arrived in a 1955 letter written by physician Count Gibson , who had heard a USPHS official explicitly state that the study’s subjects were not informed that treatment was being withheld.

Though Gibson was reportedly unsatisfied with the response he received, his colleagues urged him not to pursue the issue for fear that speaking out against these very powerful men might jeopardize his own career. He let it drop. In 1964, cardiologist Irwin Schatz voiced similar concerns, writing a letter that also questioned the study’s ethics. He never received a reply.

Concerns waved off

Indeed, the study directors continued to wave off concerns. As a set of meeting minutes from 1965 put it, “Racial issue was mentioned briefly. Will not affect the study. Any questions can be handled by saying these people were at the point that therapy would no longer help them. They are getting better medical care than they would under any other circumstances.”

In 1970, Anne R. Yobs, a co-author of one of the published papers, acknowledged that the research should come to an end. In a letter to the director of the Centers for Disease Control, she recommended closing the study, not because the charges of racism and unethical practice that had started to pour in were merited, but rather because “changes at the program level … in sensitivity to (potential) criticism” had forced administrators’ hands.

The study had become “an increasingly emotionally charged subject,” preventing “a rational appraisal of the situation,” wrote James B. Lucas, assistant chief of the USPHS’ Venereal Disease Branch, in a memo that same year.

By 1972, Peter Buxtun , a USPHS venereal disease officer who had spoken out against the study within the organization for years to no avail, had had enough. He went to the press.

Jean Heller, an Associated Press journalist, broke the story that July. A few months later, an ad hoc committee organized to evaluate the study finally ended it .

The Tuskegee study’s legacy has reverberated across the decades. In 1974, the NAACP successfully sued the federal government for $10 million, distributing the settlement money to the study subjects and their surviving family members. In 1997, President Bill Clinton publicly apologized to the men, acknowledging that what the USPHS had done was “deeply, profoundly, morally wrong.”

The study has had a material impact on medical outcomes within the African American community more broadly. Over the past several decades, researchers have connected the experiment to lower life expectancy among Black men due to broken trust in the health care system. More recently, the Covid-19 pandemic and subsequent vaccination efforts reignited discussions around Tuskegee’s impact on medical mistrust . Susan Reverby, the preeminent historian of the Tuskegee syphilis study, argues that the experiment’s legacy is far more complex than commonly stated, in no small part because of how it has been viewed historically. She notes that tying medical skepticism directly to Tuskegee erroneously suggests that the “reason for mistrust happened a long time ago,” thus turning attention away from the structural racism of today. As historian Alice Dreger succinctly puts it, “African Americans who distrust the health care system see plenty of reasons all around them to do so. They don’t have to look back 40 years.”

Perhaps, in this light, the most important takeaway from these digitized documents is not the starkly racist, unethical enterprise they so vividly record. It’s easy to condemn Vonderlehr, Smith, Yobs, Deibert and the countless others in the story whose actions are deeply troubling. But it’s more useful to observe how professional credentials and networks, philanthropic funding, warped notions of the greater good, and devotion to the scientific method provide cover to racism—and even prop it up. For it is often in these more quotidian spaces of life that racism in medicine persists .

This article is published in partnership with the Conversation under a Creative Commons license. Read the Conversation’s version .

Caitjan Gainty is a historian of 20th-century medicine and technology at King’s College London. She initially trained in public health and worked for several years in health care research before returning to academia to pursue a PhD in the history of medicine, which she received in 2012.

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Tuskegee Syphilis Experiment

The official title was “The Tuskegee Study of Untreated Syphilis in the Negro Male.” It is commonly called the Infamous Tuskegee Syphilis Experiment. Beginning in 1932 and continuing to 1972 the United States Public Health Services lured over 600 Black men, mostly sharecroppers in Tuskegee, Alabama, into this diabolical medical experiment with the promise of free health care. For 40 years, hundreds of African American men with syphilis went untreated, given placebos and other ineffective treatments, so that scientists could study the effects of the disease, even after there was a cure. None of the men who had syphilis were ever told they had it. Instead they were only told that they had “bad blood.” They were also never given penicillin, despite the fact that it had become a standard treatment by 1947.

The last survivor of the study died in 2004. This was not that long ago.

The Hippocratic Oath is used as a symbolic gesture that binds physicians to their patient’s well-being. Those who choose to take the oath makes an affirmation about treatment of those entrusted in their care, “I will do no harm or injustice to them.” It is commonly simply rephrased as, "First, do no harm." That was not the case with healthcare providers in Tuskegee, AL.

Below is an excerpt from an official admission of systematic racial discrimination issued by the United States President in 1997:

The President’s words confirmed the institutionally and racially discriminatory practices that have spanned not just decades as in this case, but centuries. Medical malfeasance is nothing new. Currently, amends are being made symbolically. In 2018, New York City finally removed an offensive statue from high atop a pedestal in Central Park. The statue depicted an infamous 19th-century gynecologist who experimented on enslaved women named Anarcha, Lucy and Betsey. He was part of a medical apartheid system that treated Black subjects as sub-human. He inflicted unimaginable torture because he operated under the ridiculous notion that Black people did not feel pain.

Remarkably, present day studies reveal that a frightening number of healthcare providers believe the myth that Black people have thicker skin and therefore need less pain management. The University of Virginia reported that racial bias partially explains research documenting how Black Americans are systemically undertreated for pain.

The Tuskegee Experiment was relatively recent and at least partially impacts the reactions to the current Novel Coronavirus pandemic. Black Americans have this recent example, in addition to a long history of other examples, explaining why it is reasonable to be suspicious of governmental medical information.

The Lasting Fallout of the Tuskegee Syphilis Study

A recent paper provides evidence that the Tuskegee Syphilis Study reduced the life expectancy of African-American men.

A new paper provides evidence that the Tuskegee Syphilis Study reduced the life expectancy of African-American men —though the Tuskegee Syphilis Study ended decades ago. What was the Tuskegee Syphilis Study and why did it have lasting reverberations?

The now-infamous 1932 Tuskegee Syphilis Study  was conducted by the U.S. Public Health Service in Macon County, Alabama. During the experiment 600 impoverished black men were studied, 399 of whom had syphilis that went untreated although the health care practitioners knew of their illness. The men were never educated about syphilis, were never told of their status or treated, although treatments did exist; they were merely told they were being seen for “bad blood.” The men underwent painful procedures like spinal taps under the guise of “free healthcare,” and were “compensated” with meals and burial insurance. The intent of the study was never even to actually help the patients, but rather to examine the course of untreated dormant syphilis in black men.

Men in the study were not allowed to access other treatment services in the area. Not only did the syphilis harm the men, many of their wives and even some of their children contracted the disease. Despite the fact that codes like the Nuremberg Code of ethics was created during the Tuskegee study, and that by 1947 penicillin had become a standard, effective treatment for syphilis, the experiment continued. The study was initially intended to be six months but continued until 1972.  It did not provide as much insight on syphilis research as it did about racism in health research.

Decades after the Tuskegee Syphilis study health statistics continue to illustrate the lack of trust black Americans have for healthcare professionals. Looking at the context and history of the beliefs can help us make sense of the trends. In the 1990s a notable chunk of the African American community believed that the government created AIDS . A 1997 study illustrated cited 32.1% of the black women surveyed agreed with a statement that scientists were not trustworthy . This significantly deviates from the 4.1 % of white women in the study who agreed with the aforementioned statement. This was despite the fact that over 80% of women surveyed recognized the benefits of medical research for society. The newer findings  delve specifically into how this mistrust of the health profession has had negative impacts on black people’s health.

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While tenets of equity in healthcare research appear to be universal , there is a long history of disparity when it comes to the distribution and quality of healthcare amongst individual people. The Hippocratic oath  compels new doctors to make blanket commitments to ethics and accountability while serving humanity regardless of gender, race, religion, political affiliation, sexual orientation, nationality, or social standing . And yet this oath belies a legacy of racism in medicine.

