- Email: [email protected]
The Tuskegee study of untreated syphilis revisited
Reflection and Reaction
The Tuskegee study of untreated syphilis revisited Following discussions in The Lancet Infectious Diseases of the Tuskegee study of untreated syphilis,1,2 my comments clarify treatments available at the time, question the origin of a photograph, and suggest management for symptomatic patients. A recent article3 provided prospective views of treatment and non-treatment of latent syphilis in the early 1930s and 1940s. This evidence-based analysis introduced medical and public-health notions about treatment and non-treatment of latent syphilis into the Tuskegee study dialogue. Other writers provided retrospective views. For example, in 1932, efficacy of treatment for latent syphilis was questioned,4–6 arsenic and heavy metal therapies were toxic,4,6 the natural course of syphilis was poorly understood,5 and 10 years after the discovery of penicillin efficacy in early syphilis, penicillin hypersensitivities appeared with increasing frequency, resulting in hesitant use of this antibiotic.4 Based on prospective and retrospective views, the state of knowledge and practice regarding treatment and non-treatment of latent syphilis seemed to permit doing the Tuskegee study. Nobel Prize winner Julius Wagner-Jauregg might not have been surprised that his tertian malaria treatment for neurosyphilis was not efficacious in black people in the Tuskegee study.2 In November 1932, George Branche of the Tuskegee Veterans Administration Hospital began an investigation of a malarial treatment for neurosyphilis in black people. Tertian, the standard used for malariotherapy in white people, did not take in black people. Branche succeeded with quartan.7,8 This difference in biological therapy—“White people respond best to tertian malaria (Plasmodium vivax); negroes to quartan (Plasmodium malariae)”—was acknowledged in both the syphilology and malariology literature.9,10 In black people, infection resistance was believed to be due to prior tertian malaria exposure. Decades later, investigators reported that absent Duffy determinants on erythrocytes—required for invasion by vivax merozoites—were responsible for the P vivax infection resistance;11 this was an inherited trait found predominantly in African and American black people. Branche worked closely with Tuskegee study investigators Taliaferro Clark and Raymond Vonderlehr.3,7 Conventional information sources about 62
the Tuskegee study,12–14 authored by non-physicians, omitted this medically and historically important racetargeted research. The photograph that accompanied the letter by Mark Taylor2 showed four black men seated at a table, receiving an intravenous infusion, with a white female health professional in attendance, and was labelled as “Patients being treated as part of the Tuskegee study”. This photograph was in A morning’s work: medical photographs from the Burns Archive & Collection15 and labelled as “The Tuskegee experiment, c 1936; Photographer unknown, Tuskegee, Alabama”. The notes on the photograph ended with comments that the picture was of a mobile treatment centre for syphilis, suggesting that the photograph was not from the Tuskegee study. No source for the photograph was cited. However, the Office of the Public Health Service Historian (accessible via the Health Services Research Library [National Institutes of Health] catalogue call number WC 140 no 3) has archived the photograph circa the 1920s. For unclear reasons, misinformation seems to seep routinely into discussions about the Tuskegee study—occurrences that may harm the health of the African American community. To answer Taylor’s question2—“Did the study at any time contain clear provision for currently established therapeutic measures to be instituted if a patient became symptomatic?”—here is a quote from the United States Public Health Service: “It is the practice of Public Health Service officers to refer men who develop syphilitic or nonsyphilitic conditions requiring therapy to the proper sources of treatment. Nevertheless, a few of the men have, on their own, sought and received antisyphilitic treatment in varying amounts. Some were treated by private physicians, a few had been inadvertently rounded up and sent to rapid treatment centers by health department workers who were unaware of the research project. Some of the patients were given therapy because of positive serologic tests for syphilis . . . or because of a history of infection; some even were treated for unrelated symptoms, rather than for specific complications of syphilis.”16 We have heard complaints of treatment denial at the rapid treatment centre. However, Tuskegee study men who received treatment should http://infection.thelancet.com Vol 6 February 2006
Reflection and Reaction
have an advantage over those who were allegedly denied treatment at the rapid treatment centre. Unless re-infected, men who received treatment before public exposure of the Tuskegee study might not have required treatment for syphilis after public exposure in 1972. This treatment and non-treatment issue has not been considered by conventional information sources. The editorial’s call for a re-analysis of the Tuskegee study1 was appropriate given that discussions have been limited, in part, to the men who were allegedly untreated, not treated, and denied treatment—but not the men who were treated.
