In the Commission’s view, the Guatemala experiments involved unconscionable violations of ethics
Their failure to exercise moral leadership cannot be excused, and their failure led to practices that were so wrong as to be fairly characterized as heinous.
- Presidential Commission for the Study of BioEthical Issues (2011)
"Ethically Impossible", yet it happened all the same.
The abhorrent Tuskegee experiments conducted by the US government from 1935 to 1972 were not confined to the United States - they were exported abroad. The secret medical experiments were extended to a Central American nation in the midst of revolution where the rule of law is often tenuous and sometimes non-existent. That place was Guatemala.
Innocent civilians were selected to continue the appalling practice of secretly infecting human subjects with syphilis and gonorrhea without their knowledge, nor their consent.
Victims such as Fredrico Ramos, now well into his nineties, and his family have quietly suffered the agony of untreated venereal disease for decades. In 1948, Ramos was a low-ranking soldier in the Guatemalan army with little choice but heed the orders of his commanding officers and present himself to a medical clinic operated by US doctors.
There, Ramos received an injection in his right arm and returned for the same treatment on several other occasions. His superior officers handed a small sum that he was told to buy prostitutes with as compensation. This was the beginning of a nightmare ordeal that would scar the young serviceman for the rest of his life.
Thousands more Guatemalans were subject to infection at the hands of US medical officials from 1946 to 1948 under the supervision of Dr. John Cutler and his research team from Public Health Service (PHS) and co-sponsored by the National Institute of Health (NIH). The agency would later be integrated under the umbrella of the Centers for Disease Control and Prevention (CDC).
It is estimated that from approximately 1500 to 5500 Guatemalans involuntarily became subjects of human experimentation.
The Tuskegee Experiments, aka the "Tuskegee Syphilis Study", describes research carried out by the US government of untreated syphilis in African American Males. Hundreds of African American men were purposefully infected with syphilis but were told that they were receiving free health care from the United States government.
Tuskegee syphilis study, official name Tuskegee Study of Untreated Syphilis in the Negro Male, 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
Astoundingly, the secret Tuskegee experiments spanned four decades in the United States. Medical researchers observed and logged the condition of the African American subjects to untreated syphilis for over 30 years without their knowledge.
Many of the very same medical experts, scientists and government officials involved in the Tuskegee Syphilis Study are also directly linked to the Guatemalan STD Experiments.
Prominent members of the US medical establishment from the PHS, NIH and the Venereal Disease Research Laboratory (VDRL) oversaw Dr. Cutler's secret research, in collaboration with doctors from John Hopkins University and the Rockefeller Foundation, also received funding from executives at Bristol-Myers Squibb (formerly - Bristol Laboratories and the Squibb Institute). Coordination with Guatemalan military doctors, Pan American Health Organization (formerly the Pan American Sanitary Bureau - PASB) and the national government was also indispensable in bringing Tuskegee to Guatemala.
Discovery of the Guatemalan Files
It wasn't until 2003 that evidence of the Guatemalan variant of the Tuskegee Experiments were unearth from an unlikely source. Medical records belonging to lead researcher Dr. Cutler, as part of a trove of medical documents which he had personally donated to the University of Pittsburgh, contained files describing human experimentation in Guatemala. Although Cutler's voluminous records had been gifted to the university in the 1990s, it took more than a decade before professor Susan Reverby of Wellesley College made the discovery.
Professor Reverby carefully examined the files and was horrified with what she uncovered. She presented her report on the revelations of human test subjects contained in Dr. Cutler's records to the CDC who were so disturbed by the findings that they began their own investigation. Ultimately, the issue reached the Whitehouse and Dr. Cutler's collection was transferred to the National Archives.
In 2010, the Obama administration launched an inquiry into the revelations. He commissioned a bioethics committee to investigate and substantiate the claims.
The findings of the nine-month and 201-page report on the Guatemalan STD Experiments carried out by PHS and VDRL medical scientists were damning and blunt.
The name of the report -
Presidential Commission for the Study of Bioethical Issues
Ethically impossible: STD Research in Guatemala from 1946 to 1948 (2011)
The War on Venereal Disease
In order to understand how American doctors ended up performing human experiments abroad, it's necessary to understand the historical context and socio-political landscape in the 1930s and 1940s.