Communities that have experienced such painful histories of being used as lab rats understandably may not be inclined to engage with healthcare providers. Beneficence and non-maleficence are cornerstones of health care provision, at least if you look at codes we like to think all healthcare providers adhere to. But fidelity was not upheld with Tuskegee and the ripple effect is evident today. Oaths do not guarantee an obligation to morality or veracity in healthcare, people do.

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How the Public Learned About the Infamous Tuskegee Syphilis Study

A s the fight over reforms to the American health-care system continues this week, Tuesday marks the 45th anniversary of a grim milestone in the history of health care in the U.S.

On July 25, 1972, the public learned that, over the course of the previous 40 years, a government medical experiment conducted in the Tuskegee, Ala., area had allowed hundreds of African-American men with syphilis to go untreated so that scientists could study the effects of the disease.

“Of about 600 Alabama black men who originally took part in the study, 200 or so were allowed to suffer the disease and its side effects without treatment, even after penicillin was discovered as a cure for syphilis,” the Associated Press reported , breaking the story. “[U.S. Public Health Service officials] contend that survivors of the experiment are now too old to treat for syphilis, but add that PHS doctors are giving the men thorough physical examinations every two years and are treating them for whatever other ailments and diseases they have developed.”

By the time the bombshell report came out, seven men involved had died of syphilis and more than 150 of heart failure that may or may not have been linked to syphilis. Seventy-four participants were still alive, but the government health officials who started the study had already retired. And, because of the study’s length and the way treatment options had evolved in the intervening years, it was hard to pin the blame on an individual — though easy to see that it was wrong, as TIME explained in the Aug. 7, 1972, issue:

At the time the test began, treatment for syphilis was uncertain at best, and involved a lifelong series of risky injections of such toxic substances as bismuth, arsenic and mercury. But in the years following World War II, the PHS’s test became a matter of medical morality. Penicillin had been found to be almost totally effective against syphilis, and by war’s end it had become generally available. But the PHS did not use the drug on those participating in the study unless the patients asked for it. Such a failure seems almost beyond belief, or human compassion. Recent reviews of 125 cases by the PHS’S Center for Disease Control in Atlanta found that half had syphilitic heart valve damage. Twenty-eight had died of cardiovascular or central nervous system problems that were complications of syphilis. The study’s findings on the effects of untreated syphilis have been reported periodically in medical journals for years. Last week’s shock came when an alert A.P. correspondent noticed and reported that the lack of treatment was intentional.

About three months later, the study was terminated, and the families of victims reached a $10 million settlement in 1974 (the terms of which are still being negotiated today by descendants). The last study participant passed away in 2004.

Tuskegee was chosen because it had the highest syphilis rate in the country at the time the study was started. As TIME made clear with a 1940 profile of government efforts to improve the health of African Americans, concern about that statistic had drawn the attention of the federal government and the national media. Surgeon General Thomas Parran boasted that in Macon County, Ala., where Tuskegee is located, the syphilis rate among the African-American population had been nearly 40% in 1929 but had shrunk to 10% by 1939. Serious efforts were being devoted to the cause, the story explained, though the magazine clearly missed the full story of what was going on:

In three years, experts predict, the disease will be wiped out. To root syphilis out of Macon County, the U. S. Public Health Service, the Rosenwald Fund and Booker T. Washington’s Tuskegee Institute all joined forces. Leader of the campaign is a white man, the county health officer, a former Georgia farm boy who drove a flivver through fields of mud, 36 miles a day to medical school. Last month, deep-eyed, sunburned Dr. Murray Smith began his tenth year in Macon County. “There’s not much in this job,” said he, “but the love and thanks of the people.” At first the Negroes used to gather in the gloomy courthouse in Tuskegee, while Dr. Smith in the judge’s chambers gave them tests and treatment. Later he set up weekly clinics in old churches or schoolhouses, deep in the parched cotton fields. Last fall the U. S. Public Health Service gave him a streamlined clinic truck. The truck, which has a laboratory with sink and sterilizer, a treatment nook with table and couch, is manned by two young Negro doctors and two nurses. Five days a week it rumbles over the red loam roads. At every crossroads it stops. At the toot of its horn, through the fields come men on muleback, women carrying infants, eager to be first, proud to have a blood test. Some young boys even sneak in to get a second or third test, and many come around to the truck long after they have been cured. One woman who had had six miscarriages got her syphilis cured by Dr. Smith with neoarsphenamine. Proudly she named her first plump baby Neo.

In the years following the disclosure, the Tuskegee study became a byword for the long and complicated history of medical research of African Americans without their consent. In 1997, President Bill Clinton apologized to eight of the survivors. “You did nothing wrong, but you were grievously wronged,” he said. “I apologize and I am sorry that this apology has been so long in coming.” As Clinton noted, African-American participation in medical research and organ donation remained low decades after the 1972 news broke, a fact that has often been attributed to post-Tuskegee wariness.

In 2016, a National Bureau of Economic Research paper argued that after the disclosure of the 1972 study, “life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women.” However, many experts argue that the discrepancy has more to do with racial bias in the medical profession.

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National Archives at Atlanta

U.S. Public Health Service (USPHS) Untreated Syphilis Study at Tuskegee

The USPHS Untreated Syphilis Study at Tuskegee began in 1929 as a cooperative study involving the USPHS, the Julius Rosenwald Fund, and state and local health departments in six southern states. During the study, a number of Black men in Tuskegee (Macon County), AL, with syphilis were left untreated, but were observed, studied, and compared to a control group which did not have the disease. The study continued until the 1970s when its existence was revealed to the public, resulting in Department of Health Education and Welfare and Congressional hearings on the ethics of medical experiments on human subjects.

This photograph depicts one of the doctors who worked with the USPHS Untreated Syphilis Study at Tuskegee drawing blood from one of the participants. Learn more about the individuals involved in this study by viewing the index .

Photograph of Participants in the Tuskegee Syphilis Study, undated. National Archives Identifier: 956091

View in National Archives Catalog

View and download the photograph of a participant of the USPHS Untreated Syphilis Study at Tuskegee  in the National Archives Catalog. This photograph is one example of the many records held at the National Archives at Atlanta, GA. You can explore more of our holdings by visiting our online  Catalog  or by visiting the  National Archives at Atlanta . This record is located within  Record Group 442: Centers for Disease Control and Prevention , Series: Tuskegee Syphilis Study Administrative Records, 1929–1972 . Many of the records in this collection have yet to be digitized. We encourage researchers to visit us onsite to explore these records and learn more about the archival collections held in the National Archives at Atlanta.

The Tuskegee Syphilis Experiment

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. . . . clearly racist. —President Clinton's apology for the Tuskegee Syphilis Experiment to the eight remaining survivors, May 16, 1997

For forty years between 1932 and 1972, the U.S. Public Health Service (PHS) conducted an experiment on 399 Black men in the late stages of syphilis. These men, for the most part illiterate sharecroppers from one of the poorest counties in Alabama, were never told what disease they were suffering from or of its seriousness. Informed that they were being treated for “bad blood,” 1 their doctors had no intention of curing them of syphilis at all. The data for the experiment was to be collected from autopsies of the men, and they were thus deliberately left to degenerate under the ravages of tertiary syphilis—which can include tumors, heart disease, paralysis, blindness, insanity, and death. “As I see it,” one of the doctors involved explained, “we have no further interest in these patients until they die.”

Using Human Beings like Laboratory Animals

The true nature of the experiment had to be kept from the subjects to ensure their cooperation. The sharecroppers' grossly disadvantaged lot in life made them easy to manipulate. Pleased at the prospect of free medical care—almost none of them had ever seen a doctor before—these unsophisticated and trusting men became the pawns in what James Jones, author of the excellent history on the subject, Bad Blood, identified as “the longest nontherapeutic experiment on human beings in medical history.”