4 5 6 7 8 9 10
11
12
Robert M White
13
12054 Eaglewood Court, Silver Spring, MD 20902, USA. [email protected]
14
1
15
2 3
The Lancet Infectious Diseases. Clearing the myths of time: Tuskegee revisited. Lancet Infect Dis 2005; 5: 127. Taylor MB. Tuskegee revisited. Lancet Infect Dis 2005; 5: 467–68. White RM. Unraveling the Tuskegee study of untreated syphilis. Arch Intern Med 2000; 160: 585–98.
16
Crissey JT. Treatment of syphilis: a 1932 advertisement. Ann Intern Med 1977; 87: 30. Angell M. Tuskegee revisited. Wall Street Journal October 28, 1997: A22. Thomas SB, Curran JW. Tuskegee: from science to conspiracy metaphor. Am J Med Sci 1999; 317: 1–4. Branche GC. Therapeutic quartan malaria in the treatment of neurosyphilis among Negroes. J Nerv Ment Dis 1936; 83: 177–88. Branche GC. Therapeutic quartan malaria in the treatment of neurosyphilis among Negroes. Am J Psychiatry 1940; 96: 967–78. Robinson HM. Syphilis. Treatment of neurosyphilis. In: Practical dermatology and syphilis. Baltimore: Chelsea Pub Co, 1947: 110. Becker FT. Induced malaria as a therapeutic agent. In: Boyd MF, ed. Malariology. A comprehensive survey of all aspects of this group of diseases from a global standpoint. Volume II. Philadelphia: WB Saunders Co, 1949: 1145–57. Miller LH, Mason SJ, Clyde DF, McGinniss MH. The resistance factor to Plasmodium vivax in blacks. The Duffy-blood-group genotype, FyFy. N Engl J Med 1976; 295: 302–04. Jones JH. Bad blood: the Tuskegee syphilis experiment. New York, NY, USA: Free Press, 1993. Gray FD. The Tuskegee syphilis study: the real story and beyond. Montgomery, AL, USA: Black Belt Press, 1998. Reverby SM. Tuskegee’s truths: rethinking the Tuskegee syphilis study. Chapel Hill, NC, USA: University of North Carolina Press, 2000. Burns SB. A morning’s work: medical photographs from the Burns Archive & Collection. Santa Fe, NM, USA: Twin Palms, 1998. Schuman SH, Olansky S, Rivers E, Smith CA, Rambo DS. Untreated syphilis in the male negro. Background and current status of patients in the Tuskegee study. J Chron Dis 1955; 2: 543–58.
Polio eradication and measles immunisation in Nigeria Almost 11 million children under the age of 5 years die annually worldwide, with 80% of these deaths occurring in Africa. These daunting figures are from the World Health Report 2005, which shows the current status of progress towards the Millennium Development Goals.1 One of the main goals is a reduction of childhood (under 5) mortality by twothirds by 2015 compared with 1990 levels. Measles is responsible for 5% of deaths in children under 5 years in the African region.2 A recent study by Otten and colleagues3 shows that measles deaths have dropped substantially in several African countries, while the Measles Initiative has publicised a decrease of 60% since 1999 for the whole of Africa.4 However, measles remains a major cause of childhood mortality, estimated to have claimed 282 000 lives in 2003;5,6 half of these occurred in Nigeria.7 In 2003, the under-5 mortality rate in Nigeria was estimated at 198 per 1000 live births.1 Current predictions show that the goal of reducing this mortality rate by two-thirds is unlikely to be met8 without a more integrated approach. Nigeria is one of only ten countries in the world with vaccine coverage of less than 50% and one of nine countries in which children do not have a chance of a http://infection.thelancet.com Vol 6 February 2006
second measles vaccination.7 With vaccine coverage remaining persistently below 40% since 1997,9 measles has remained hyperendemic. At the beginning of 2005, a large epidemic was reported in Adamawa state in northeastern Nigeria.10 Large-scale outbreaks of measles were also reported in other northern Nigerian states.10 Nigeria has the highest prevalence of circulating wild poliovirus in the world.11 It is under immense pressure from the international community to get its polio vaccination back on track after a 1-year suspension in Kano, northern Nigeria, following concerns about
Figure: Billboard of the National Programme on Immunization, near Yola, Adamawa state, Nigeria
63