The phrase "Ethically Impossible", actually derives from the lament of some early military researchers into the spread of STDs and the desire of the US medical officials to conduct testing on human subjects which was forbidden by US law and, undoubtedly, something that would be unacceptable to the American public.
One of main driving forces behind STD research is attributed to the elevated loss of man-hours caused by STDs in the military during WWII when servicemen contracted syphilis and other venereal diseases taking them out of action for prolonged periods of time. It's estimates that syphilis and other venereal diseases cost the military nearly 7 million working days per year.
This period marks the early days of research into STDs and had a lot of support from the leaders of the American medical and scientific communities as well as high-ranking military officials. Much of the early research involved testing, prevention and control of venereal diseases. Of particular interest, testing the efficacy of penicillin both as a treatment as well as a potential prophylaxis was a top priority.
Dr. Thomas Parran Jr., US Surgeon General from 1936-1948, was a leading advocate of such research even penning a book on syphilis in 1937 titled "Shadow on the Land". Though Parran received much admiration and recognition for his work combatting STDs, his connections to both the Tuskegee experiments in the US and Guatemalan STD experiments casts a shadow over his own career and legacy.
Parran's leadership role in international health affairs dated back to the 1930s with the Rockefeller Foundation and the Pan American Health Organization. Parran chaired the International Health Conference where the World Health Organization (WHO) draft constitution was adopted (1946) and led subsequent U.S. delegations.
Other enthusiastic supporters of STD research during the WWII and Cold War eras included the Director of the PHS Dr. John Mahoney, also with the VDRL at Staten Island, and Dr. Joseph Earle Moore. Moore was the Chairman of the National Research Council (NRC) Subcommittee on Venereal Diseases and Venereal Disease Division at Johns Hopkins University. In this capacity, Moore served advisor to Surgeon General of the Army, Navy and PHS on STD control.
Together these men, and other leaders in the field, declared war on syphilis and gonorrhea and played pivotal roles in the development of national education, prevention and treatment efforts, including within the military. As stated by Dr. Mahoney, the prevention of syphilis "still constitutes one of the most pressing problems of military medicine".
Prisoner Experiments at Terre Haute
In 1943, PHS researchers were granted permission to perform limited human experiments into gonorrhea on US soil at Terre Haute Penitentiary in Indiana. The consensus in the medical field at the time was that human experimentation was justifiable in order to help combat the spread of gonorrhea and being of "major military importance".
Unlike the secret Tuskegee experiments carried out on unsuspecting African Americans, the experiments at the prison required the consent of the inmates. Volunteers were compensated with $100, a certificate of merit and a recommendation for parole for their participation.
The aims of the Terre Haute researchers were essentially the same as those later pursued in Guatemala - to find an effective prophylaxis for syphilis and gonorrhea.
The research experiments conducted at Terre Haute were led by Dr. Mahoney and his young assistant doctor John Cutler who began by attempting to find reliable methods of infecting their subjects with gonorrhea.
All subjects were inoculated with bacteria deposited into the end of the penis. The researchers tried a variety of strains and concentrations of gonorrhea.
After only 10 months at the prison, the experiments were discontinued due to the difficulties in infecting subjects with adequate consistency necessary for the study of prophylactic agents, much to the disappointment of its lead researchers. Both Mahoney and Cutler felt that the prison experiments failed to provide the answers their research set out to uncover and that their work was incomplete.
It's plainly evident that many of the medical experts leading the Terre Haute trials were the very same officials immersed in the Guatemalan experiments.
The Terre Haute experiments were conducted and supported by many of the same people involved in the Guatemala experiments, including Dr. Cutler, Dr. JohnF. Mahoney, Dr. Thomas Parran, Dr. Joseph Earle Moore, and Dr. Cassius J. Van Slyke.
[Biometrics Commission Report]
A Breakthrough in Treatment
Around the same time, Dr. Mahoney was also separately researching the effects of penicillin as a treatment for syphilis (post-infection) on a small control group and soon observed significant results. The standard treatment at the time involving arsenic needed 18 months to have an effect while treatment with penicillin eliminated symptoms within only 8 days they found in their initial results. A larger medical trial was immediately launched by Dr. Mahoney and Dr. Moore that included 1,400 subjects and by June 1944 penicillin was adopted as the standard treatment for syphilis.