The study was meant to discover how syphilis affected Black people as opposed to whites—the theory being that whites experienced more neurological complications from syphilis whereas Black people were more susceptible to cardiovascular damage. How this knowledge would have changed clinical treatment of syphilis is uncertain. Although the PHS touted the study as one of great scientific merit, from the outset its actual benefits were hazy. It took almost forty years before someone involved in the study took a hard and honest look at the end results, reporting that “nothing learned will prevent, find, or cure a single case of infectious syphilis or bring us closer to our basic mission of controlling venereal disease in the United States.” When the experiment was brought to the attention of the media in 1972, news anchor Harry Reasoner described it as an experiment that “used human beings as laboratory animals in a long and inefficient study of how long it takes syphilis to kill someone.”

A Heavy Price in the Name of Bad Science

By the end of the experiment, 28 of the men had died directly of syphilis, 100 were dead of related complications, 40 of their wives had been infected, and 19 of their children had been born with congenital syphilis. How had these men been induced to endure a fatal disease in the name of science? To persuade the community to support the experiment, one of the original doctors admitted it “was necessary to carry on this study under the guise of a demonstration and provide treatment.” At first, the men were prescribed the syphilis remedies of the day—bismuth, neoarsphenamine, and mercury—but in such small amounts that only 3 percent showed any improvement. These token doses of medicine were good public relations and did not interfere with the true aims of the study. Eventually, all syphilis treatment was replaced with “pink medicine”—aspirin. To ensure that the men would show up for a painful and potentially dangerous spinal tap, the PHS doctors misled them with a letter full of promotional hype: “Last Chance for Special Free Treatment.” The fact that autopsies would eventually be required was also concealed. As a doctor explained, “If the colored population becomes aware that accepting free hospital care means a post-mortem, every darky will leave Macon County…” Even the Surgeon General of the United States participated in enticing the men to remain in the experiment, sending them certificates of appreciation after 25 years in the study.

Following Doctors' Orders

It takes little imagination to ascribe racist attitudes to the white government officials who ran the experiment, but what can one make of the numerous African Americans who collaborated with them? The experiment's name comes from the Tuskegee Institute, the Black university founded by Booker T. Washington. Its affiliated hospital lent the PHS its medical facilities for the study, and other predominantly Black institutions, as well as local Black doctors, also participated. A Black nurse, Eunice Rivers, was a central figure in the experiment for most of its forty years. The promise of recognition by a prestigious government agency may have obscured the troubling aspects of the study for some. A Tuskegee doctor, for example, praised “the educational advantages offered our interns and nurses as well as the added standing it will give the hospital.” Nurse Rivers explained her role as one of passive obedience: “we were taught that we never diagnosed, we never prescribed; we followed the doctor's instructions!” It is clear that the men in the experiment trusted her and that she sincerely cared about their well-being, but her unquestioning submission to authority eclipsed her moral judgment. Even after the experiment was exposed to public scrutiny, she genuinely felt nothing ethical had been amiss.

One of the most chilling aspects of the experiment was how zealously the PHS kept these men from receiving treatment. When several nationwide campaigns to eradicate venereal disease came to Macon County, the men were prevented from participating. Even when penicillin was discovered in the 1940s—the first real cure for syphilis—the Tuskegee men were deliberately denied the medication. During World War II, 250 of the men registered for the draft and were consequently ordered to get treatment for syphilis, only to have the PHS exempt them. Pleased at their success, the PHS representative announced: “So far, we are keeping the known positive patients from getting treatment.” The experiment continued in spite of the Henderson Act (1943), a public health law requiring testing and treatment for venereal disease, and in spite of the World Health Organization's Declaration of Helsinki (1964), which specified that “informed consent” was needed for experiment involving human beings.

Blowing the Whistle

The story finally broke in the Washington Star on July 25, 1972, in an article by Jean Heller of the Associated Press. Her source was Peter Buxtun, a former PHS venereal disease interviewer and one of the few whistle blowers over the years. The PHS, however, remained unrepentant, claiming the men had been “volunteers” and “were always happy to see the doctors,” and an Alabama state health officer who had been involved claimed “somebody is trying to make a mountain out of a molehill.”

Under the glare of publicity, the government ended their experiment, and for the first time provided the men with effective medical treatment for syphilis. Fred Gray, a lawyer who had previously defended Rosa Parks and Martin Luther King, filed a class action suit that provided a $10 million out-of-court settlement for the men and their families. Gray, however, named only whites and white organizations in the suit, portraying Tuskegee as a black and white case when it was in fact more complex than that—Black doctors and institutions had been involved from beginning to end.

The PHS did not accept the media's comparison of Tuskegee with the appalling experiments performed by Nazi doctors on their Jewish victims during World War II. Yet in addition to the medical and racist parallels, the PHS offered the same morally bankrupt defense offered at the Nuremberg trials: they claimed they were just carrying out orders, mere cogs in the wheel of the PHS bureaucracy, exempt from personal responsibility.

The study's other justification—for the greater good of science—is equally spurious. Scientific protocol had been shoddy from the start. Since the men had in fact received some medication for syphilis in the beginning of the study, however inadequate, it thereby corrupted the outcome of a study of “untreated syphilis.”

In 1990, a survey found that 10 percent of African Americans believed that the U.S. government created AIDS as a plot to exterminate Black people, and another 20 percent could not rule out the possibility that this might be true. As preposterous and paranoid as this may sound, at one time the Tuskegee experiment must have seemed equally farfetched. In light of this and many other shameful episodes in our history, African Americans' widespread mistrust of the government and white society in general should not be a surprise to anyone.

Bad Blood: The Tuskegee Syphilis Experiment, James H. Jones, expanded edition (New York: Free Press, 1993).

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Digitized Document Collection from USPHS Untreated Syphilis Study at Tuskegee Now Publicly Available Through NLM

Leaders from the Voices for Our Fathers Legacy Foundation, descendants of the men who were treated unethically in the study, visit with NIH leadership in September 2023 to view contents of the physical collection before the release of the digitized collection.

A collection of reproduced documents from the 1932 study by the U.S. Public Health Service (USPHS) on the effects of untreated syphilis in Black men at Tuskegee Institute is now available as a digitized collection through the National Library of Medicine (NLM). The USPHS Untreated Syphilis Study at Tuskegee was conducted without informed consent and led to major reforms to protect participants in biomedical research. The digitized collection, which can be viewed as part of NLM’s Digital Collections , was made possible through permission from Fisk University, Nashville, a historically Black university, which holds a portion of original documents at the John Hope and Aurelia E. Franklin Library, Special Collections, Julius Rosenwald Fund Archives. NLM is part of the National Institutes of Health. NIH has worked with Fisk University to make these important documents, previously only available in their physical form, more broadly available to ensure this chapter in history is never repeated and build greater trust in current biomedical research through transparency.

The USPHS is part of the Department of Health and Human Services. HHS and its divisions, including NIH, take very seriously our responsibility to ensure the ethical conduct of the studies we support. Additionally, HHS established the Office for Human Research Protections to provide leadership in the protection of the rights, welfare, and wellbeing of those involved in HHS-conducted or -supported human research. HHS and its divisions have built mechanisms into our review, funding, and management of projects to ensure that research participants are protected and that a study like the USPHS Untreated Syphilis Study at Tuskegee will never happen again.

The collection, which consists of more than 3,000 reproduced copies of correspondence, memoranda, meeting minutes, reports, and scientific articles, constitutes a distinct historical record that has informed research led by historians, medical ethicists, and many others across a variety of disciplines. NLM’s stewardship of this collection supports its mission to enable biomedical research and support health care and public health through free online access to scholarly biomedical literature.

About the Study

Cover page of meeting minutes from the Ad Hoc Advisory Panel held on February 23, 1973, superimposed over an image of a Black participant in the study included in the NLM’s digital collection.