The Tuskegee study of untreated syphilis revisited Following discussions in The Lancet Infectious Diseases of the Tuskegee study of untreated syphilis,1,2 my comments clarify treatments available at the time, question the origin of a photograph, and suggest management for symptomatic patients. A recent article3 provided prospective views of treatment and non-treatment of latent syphilis in the early 1930s and 1940s. This evidence-based analysis introduced medical and public-health notions about treatment and non-treatment of latent syphilis into the Tuskegee study dialogue. Other writers provided retrospective views. For example, in 1932, efficacy of treatment for latent syphilis was questioned,4–6 arsenic and heavy metal therapies were toxic,4,6 the natural course of syphilis was poorly understood,5 and 10 years after the discovery of penicillin efficacy in early syphilis, penicillin hypersensitivities appeared with increasing frequency, resulting in hesitant use of this antibiotic.4 Based on prospective and retrospective views, the state of knowledge and practice regarding treatment and non-treatment of latent syphilis seemed to permit doing the Tuskegee study. Nobel Prize winner Julius Wagner-Jauregg might not have been surprised that his tertian malaria treatment for neurosyphilis was not efficacious in black people in the Tuskegee study.2 In November 1932, George Branche of the Tuskegee Veterans Administration Hospital began an investigation of a malarial treatment for neurosyphilis in black people. Tertian, the standard used for malariotherapy in white people, did not take in black people. Branche succeeded with quartan.7,8 This difference in biological therapy—“White people respond best to tertian malaria (Plasmodium vivax); negroes to quartan (Plasmodium malariae)”—was acknowledged in both the syphilology and malariology literature.9,10 In black people, infection resistance was believed to be due to prior tertian malaria exposure. Decades later, investigators reported that absent Duffy determinants on erythrocytes—required for invasion by vivax merozoites—were responsible for the P vivax infection resistance;11 this was an inherited trait found predominantly in African and American black people. Branche worked closely with Tuskegee study investigators Taliaferro Clark and Raymond Vonderlehr.3,7 Conventional information sources about 62
the Tuskegee study,12–14 authored by non-physicians, omitted this medically and historically important racetargeted research. The photograph that accompanied the letter by Mark Taylor2 showed four black men seated at a table, receiving an intravenous infusion, with a white female health professional in attendance, and was labelled as “Patients being treated as part of the Tuskegee study”. This photograph was in A morning’s work: medical photographs from the Burns Archive & Collection15 and labelled as “The Tuskegee experiment, c 1936; Photographer unknown, Tuskegee, Alabama”. The notes on the photograph ended with comments that the picture was of a mobile treatment centre for syphilis, suggesting that the photograph was not from the Tuskegee study. No source for the photograph was cited. However, the Office of the Public Health Service Historian (accessible via the Health Services Research Library [National Institutes of Health] catalogue call number WC 140 no 3) has archived the photograph circa the 1920s. For unclear reasons, misinformation seems to seep routinely into discussions about the Tuskegee study—occurrences that may harm the health of the African American community. To answer Taylor’s question2—“Did the study at any time contain clear provision for currently established therapeutic measures to be instituted if a patient became symptomatic?”—here is a quote from the United States Public Health Service: “It is the practice of Public Health Service officers to refer men who develop syphilitic or nonsyphilitic conditions requiring therapy to the proper sources of treatment. Nevertheless, a few of the men have, on their own, sought and received antisyphilitic treatment in varying amounts. Some were treated by private physicians, a few had been inadvertently rounded up and sent to rapid treatment centers by health department workers who were unaware of the research project. Some of the patients were given therapy because of positive serologic tests for syphilis . . . or because of a history of infection; some even were treated for unrelated symptoms, rather than for specific complications of syphilis.”16 We have heard complaints of treatment denial at the rapid treatment centre. However, Tuskegee study men who received treatment should http://infection.thelancet.com Vol 6 February 2006
Reflection and Reaction
have an advantage over those who were allegedly denied treatment at the rapid treatment centre. Unless re-infected, men who received treatment before public exposure of the Tuskegee study might not have required treatment for syphilis after public exposure in 1972. This treatment and non-treatment issue has not been considered by conventional information sources. The editorial’s call for a re-analysis of the Tuskegee study1 was appropriate given that discussions have been limited, in part, to the men who were allegedly untreated, not treated, and denied treatment—but not the men who were treated.