Even with the breakthrough discovery of penicillin as an effective treatment many unanswered questioned remained about its long term effectiveness and also the lingering desire by officials to produce an effective prophylaxis.
What the PHS researchers longed for was to study the effects of syphilis and gonorrhea under "natural conditions" where they could practice, in Dr. Cutler's words, "pure science" essentially observing the spread of disease in the wild. In other words, 'natural conditions' referred to the transmission of STDs through intercourse while 'pure science' alluded to the employment of human experimentation. In such an environment research would be unobstructed by the law and by burdensome ethical concerns.
The Study Spreads Further South
During this period, Juan Funes a visiting doctor from Guatemala who also previously worked closely with Dr. Mahoney at the Terre Haute penitentiary experiments, suggested to his colleagues that his homeland would provide the perfect setting for the types of experimentation that they had been dreaming of.
Reasoning that since prostitution was (and still is) legal in the country, combined with the nation's general low rates of venereal disease, plus existing requirements that workers have regular health check-ups, Guatemala would provide ideal proving grounds for the study of STD transmission.
It also had one more overarching benefit, conducting human experiments outside of the United States would be beyond the reach of US law and public scrutiny.
Not long after Juan Funes suggested his homeland as an option for the clandestine research, it received the backing from the top brass at the PHS. Dr. John Cutler was tasked with the undertaking and was quickly dispatched to Guatemala. Human experiments, with funding and the backing of the NIH, began in 1946.
"This decision to move to Guatemala was part of a deliberate plan to continue the Tuskegee testing offshore, where it would not be subject to the same level of oversight as in the United States
Two critical factors helped set the stage for the Guatemalan experiments. First, the military demonstrated their willingness to conduct medical experiments on human subjects at Terre Haute. Second, the unsatisfactory results in the minds of the researchers fuelled a desire to complete their research in a more conducive environment.
Ethically Impossible Commission Report
The bioethics commission's findings prompted then president Obama to call the president of Guatemala, Alvaro Colom, and formally apologize on behalf of the United States some 70 years later.
The report painstakingly details the grotesque nature of the operation and the revolting lack of compassion for those unfortunate Guatemalans that unknowingly took part in the deception.
While an extensive amount of records were produced from Dr. Cutler's personal documents, the quality of the reporting is somewhat incomplete as Cutler mostly summarized the experiments retrospectively in 1952. However, the records still provide ample evidence of medical malfeasance.
Here are some exerts from the the Commissions findings:
The studies encompassed research on three STDs—syphilis, gonorrhea, and chancroid—and involved the intentional exposure to STDs of 1,308 research subjects from three populations: prisoners, soldiers, and psychiatric patients. Of the 1,308 subjects exposed to an STD, the researchers documented some form of treatment for 678 subjects. Commercial sex workers, who in most cases were also intentionally infected with STDs, were used to transmit disease. In addition, to improve diagnostics, the researchers conducted diagnostic testing of 5,128 subjects including soldiers, prisoners, psychiatric patients, children, leprosy patients, and Air Force personnel at the U.S. base in Guatemala. This diagnostic testing, which included blood draws as well as lumbar and cisternal punctures, continued through 1953.
The records show that these events involved many officials and researchers in the United States as well as Guatemala. The records reveal the unconscionable ways in which the researchers sometimes used people as a mere means to advance what Dr. Cutler sometimes called “pure science,” hidden from public scrutiny in the United States.
...despite awareness on the part of government officials and independent medical experts of then existing basic ethical standards to protect against using individuals as a mere means to serve scientific and government ends, those standards were violated. The events in Guatemala serve as a cautionary tale of how the quest for scientific knowledge without regard to relevant ethical standards can blind researchers to the humanity of the people they enlist into research.
Certain sections of the report detailed the brutal and inhumane treatment some victims received at the hands of Dr. Cutler and his team of researchers. The death of one psychiatric patient named Berta is particularly disturbing.