In 1932, a study began on the effects of untreated syphilis on Black men in Alabama. Researchers conducting the study did not obtain informed consent from participants and did not offer treatment, even after it was widely available. In 1972, an ad hoc federal panel was created to investigate the study. The final report found the study to be ethically unjustified and that participants were not informed about the nature of the disease and given treatment once a highly effective treatment was found. In 1972, the study officially ended after advisement from the panel. The investigation and its subsequent findings led to compensation for victims of the research and major changes in research practices.

In 1973, Dr. R.C. Backus, Executive Secretary of the Ad Hoc Advisory Panel, donated to NLM photocopies of the original documents on the origin, development, and investigation of the USPHS Untreated Syphilis Study at Tuskegee. In making this collection more widely available, NIH is recognizing the participants in the USPHS study and the injustices they and their families suffered. NIH also recognizes the work of the Ad Hoc Advisory Panel to address the unethical actions of the study which ushered in new protections for the rights of research participants.

The NLM collects, preserves, and makes publicly available collections such as that of the USPHS Untreated Syphilis Study at Tuskegee to advance open access, improve transparency in research, and ensure that lessons of the past inform the present and future of biomedical research, health care, public health, and healthy behavior. View NLM’s YouTube video and Circulating Now post to learn more about the USPHS Untreated Syphilis Study at Tuskegee.

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First, Do No Harm: The US Sexually Transmitted Disease Experiments in Guatemala

Both authors contributed substantially to the conceptualization and design of the article and to critical revisions of the article for important intellectual content.

Beginning in 1946, the United States government immorally and unethically—and, arguably, illegally—engaged in research experiments in which more than 5000 uninformed and unconsenting Guatemalan people were intentionally infected with bacteria that cause sexually transmitted diseases. Many have been left untreated to the present day.

Although US President Barack Obama apologized in 2010, and although the US Presidential Commission for the Study of Bioethical Issues found the Guatemalan experiments morally wrong, little if anything has been done to compensate the victims and their families.

We explore the backdrop for this unethical medical research and violation of human rights and call for steps the United States should take to provide relief and compensation to Guatemala and its people.

Today, Guatemala has a total population of 14.76 million people; 53.7% live in poverty. 1 The average level of education was 4.1 years in 2011, 1 and Guatemala is considered a lower-middle-income country. 1 In 1946, these demographic characteristics were even more dismal and without the benefit of more than 60 years of national, economic, and cultural development.

In the context of these inequalities in 1946, Public Health Service investigators in a study funded by the National Institutes of Health, with the cooperation of Guatemalan authorities, engaged in a series of immoral and unethical human medical experiments conducted without the participants’ informed consent. The study involved at least 5128 vulnerable people, including children, orphans, child and adult prostitutes, Guatemalan Indians, leprosy patients, mental patients, prisoners, and soldiers. Between 1946 and 1948, health officials intentionally infected at least 1308 of these people with syphilis, gonorrhea, and chancroid and conducted serology tests on others. The study originally began in the United States but was moved to Guatemala when researchers were unable to consistently produce gonorrhea infections in prisoners at a Terre Haute, Indiana, prison. The public had no knowledge of the experiments for more than half a century, and even today little is known about these violations of medical ethics and human rights. 2

It is important to emphasize the facts surrounding the Guatemala sexually transmitted disease (STD) experiments to properly evaluate the moral, ethical, and legal implications of the experiments. The experiments were not conducted in a sterile clinical setting in which bacteria that cause STDs were administered in the form of a pin prick vaccination or a pill taken orally. The researchers systematically and repeatedly violated profoundly vulnerable individuals, some in the saddest and most despairing states, and grievously aggravated their suffering. For example:

Berta was a female patient in the psychiatric hospital. Her age and the illness that brought her to the hospital are unknown. In February 1948, Berta was injected in her left arm with syphilis. A month later, she developed scabies (an itchy skin infection caused by a mite). Several weeks later, [lead investigator Dr. John] Cutler noted that she had also developed red bumps where he had injected her arm, lesions on her arms and legs, and her skin was beginning to waste away from her body. Berta was not treated for syphilis until three months after her injection. Soon after, on August 23, Dr. Cutler wrote that Berta appeared as if she was going to die, but he did not specify why. That same day he put gonorrheal pus from another male subject into both of Berta’s eyes, as well as in her urethra and rectum. He also re-infected her with syphilis. Several days later, Berta’s eyes were filled with pus from the gonorrhea, and she was bleeding from her urethra. On August 27, Berta died. 3

In 2010, US President Barack Obama apologized to Guatemalan President Alvaro Colom and the people affected, expressing the United States’ commitment to the ethical and legal conduct of contemporary human medical studies. 4 The US Presidential Commission for the Study of Bioethical Issues (hereafter the Commission) has since issued 2 reports: “Ethically Impossible” STD Research in Guatemala from 1946–1948 3 and Moral Science: Protecting Participants in Human Subjects Research . 5

The Commission’s first report condemned the experiments as “impossible” under current ethical standards. The second report acknowledged an inability by the United States to confirm that all federally funded research provides optimal protections against avoidable harms and unethical treatment today 5 ; the report also recommended reforms, none of which have been implemented as of yet. No mention of reparation or compensation for the victims was made in either report. In addition, little was said about the violations against human rights, which, when considered in conjunction with medical ethics, should provide protection to vulnerable populations. 6

By contrast, the Guatemalan government issued a separate report, Consentir el Daño: Experimentos Médicos de Estados Unidos en Guatemala (To Agree to the Harm: Medical Experiments by the United States in Guatemala), which went beyond the US reports to state that the experiments were “a crime against humanity” and that racism and discrimination were present throughout the experiments in an explicit and conscious way. 7 The Guatemalan report called for reparation and compensation for the victims. In addition, 2 independent reports, written by the United Nations 8 and the Catholic Church 9 on human rights violations and genocide in Guatemala from the 1950s to the 1990s, bolster the Guatemalan commission’s declarations with respect to discrimination, reparations, and human rights and highlight weaknesses in the US reports. 7 There is little evidence that the US government, the public health community, academic publications, or the media have acknowledged the Guatemalan report.

In spring 2012, when the case against the US government was considered by a federal district court as a class action lawsuit brought on behalf of the Guatemalan victims and their survivors, the court dismissed the case on grounds of sovereign immunity. 10 Plaintiffs relied on the Ethically Impossible report in reciting the facts in the class action complaint. The US Justice Department did not dispute the facts in moving to dismiss the case, raising only technical arguments about sovereign immunity and the plaintiffs’ failure to exhaust administrative remedies before filing suit. The district court is required to assume the veracity of the plaintiff’s allegations when there is a motion to dismiss for failing to state a legally cognizable claim. The case was never heard on its merits and was dismissed on June 12, 2012, even though the court had set a hearing on the matter for July 26, 2012.

The court wrote that

the Guatemala Study is a deeply troubling chapter in our Nation’s history. Yet…this Court is powerless to provide any redress to the plaintiffs. The pleas are more appropriately directed to the political branches of our government, who, if they choose, have the ability to grant some modicum of relief to those affected by the Guatemala Study. 10

To date, the political branches have provided no relief to the plaintiffs. 11

However, on January 10, 2012, one day after the Justice Department moved to dismiss the case in Gudiel v Sebelius , 10 the Department of Health and Human Services announced funding of approximately $1.8 million to improve treatment and prevention of HIV and other sexually transmitted infections (STIs) in Guatemala and to further strengthen ethical training on human research protections. 12 In addition, the Centers for Disease Control and Prevention was tasked with developing a case study on the unethical research conducted in Guatemala. The study will include learning objectives focused on scientific and ethical issues in designing a field investigation. Legal training appears to be missing from the Department of Health and Human Services directive. 12 General funding of global human research protections and STI health initiatives in Guatemala is no substitute for treatment of and compensation to the victims.