4 5 6 7 8 9 10
11
12
Robert M White
13
12054 Eaglewood Court, Silver Spring, MD 20902, USA. [email protected]
14
1
15
2 3
The Lancet Infectious Diseases. Clearing the myths of time: Tuskegee revisited. Lancet Infect Dis 2005; 5: 127. Taylor MB. Tuskegee revisited. Lancet Infect Dis 2005; 5: 467–68. White RM. Unraveling the Tuskegee study of untreated syphilis. Arch Intern Med 2000; 160: 585–98.
16
Crissey JT. Treatment of syphilis: a 1932 advertisement. Ann Intern Med 1977; 87: 30. Angell M. Tuskegee revisited. Wall Street Journal October 28, 1997: A22. Thomas SB, Curran JW. Tuskegee: from science to conspiracy metaphor. Am J Med Sci 1999; 317: 1–4. Branche GC. Therapeutic quartan malaria in the treatment of neurosyphilis among Negroes. J Nerv Ment Dis 1936; 83: 177–88. Branche GC. Therapeutic quartan malaria in the treatment of neurosyphilis among Negroes. Am J Psychiatry 1940; 96: 967–78. Robinson HM. Syphilis. Treatment of neurosyphilis. In: Practical dermatology and syphilis. Baltimore: Chelsea Pub Co, 1947: 110. Becker FT. Induced malaria as a therapeutic agent. In: Boyd MF, ed. Malariology. A comprehensive survey of all aspects of this group of diseases from a global standpoint. Volume II. Philadelphia: WB Saunders Co, 1949: 1145–57. Miller LH, Mason SJ, Clyde DF, McGinniss MH. The resistance factor to Plasmodium vivax in blacks. The Duffy-blood-group genotype, FyFy. N Engl J Med 1976; 295: 302–04. Jones JH. Bad blood: the Tuskegee syphilis experiment. New York, NY, USA: Free Press, 1993. Gray FD. The Tuskegee syphilis study: the real story and beyond. Montgomery, AL, USA: Black Belt Press, 1998. Reverby SM. Tuskegee’s truths: rethinking the Tuskegee syphilis study. Chapel Hill, NC, USA: University of North Carolina Press, 2000. Burns SB. A morning’s work: medical photographs from the Burns Archive & Collection. Santa Fe, NM, USA: Twin Palms, 1998. Schuman SH, Olansky S, Rivers E, Smith CA, Rambo DS. Untreated syphilis in the male negro. Background and current status of patients in the Tuskegee study. J Chron Dis 1955; 2: 543–58.
Polio eradication and measles immunisation in Nigeria Almost 11 million children under the age of 5 years die annually worldwide, with 80% of these deaths occurring in Africa. These daunting figures are from the World Health Report 2005, which shows the current status of progress towards the Millennium Development Goals.1 One of the main goals is a reduction of childhood (under 5) mortality by twothirds by 2015 compared with 1990 levels. Measles is responsible for 5% of deaths in children under 5 years in the African region.2 A recent study by Otten and colleagues3 shows that measles deaths have dropped substantially in several African countries, while the Measles Initiative has publicised a decrease of 60% since 1999 for the whole of Africa.4 However, measles remains a major cause of childhood mortality, estimated to have claimed 282 000 lives in 2003;5,6 half of these occurred in Nigeria.7 In 2003, the under-5 mortality rate in Nigeria was estimated at 198 per 1000 live births.1 Current predictions show that the goal of reducing this mortality rate by two-thirds is unlikely to be met8 without a more integrated approach. Nigeria is one of only ten countries in the world with vaccine coverage of less than 50% and one of nine countries in which children do not have a chance of a http://infection.thelancet.com Vol 6 February 2006
second measles vaccination.7 With vaccine coverage remaining persistently below 40% since 1997,9 measles has remained hyperendemic. At the beginning of 2005, a large epidemic was reported in Adamawa state in northeastern Nigeria.10 Large-scale outbreaks of measles were also reported in other northern Nigerian states.10 Nigeria has the highest prevalence of circulating wild poliovirus in the world.11 It is under immense pressure from the international community to get its polio vaccination back on track after a 1-year suspension in Kano, northern Nigeria, following concerns about
Figure: Billboard of the National Programme on Immunization, near Yola, Adamawa state, Nigeria
63