In one case, detailed by the bioethics commission, the US doctors infected a woman named Berta, a patient at the psychiatric hospital, with syphilis, but did not treat her for three months. Her health worsened, and within another three months Cutler reported that she seemed close to death. He re-infected Berta with syphilis, and inserted pus from someone with gonorrhoea into her eyes, urethra and rectum. Over several days, pus developed in Berta's eyes, she started bleeding from her urethra and then she died.
Dr. Cutler's research involved both 'natural' and artificial means of infection. The early stages of the experiments involved the use of prostitutes who were infected with gonorrhea and were instructed to have sexual intercourse with Guatemalan prisoners and later soldiers.
Although Dr. Cutler refers to the soldiers as "volunteers" in his reports there are no records that any of the 510 soldiers consented to the experiments. Likewise, there is no evidence that of the 4 to 12 prostitutes who participated gave their consent either.
As luck would have it, Dr. Funes who had helped bring the study to Guatemala in the first place, had become the Chief of Medicine at the VDSPH (Venereal Disease and Sexual Prophylaxis Hospital) in Guatemala City. Dr. Funes selected sex workers already infected with gonorrhea for the experiments who had come under care at the VDSPH.
At least 4 women who were determined to be infected with naturally occurring gonorrhea were instructed to have sexual intercourse with soldiers. Some women were made to have sexual intercourse with multiple men successively, some seeing eight men in just over an hour.
Despite their efforts, 'natural' transmission once again proved to be difficult leading to increasingly cruder methods.
In one early study, he infected prostitutes by moistening a cotton swab with pus carrying gonorrhea bacteria and inserting it into their genitals “with considerable vigor.” There is no evidence they were informed about the risk. All of them contracted the disease.
Unsatisfied with the low rates of infection in their initial attempts, Dr. Cutler and his team proceeded to focus on artificial means of infecting their subjects. They inoculate subjects, both male and female, with various strains of gonorrhea and syphilis.
So researchers turned to inoculation, swabbing the urethra with an infected solution, or using a toothpick to insert the swab deep into the urethra. At the National Psychiatric Hospital of Guatemala, scientists scratched male patients' penises before artificial exposure to improve infection rates, and injected syphilis into the spinal fluid of seven female patients.
In many ways the experiments echoed the prisoner experiments at Terre Haute, where very similar methods were employed and where low infection rates frustrated the experimenters.
Back in the United States, doubts about the efficacy of the research in Guatemala were growing among the original supporters of the study, including PHS director Dr. Mahoney who expressed his disappointment and apprehension in a letter to Dr. Cutler.
The experiments lasted until 1948 when support back in the United States began to fade. Surgeon General Thomas Parran, who had supported the research no longer held the position. Upon consulting with PHS director Dr. Mahoney, Dr. Cutler decided to abandon the STD experiments and return home leaving his Guatemalan counterparts to continue some components of the study.
Along with the STD tests, Cutler's research team in Guatemala extended serological tests until the mid-1950s (serology tests are a tool to determine the presence of antibodies that would indicate infection). When participants in Dr. Cutler's serology experiments are included, the number of victims increases to over 5,000 Guatemalans.
According to Dr. Cutler's records, these were conducted to measure the natural spread of STDs by taking biopsy specimens from different parts of the population. This portion of the research included children from local orphanages, mental patients from psychiatric hospitals, and leprosy patients.
As with the victims involved in the STD experiments, there's no evidence that the caretakers, nor the legal guardians of the children provided consent. The same is true of the hospital patients and mentally ill who were part of the serology tests.
Correspondence and Coordination
Correspondences between PHS director and Dr. Cutler in Guatemala prove that there was a concerted effort to conceal the research and shield it from the American people and press. They knew well that if the press ever got wind of what was being done in Guatemala their research would be terminated.
Among the files contained in Dr. Cutler's collection, there are several correspondences between high ranking medical officials at the US PHS/NIH that clearly demonstrate awareness of the immoral nature of Dr. Cutler's research in Guatemala. Dr. John Mahoney of (title and agency) urges Cutler to "quote (keep things secret").
In another correspondence Cutler seems to find the double-dealing nature of his work to be thrilling at times.