Despite the Department of Health and Human Services’ announcement and the Commission’s reports, the lack of publicity received by the Guatemalan case is startling. The American public is largely unaware of these experiments and the outrageous treatment of Guatemalans, the reports by the US and Guatemalan commissions, or the victims’ lack of reparations, compensation, and access to justice through the courts. The media has devoted little attention to the case. Unlike other cases in which human rights were violated in human subjects research (e.g., the Tuskegee syphilis experiments), few, if any, organizations have taken up the cause for human justice with respect to this vulnerable Guatemalan population.

The wrongful actions by US officials can be characterized by several facts. First, US officials intentionally infected victims with bacteria that cause STDs without informed consent. Second, they have failed to provide victims with treatment or compensation. Finally, they covered up and did not publish or disclose the experiments, including the intentional infections and their failure to provide treatment.

In summary, the US and Guatemalan commissions have documented many of the facts of the STD experiments and are in agreement on many salient points. Each report has determined that the Public Health Service investigators violated contemporaneous medical research ethics standards, and the Guatemalan report determined that the experiments violated human rights law. Given the state of the records, the few judicial precedents, the increasingly unreceptive attitude of the US Supreme Court toward class actions, and the complicated questions of sovereign immunity, the plaintiffs’ quest for access to justice through the courts will be long and uncertain.

VIOLATION OF CUSTOMARY INTERNATIONAL LAW

A significant omission of the Commission’s reports is the lack of an explicit discussion of legal responsibility and accountability. The Guatemalan report asserts that the investigation was immoral and constituted a crime against humanity. 7 The report states that it focuses on the moral plane because most of the responsible principals are surely dead. The report refers to international human rights authorities and ethical principles such as the United Nations Declaration of Universal Human Rights (ratified by both the United States and Guatemala), the Interamerican Declaration on the Rights and Responsibilities of Man, the Rights of Man in the Charter of the Organization of American States, the 1978 Belmont report of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, and the Declaration of Helsinki. It also references the Nazi Nuremberg trials and the Tuskegee syphilis experiments. 7

The Obama administration has not conducted a public analysis to determine whether the experiments violated US or international legal standards. There is judicial precedent, however, to support the proposition that the Guatemala experiments violated international human rights standards. In the 2009 case of Abdullahi v Pfizer , 13 the United States Court of Appeals for the Second Circuit held that nonconsensual medical experimentation on human beings violates customary international law because, among other reasons, the prohibition is sufficiently specific and focused and is accepted by nations around the world.

The relevant question with respect to the Guatemala STD experiments is “At what point in time did customary international law first prohibit nonconsensual medical experimentation?” The Nuremberg code, prohibiting human medical research without informed consent, was upheld with the conviction of German doctors on August 19, 1947; a case can be made that the intentional STIs in Guatemala violated this code beginning on that date, at a minimum, when US sexually transmitted disease investigators in Guatemala would have known of these developments in human rights law. 3

Whereas US legal standards govern US-led research but do not necessarily protect residents of other nations, international laws protect all citizens of the world and should be closely considered in this case. For example, according to Article 7 of the International Covenant on Civil and Political Rights, 14 “no one shall be subjected without his free consent to medical or scientific experimentation.” This covenant, adopted in 1966 and put in force in 1976, is monitored by the United Nations Human Rights Committee and is part of the International Bill of Rights. Some might argue that the Guatemalan case should be heard by the United Nations governing body to speed up the process of bringing compensation and relief to the victims. Other international human rights authorities and laws, including several articles from the 1948 Universal Declaration of Human Rights, also provide international standards for human subjects research, standards that surely were violated in the Guatemalan experiments.

Not only should human rights laws have been applied to the Guatemalan experiments; medical research is also governed by principles of biomedical ethics 15 that call for patient safety, respect, beneficence, justice, and nonmaleficence (“first do no harm”). Today’s medical professionals and researchers are trained in these biomedical values and ethics. Most notably, the International Ethical Guidelines for Biomedical Research Involving Human Subjects, promulgated by the Council for International Organizations of Medical Sciences, define how the principles of the Declaration of Helsinki can be applied to developing countries in light of their socioeconomic circumstances. Although these guidelines were developed after the Guatemalan experiments, they recognize that, even in developing countries, informed consent and other basic principles of research ethics clearly apply. Surely, the researchers involved in the Guatemalan experiments were not abiding by many of these principles of biomedical research ethics.

International human rights standards provide one avenue to address structural injustice and institutional and national responsibility, including discrimination based on gender, race, and class in Guatemala and the complex of political, economic, military, and social relations between Guatemala and the United States. The actions in Guatemala went beyond domestic crimes such as rape, battery, assault, and conspiracy and violated international law. 16

UNEQUAL JUSTICE AND DISCRIMINATION

The Commission reports 3,5 generally allude to the possibility that discrimination played a role in the Guatemala investigations, but the reports do not address the issue adequately 16 or systematically. For example, in Ethically Impossible , 3 the authors discuss why the investigators selected Guatemala as a setting: “A possible remaining but clearly unacceptable explanation for choosing Guatemala would reflect the notion that the Guatemalans were a suitable, if not preferable, experimental population by virtue of poverty, ethnicity, race, remoteness, national status, or some combination of these factors.” 3 The Moral Science report makes only a passing, ambiguous reference to racism in a footnote, stating simply, “The Commission here focuses on the issues of justice.” 5

By contrast, the Guatemala report discusses discrimination in much stronger terms. The report states that racism and discrimination were present throughout the experiments in an explicit and conscious way. The report recommends strengthening compliance with the constitutional requirements of equality among human beings to combat discrimination and racism.

Ultimately, the nonconsensual human experiments and serology tests conducted, the process of intentionally infecting people with bacteria that cause STDs, and the failure to provide treatment were immoral and unethical and violated both US and international legal standards, regardless of the race, color, national origin, or socioeconomic status of the victims here. Discrimination in the context of the Guatemalan experiments includes discrimination by US officials against Guatemalan people and discrimination within Guatemalan society by elites against lower-class indigenous and nonindigenous people. Discrimination is an aggravating, unacceptable factor that warrants additional review and discussion.

The US equal protection principles and laws are relevant when examining evidence of discrimination and the inferences to be drawn from the facts. The laws also provide guidance on how to address discrimination in other human research contexts with respect to underrepresented, minority, and vulnerable populations. The US Supreme Court and other authorities recognize that the following factors are relevant in evaluating a claim of intentional discrimination based on race, color, or national origin: the impact of the action and whether it bears more heavily on one group than another, a pattern or history of discrimination, departures from substantive norms, departures from procedural norms, and knowledge of the harm discrimination will cause (see, e.g., Village of Arlington Heights v Metropolitan Housing Dev. Corp . 17 and Guardians Ass’n v Civil Serv. Comm’n 18 ).

Under these parameters, evidence of discrimination abounds in the Guatemalan experiments. First, these experiments were limited to the Guatemalan people. Second, the United States has a history of discrimination and oppression against the people of Guatemala. For example, the Cold War and the war on drugs by the United States devastated Guatemala’s civic society and economy for decades. In 1954, the United States overthrew the country’s democratically elected government. 19 Military dictatorships, backed by the United States, assassinated almost 200 000 8 people in the next 40 years. The Guatemalan government engaged in mass killings of Mayans, obliterating entire villages. 8,9 Bishop Juan Gerardi was bludgeoned to death in 1998 for publishing a report by the Catholic Church documenting the killings. 20

Third, the United States and Guatemala reports document departures from substantive and procedural norms in the Guatemala investigations. Fourth, the investigators knew of the harms they caused. Finally, civil rights statutes and federal regulations also prohibit unjustified discriminatory actions without requiring a showing of intent or individual racial animus. 17,18 These standards of discrimination provide an analytic framework to evaluate evidence of discrimination in the context of the Guatemalan experiments. Indeed, these are the kinds of evidence that the Guatemala commission report cites in concluding that discrimination and racism were present throughout the experiments. 7

UNEQUAL JUSTICE: GUATEMALA AND TUSKEGEE

The Tuskegee syphilis experiments, involving recompense for past injustice, are directly relevant to the Guatemala injustices. In both the Guatemala and the Tuskegee experiments, directed by the same principal investigator, the US government engaged in concededly immoral and unethical actions: conducting nonconsensual human medical experiments, not treating infected victims, and deceiving victims and the public. In Guatemala, researchers intentionally infected the victims and generally left them without treatment or compensation for the remainder of their lives. In Tuskegee, the nearly 400 victims were already infected but were left without treatment beginning in the 1930s.

The United States eventually provided treatment and compensation for victims, families, and heirs in Tuskegee, including funding to locate the victims and pay attorneys’ fees. The ethical principle of equal justice strongly suggests that similar relief should be provided for the Guatemalan victims. However, reparation in Tuskegee was made only after organizations championed the cause, made the wrongful acts known to the general public, sought access to justice through the courts, and applied pressure on the government to take action. 2 This has not occurred in the context of the Guatemalan STD experiments.

REPARATIONS AND COMPENSATION

Academicians have long noted that, in addition to a duty of justice, an obligation of reparation arises from one’s wrongful acts. 21 Scholars note that such compensatory action is morally essential not only to “repair” the harm but also to render victims their due and thereby acknowledge them as agents worthy of respect and entitled to atonement. 22 The authors of the Guatemalan report also articulated the principles of compensation and reparations (as did Cohen and Adashi 11 ), which remain valid and extend to the need to address legal issues. A summary of these principles as they apply to the Guatemalan victims is informative.

First, as a matter of corrective justice, surviving participants or their affected contacts should be compensated in full for injuries sustained. Surviving family members should also be made whole for harm incurred, whether direct (e.g., disease transmission) or indirect (e.g., emotional distress, loss of a family member at a younger age) in nature. A political solution between the US government and the Guatemalan government can make this happen. Second, a compensation and reparations program would more concretely and permanently acknowledge the wrongful nature of the conduct in question, in keeping with the expressive function of both US and international law. Such a program would also reaffirm the legal and ethical standards undergirding human participant research.

Third, compensation and reparations would advance healing and reconciliation and constitute an important, tangible, goodwill gesture to the Guatemalan people and nation. Fourth, compensation and reparations could be tailored to enhance the legal and ethical training of current and future investigators, mitigating potential educational shortcomings and preventing future misconduct. Finally, as a matter of deterrence, compensation and reparations may obviate legal and ethical violations in the future.

History has provided a few models of compensation programs that the US response to Guatemala may do well to emulate. For example, in response to a class-action lawsuit ( Allen v United States 23 ), the US Congress passed the Radiation Exposure Compensation Act of 1990. 24 As of October 2011, more than $1.5 billion had been disbursed to more than 23 000 approved claimants exposed to ionizing radiation during US-based nuclear experiments. 25

It is this type of compensation that is required to correct the injustices suffered by the Guatemalan people, not the mere $1.8 million set aside for prevention programs and ethical training on human research protections. The Tuskegee payment structure 26,27 ($37 500 for each living participant, $15 000 for each surviving dependent, $16 000 for each living control group participant, $5000 to heirs of deceased members of the control group) totaled $10 million in 1974 (approximately $47 million in 2013 currency). A similar payment structure applied to the Guatemalan victims would still be a relatively small amount in comparison with the $1.5 billion already awarded to victims of radiation research.

CONCLUSIONS

In its Ethically Impossible report addressing the Guatemalan experiments, the Commission expressed the need to be ever vigilant to ensure that such reprehensible exploitation of our fellow human beings is never repeated. As such, it is critical to adopt legal and ethical reforms to provide treatment and compensation for individuals involved in improperly conducted human experiments, waive sovereign immunity for federally funded human research in the United States and abroad, ensure that parallel protections apply to privately funded research, and respect autonomy and equality for all. Greater application of legal strategies may promote a stronger structural foundation for preventing such unethical acts in the future.

Acknowledgments

This work was supported by the Blum Center on Poverty and Health in Latin America and by a grant from the National Institutes of Health ( 2P20MD000182 ).

Note. The findings are those of the authors and do not necessarily represent the views of the funders.

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Peter Buxtun, the Tuskegee syphilis study whistleblower, has died at 86

Debbie Elliott

Peter Buxtun has died at age 86. He is known as the whistleblower who revealed the U.S. government was leaving Black men untreated for syphilis during a study in Tuskegee, Ala.

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U.S. Apologizes for ‘Reprehensible’ 1940s Syphilis Study in Guatemala

U.S. officials apologized Friday for unethical medical experiments conducted in Guatemala more than 60 years ago, in which prison inmates were deliberately infected with syphilis.

The experiments were conducted between 1946 and 1948 by Dr. John C. Cutler, a U.S. public health service doctor who was also involved in the infamous Tuskegee syphilis study in the United States.

Secretary of State Hillary Clinton and Health and Human Services Secretary Kathleen Sebelius issued a joint statement apologizing for the experiments:

“The sexually transmitted disease inoculation study conducted from 1946-1948 in Guatemala was clearly unethical. Although these events occurred more than 64 years ago, we are outraged that such reprehensible research could have occurred under the guise of public health. We deeply regret that it happened, and we apologize to all the individuals who were affected by such abhorrent research practices.”

The history of the Guatemala study was uncovered by Wellesley College professor Susan Reverby, a medical historian who has written two books about the Tuskegee case, in which black men with syphilis were observed — but not treated — by U.S. government researchers for nearly 40 years. Reverby was reading Cutler’s papers in an archive at the University of Pittsburgh, looking for references to the Tuskegee study, when she came across descriptions of the experiments in Guatemala.

“So I started to read it, and I said, ‘Oh my god,'” Reverby says.

In the study, the researchers were investigating whether penicillin — which was already being used to treat syphilis — could prevent the disease if it was administered right after someone was exposed to the bacteria.

The researchers exposed hundreds of people in Guatemala to the disease. Many were men who were prison inmates, others were residents of an army barracks and mental hospital. None of the subjects were asked for their consent. The researchers used visits with prostitutes who were infected with syphilis to expose the men to the disease (such visits were legal in Guatemala at the time). They also, Reverby writes, “used direct inoculations made from syphilis bacteria poured into the men’s penises and on forearms and faces that were slightly abraded when the ‘normal exposure’ produced little disease.”

They did treat the people with penicillin afterwards, but, Reverby writes, it’s not clear whether everyone was cured, or even whether they received what would have been considered adequate treatment.

The Guatemala experiment differed from the Tuskegee case, Reverby says, because people were actually exposed to the disease and then treated, instead of being denied access to treatment for a disease that they already had, as happened in the Tuskegee case.

Even within the context of the much more lax research ethics standards of the time, Reverby says, the research “fell off the edge” of what was acceptable.

“Even within the context of history, this was something they shouldn’t have been doing — and they knew that,” Reverby said. In fact, she cites a letter in which Surgeon General Thomas Parran said “You know, we couldn’t do such an experiment in this country.”

Reverby presented her findings at a medical history association meeting in May, and also wrote them up for publication — they’ll be published in January in the Journal of Policy History, but a pre-publication version of the four-page paper is available on Reverby’s website.

The government got involved in the spring, when Reverby showed the paper to David Sencer, a retired director at the Centers for Disease Control and Prevention whom she knew from her research on the Tuskegee experiment’s history. Sencer passed it on to current CDC officials, and the agency sent a syphilis specialist to examine the papers in the University of Pittsburgh archive. That specialist confirmed the accuracy of Reverby’s report.

Now, the government, in addition to issuing its apology, will also convene a panel of independent experts through the National Academies of Sciences Institute of Medicine to conduct a fact-finding probe of the events in Guatemala.

And Sofia Porres, of the Guatemalan Embassy, told the Washington Post that the Guatemalan government would also investigate. “We of course are very upset about this, and we think it’s a very unfortunate event,” she said. “We’re going to do an investigation as well to see if there are any survivors, family, etc.”