In regard to the amount of gossip which the work in Guatemala has engendered, we are doing our utmost here to restrict our own conversations and those of others bearing upon the matter. We have also ben aware of considerable conversation and discussion being carried out in rather high places, much of which has not helped the work greatly. We are forwarding all of your reports to Doctor Heller in a way which we hope will prevent their being read by unauthorized persons...
I hope that you will not hesitate to stop the experimental work in the event of there being an undue amount of interest in that phase of the study. It would be preferable to delay the work than to risk the development of an antagonistic atmosphere.
It is becoming just as clear to us as it appears to be to you that it would not be advisable to have too many people concerned with this work in order to keep down talk and premature writing. I hope that it would be possible to keep the work strictly in your hands without necessity for outside advisors or workers other than those who fit into your program and who can be trusted not to talk. We are just a little bit concerned about the possibility of having anything said about our program that would adversely affect its continuation.
-John C. Cutler (S.A. Surgeon - Guatemala)
Conclusions of the Commission
The Commission concludes that the Guatemala experiments were "especially egregious moral wrongs" performed by representatives of public institutions.
The PHS research involved intentionally exposing and infecting vulnerable populations to sexually transmitted diseases without the subjects’ consent. “In the Commission’s view, the Guatemala experiments involved unconscionable basic violations of ethics, even as judged against the researchers’ own recognition of the requirements of the medical ethics of the day,” Commission Chair Amy Gutmann, Ph.D., said. “The individuals who approved, conducted, facilitated and funded these experiments are morally culpable to various degrees for these wrongs.”
the Commission has concluded that the Guatemala experiments involved gross violations of ethics as judged against both the standards of today and the researchers’ own understanding of applicable contemporaneous practices. It is the Commission’s firm belief that many of the actions undertaken in Guatemala were especially egregious moral wrongs because many of the individuals involved held positions of public institutional responsibility.
While it is true that scientific standards have evolved since the 1940s, the fact remains that the doctors must have been aware of the harm they inflicted on their test subjects. Their conduct clearly demonstrates a violation of the Hippocratic oath of "First, do no harm".
This isn't a case of 'a few bad apples', this was a system failure of the PHS and NIH whose own directors were well aware of the immoral nature of the experiments.
Ironically, the Nuremberg trials condemning the crimes of Nazi doctors like Mengele who preform attrocious experiments on prisoners of war were wrapping up in Germany simultaneously in 1947. Leading to a set of principles surrounding ethical scientific research known widely as the Nuremberg Code that aimed to protect human beings from cruel and exploitative treatment.
The Nuremberg Trials revealed that Nazi human experiments primarily focused their 'research' on the most vulnerable members of society: prisoners at concentration camps, the mentally challenged, the mentally ill, and the physically impaired.
At the conclusion of the Nuremberg trials, 16 of the 23 Nazi doctors on trial at Nuremberg were found guilty of Crimes Against Humanity, 7 of whom were executed and 10 others received sentences from 10 years to life in prison.
As a result of the 2011 Commission on Bioethics final report, US leaders issued a series of public apologies to the people of Guatemala. Then Secretary of State, Hilary Clinton, also issued an apology concerning the commissions findings in Guatemala.
"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"
While the commission acknowledges the cruelty and inhumane treatment of innocent Guatemalan citizens, and recommends more stringent ethical guidelines and safeguards to ensure this never happens again, it stops short of recommending any course of action or any forms of redress for the victims. The commission stresses concerns surrounding compensation for what happened in Guatemala were beyond the scope of their mandate.
In the final assessment commission chair Amy Gutmann maintains that:
The commission is confident that what happened in Guatemala in the 1940s could not happen today
We also are confident that there is room for improvement in protecting human subjects from harm -- avoidable harm -- and unethical treatment.
In the face of such gross and indefensible medical misconduct, there was almost complete silence regarding any forms of compensation or restitution for the victims and their families of the horrific experiments. Equally there is nearly no discussion of any criminal charges being brought to the courts. To date, there have been no efforts by the USG to take responsibility for these crimes against humanity.
Many of the victims who survive to this day, such as Fredrico Ramos, have not even received treatment for their malady some 70 years on.
END OF PART I
Human Medical Experimentation: From Small Pox Vaccines to Secret Government Experiments - Frances R. Frankenburg (2017) p226-p2