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Guest Essay

How on Earth Is There a Syphilis Epidemic in 2024?

By Ina Park

Dr. Park is a professor of family and community medicine at the University of California, San Francisco.

Nobody should be dying of syphilis in 2024. That’s the credo of Elizabeth Glaser, a public health nurse for the Indian Health Service, who drives thousands of miles throughout the Navajo Nation searching for community members with the infection. Once they’re found, Dr. Glaser administers shots of penicillin as treatment, at people’s homes, RVs, even in the back seat of her car.

Yet despite the good work of those like Dr. Glaser and the availability of cheap and effective treatment, the United States is experiencing rampant increases in syphilis. Left untreated, infection can lead to devastating neurological consequences such as blindness , deafness, madness and death. While other reportable sexually transmitted infections declined or remained flat during the pandemic, over 207,000 cases of syphilis were reported in 2022 , an 80 percent increase since 2018 and the highest number reported since 1950.

Most disturbing within this trend is the rise in congenital syphilis. Over 3,700 cases were reported in 2022, which is more than double the number of cases of mother-to-child transmission of H.I.V. at the height of the AIDS crisis. Nearly 300 infected babies were stillborn or died in the first year of life.

How did we get into this situation? More important, how do we get out of it? The answers differ for each population most affected by the epidemic: pregnant women, and gay and bisexual men. To tackle congenital syphilis, we must cast off societal squeamishness about S.T.I.s and invest in proven control strategies: public education, testing, treatment and contact tracing. For gay and bisexual men, we need to embrace novel prevention interventions if we are to outwit this wily disease.

Syphilis is often referred to as the Great Masquerader: a painless genital ulcer or rash on the hands and feet are textbook signs, but a bloodshot eye, a white patch on the tongue or hair loss can be signs too. It can look like anything yet often looks like nothing, able to lie dormant for decades with no apparent symptoms.

But the surge in congenital syphilis isn’t due to the infection’s many disguises; it’s because of failures of our health system and safety net. According to the C.D.C., nine of 10 congenital syphilis cases in 2022 were preventable ; lack of prenatal testing and timely treatment were the most common culprits, intersecting with social ills such as poverty, homelessness, substance use and incarceration. Because of systemic inequities, Indigenous, Pacific Islander and Black communities are hardest hit; one in 155 Native American births was affected by congenital syphilis in 2022.

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Babies infected with syphilis are part of a growing tragedy – one that could be easily prevented

Epidemiologist, The Kirby Institute, UNSW Sydney

Infectious disease researcher, UNSW Sydney

Project officer, Aboriginal and Torres Strait Islander Health Program, Surveillance and Evaluation Research Program, Kirby Institute, UNSW Sydney

Disclosure statement

Skye McGregor is the recipient of a National Health and Medical Research Council Emerging Leadership Level 1 Investigator Grant 2025240. The Kirby Institute receives funding from the Australian Government Department of Health and Aged Care.

Belinda Hengel and Robert Monaghan do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

UNSW Sydney provides funding as a member of The Conversation AU.

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Data just published online shows a worrying increase in infectious syphilis cases in women living in Australia aged 15–44 (referred to as “reproductive age”) and a subsequent rise in transmission from pregnant parent to child. This is called congenital syphilis .

Congenital syphilis is easily prevented through timely testing and treatment of syphilis during pregnancy. Left untreated, congenital syphilis can have devastating outcomes in more than 50% of cases including miscarriage, stillbirth, neonatal death and permanent disability.

We reviewed all cases of congenital syphilis in Australia between 2011 and 2021 and found tragically 25% were stillborn. For the birthing parent of babies with congenital syphilis, we found less than 40% were tested for syphilis in pregnancy. Nearly half had no record of receiving any antenatal care.

Experts have been aware of the resurgence of syphilis in Australia for some time. But ours is the first analysis that reveals significant gaps in antenatal care, leading to devastating outcomes.

Syphilis cases have been rising for a decade

Between 2011 and 2021, the rate of infectious syphilis rose by more than 500% in women aged 15–44 years, from 141 in 2011 to 902 in 2021. This reflects an increase more broadly among young people .

Prior to 2011, infectious syphilis was rare. When cases began to rise, it was initially in men with male sexual partners in metropolitan areas, and young heterosexual people in remote Aboriginal and Torres Strait Islander communities. Health departments increased testing and initiated public health campaigns to decrease transmission.

Despite these efforts, syphilis cases have continued to rise , and the initial outbreaks have expanded across Australia. There has been significant investment by federal, state and territory governments to enhance syphilis detection and treatment including community-based screening, mass media campaigns, health workforce education, and rapid test results through point-of-care testing .

Cases of congenital syphilis have also been steadily rising in Australia, mirroring international trends .

Between 2011 and 2019 there was a median of four congenital syphilis cases per year in Australia, increasing to 17 cases in 2020, and 15 in 2021 and 2022. There were 20 cases reported in 2023.

These numbers might seem small. But without action, this upward trend will lead to more deaths and permanent disability in babies with congenital syphilis – a preventable disease.

What can we do about it?

It’s time for a direct focus on reducing syphilis transmissions, and particularly the impact of syphilis in pregnancy.

Testing during pregnancy range from one test at the first antenatal appointment to five tests throughout pregnancy, if the pregnant person is considered high risk or lives in an outbreak area in remote Australia. Recommendations are provided by state and territory health departments, and vary across Australia, but work is underway to make guidelines consistent.

But in many instances no screening is taking place at all.

Increases in infectious and congenital syphilis are likely associated with social social determinants of health (the non-medical factors that influence health outcomes) including homelessness, unstable housing, poverty, domestic violence, mental illness, drug and alcohol use, cultural barriers or language, racism, and discrimination in health care.

Our study found Aboriginal and Torres Strait Islander women reported 35 times higher rates of syphilis than non-Indigenous women. This is likely due to the lasting effects of colonisation, along with structural barriers and access to health care.

To reverse the current trend of increasing numbers of babies with congenital syphilis we urgently need to:

explore accessible models of care for pregnant women wherever they engage with the health system

enhance partner testing and treatment

improve surveillance on testing in pregnancy.

Not just medical check ups

For pregnant women, we need to ensure a holistic approach to care co-designed in partnership with affected communities. For Aboriginal and Torres Strait Islander women, this could include greater access to Birthing on Country programs .

The World Health Organization (WHO) also recommends partners are routinely tested for syphilis to achieve elimination of congenital syphilis.

And we need better monitoring of syphilis testing during pregnancy. The WHO has set a global goal of elimination of congenital syphilis with a target of 95% of pregnant people tested for syphilis during pregnancy. Currently in Australia there is no way to know how close or far away we are from this goal.

Congenital syphilis is entirely preventable, and it is a tragedy any pregnancy results in this outcome.

The authors would like to acknowledge the contribution of Lorraine Anderson of Kimberley Aboriginal Medical Services, who provided guidance on the study on which this article is based.

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• Congenital syphilis

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• Diseases & Conditions

Your health care team can find syphilis by testing samples of:

• Blood. Blood tests can confirm the presence of proteins called antibodies. The immune system makes these to fight infections. The antibodies to the bacteria that causes syphilis stay in the body for years. So blood tests can be used to find a current or past infection.
• Fluid from a sore. A laboratory can study this fluid under a microscope to confirm that syphilis caused the sore.
• Fluid that surrounds the brain and spinal cord. Another name for this is cerebrospinal fluid. If your care team thinks that you have nervous system problems from syphilis, they might recommend testing this fluid. A needle is used to take a sample of cerebrospinal fluid from between two of the bones in the back. This procedure is called a lumbar puncture.

Remember, your local health department may offer partner services. These help you notify your sexual partners that they may be infected. Your partners can be tested and treated, limiting the spread of syphilis.

Medications

Syphilis is simple to cure when it's found and treated in its early stages. The preferred treatment at all stages is penicillin. This antibiotic medicine can kill the bacteria that causes syphilis.

If you're allergic to penicillin, your health care team may suggest another antibiotic. Or they may recommend a process that safely helps your body get used to penicillin over time.

The recommended treatment for primary, secondary or early-stage latent syphilis is a single shot of penicillin. If you've had syphilis for longer than a year, you may need additional doses.

Penicillin is the only recommended treatment for pregnant people with syphilis. Those who are allergic to penicillin can follow a process that may allow them to take the medicine. The procedure is called penicillin desensitization.

It's done by a specialist called an allergist or an immunologist. It involves taking tiny amounts of penicillin every 15 to 20 minutes over about 4 hours.

Even if you're treated for syphilis during your pregnancy, your newborn should be tested for congenital syphilis. A baby infected with the syphilis bacterium receives antibiotic treatment.

The first day you receive treatment, you may have what's known as the Jarisch-Herxheimer reaction. Symptoms include a fever, chills, nausea, achy pain and a headache. Most often, this reaction doesn't last more than one day.

Treatment follow-up

After you're treated for syphilis, your health care team likely will ask you to:

• Have regular blood tests and exams to make sure the penicillin treatment is working. The follow-up tests you need depend on the stage of syphilis you have.
• Do not have sexual contact with new partners until the treatment is finished. Blood tests should show that the infection has been cured, and any sores should be gone.
• Tell your sex partners so they can be tested and get treatment if needed.
• Get tested for HIV .

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Finding out you have syphilis can be upsetting. You might get angry if you feel you've been betrayed by a partner. Or you might feel shame if you think you've infected others.

Hold off placing any blame. Don't assume that your partner has been unfaithful to you. One or both of you may have been infected by a past partner.

Preparing for your appointment

Many people don't feel comfortable sharing the details of their sexual experiences. But it's important to have a private talk with your health care team about this information, so you can get the right care.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance.
• Write down any symptoms you have. Include any that may not seem related to the reason for which you made the appointment.
• Make a list of all medicines, vitamins or supplements you take. Include the amounts you take, also called the doses.
• Write down questions to ask your health care team.

Some basic questions to ask include:

• What's the medical name of the infection I have?
• How does it spread?
• Will it keep me from having children?
• If I get pregnant, could I give it to my baby?
• Is it possible to catch this again?
• Could I have caught this from someone I had sex with only once?
• Could I give this to someone by having sex with that person just once?
• How long have I had it?
• I have other health conditions. How can I best manage them together?
• Should I stop sexual activity while I'm being treated?
• Does my partner have to be treated?

What to expect from your doctor

Give your health care team a complete report of your symptoms and sexual history. This helps the team figure out how to best care for you. Here are some of the things you may be asked:

• What symptoms made you decide to come in? How long have you had these symptoms?
• With whom do you have sex?
• Do you currently have one sex partner or more than one?
• How long have you been with your current partner or partners?
• Have you ever injected yourself with drugs?
• Have you ever had sex with someone who has injected drugs?
• What do you do to protect yourself from sexually transmitted infections (STIs)?
• What do you do to prevent pregnancy?
• Has a doctor or nurse ever told you that you have chlamydia, herpes, gonorrhea, syphilis or HIV ?
• Have you ever been treated for genital discharge, genital sores, painful urination or an infection of your sex organs?
• How many sex partners have you had in the past year? In the past two months?
• When was your most recent sexual encounter?

What you can do in the meantime

If you think you might have syphilis, it's best to not have any sexual contact until you've talked with your health care team. If you have sexual activity before you see your care team, follow safe sex practices such as using a condom.

• Syphilis — CDC detailed fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm. Accessed April 27, 2023.
• Sexually transmitted infections treatment guidelines, 2021: Syphilis. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/syphilis.htm. Accessed April 27, 2023.
• Hicks CB, et al. Syphilis: epidemiology, pathophysiology, and clinical manifestations in patients without HIV. https://www.uptodate.com/contents/search. Accessed April 27, 2023.
• Syphilis. Merck Manual Professional Version. https://www.merckmanuals.com/professional/infectious-diseases/sexually-transmitted-diseases-stds/syphilis. Accessed April 27, 2023.
• Hicks CB, et al. Syphilis: Treatment and monitoring. https://www.uptodate.com/contents/search. Accessed April 27, 2023.
• Hicks CB, et al. Syphilis: Screening and diagnostic testing. https://www.uptodate.com/contents/search. Accessed April 27, 2023.
• Syphilis — CDC basic fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm. Accessed April 27, 2023.
• Loscalzo J, et al., eds. Syphilis. In: Harrison's Principles of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed July 14, 2019.
• AskMayoExpert. Syphilis (adult). Mayo Clinic; 2021.
• Sexually transmitted infections. Office on Women's Health. http://womenshealth.gov/publications/our-publications/fact-sheet/sexually-transmitted-infections.html. Accessed April 27, 2023.
• Tosh PK (expert opinion). Mayo Clinic. May 1, 2023.
• Cáceres CF, et al. Syphilis in men who have sex with men: advancing research and human rights. The Lancet Global Health. 2021; doi:10.1016/S2214-109X(21)00269-2.
• How can partner services programs help me and my patients? Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/clinicians/screening/partner-notification.html. Accessed April 28, 2023.
• Penicillin allergy FAQ. American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/penicillin-allergy-faq. Accessed April 28, 2023.
• Just diagnosed? Next steps after testing positive for gonorrhea or chlamydia. Centers for Disease Control and Prevention. https://www.cdc.gov/std/prevention/NextSteps-GonorrheaOrChlamydia.htm. Accessed May 1, 2023.
• Bachmann LH, et al. CDC clinical guidelines on the use of doxycycline postexposure prophylaxis for bacterial sexually transmitted infection prevention, United States, 2024. MMWR Recommendations and Report 2024;doi:10.15585/mmwr.rr7302a1.
• Mayo Clinic Minute: Signs and symptoms of syphilis
• Primary syphilis

News from Mayo Clinic

• Newborns diagnosed with syphilis at alarming rates Feb. 19, 2024, 03:30 p.m. CDT
• Mayo Clinic Minute: Syphilis surge is cause for concern Feb. 03, 2024, 12:00 p.m. CDT

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Frequently Asked Questions

No. According to a journal article  about the study, published in 1936, the 399 men in the syphilitic group were initially recruited because they already had late-latent syphilis. The 201 men in the control group did not have the disease.

Tuskegee community members were aware of the study but understood it to be a special government health care program.  1

According to the Assistant Secretary for Health and Scientific Affairs’ Ad Hoc Advisory Panel’s  published report , “…the Macon County Health Department and Tuskegee Institute were cognizant of the study.”

There is no evidence that researchers obtained informed consent from participants, and participants were not offered available treatments, even after penicillin became widely available.

You can learn more about changes made to standard research practices after Tuskegee in Research Implications .

No women were included in the study. The study was limited to Black men 25 years of age or older. However, as a result of lack of treatment, some women contracted syphilis from men who participated in the study’s syphilitic group.

The National Archives, Southeastern Region, maintains a list of  Tuskegee patient medical files.

The National Archives maintains  photos related to the study.

The $10-million settlement was divided into four categories:

• Living syphilitic group participants received $37,500.
• Heirs of deceased syphilitic group participants received $15,000.
• Living control group participants received $16,000.
• Heirs of deceased control group participants received $5,000. 2

1 Vonderlehr to Clark, October 20, 1932, Records of the USPHS Venereal Disease Division, Record Group 90, National Archives, Washington National Record Center, Suitland, Maryland.

2 Gray, Fred D. The Tuskegee Syphilis Study: An Insider’s Account of the Shocking Medical Experiment Conducted by Government Doctors against African American Men. Montgomery: Fred D. Gray, 2013.

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 Related Links

• Facts & Information about Syphilis
• STD Health Equity
• Tuskegee University National Center for Bioethics in Research and Health Care