Twenty-eight years ago today, then-President Bill Clinton delivered a speech at the White House apologizing for the United States Public Health Service (PHS) syphilis experiments on Black men in Tuskegee, Alabama (1932-1972). My first memory of learning about these experiments was well into my undergraduate training as a scientist at an ethics talk for summer interns. I learned of the nearly 600 men who were enrolled in the study (400 with syphilis, the rest without) under the false promise that they were being treated for “bad blood” and of the researchers who intentionally withheld treatment despite penicillin being a well-known cure for syphilis since the 1940s. We talked about informed consent, beneficence, and justice but we did not discuss the conditions that empowered the PHS to exploit these men or the ways that the belief systems that justified this study show up in our work today. As I moved from bench research to “human subjects” I learned that this was the norm—talk a little bit about the study’s ethics so we can be good researchers and move on.
Within Clinton’s apology was an award of $200,000 to Tuskegee University to establish the National Center for Bioethics in Research and Health Care. In 2019, I had the privilege of visiting this center when I attended the 8th Annual Public Health Ethics Intensive whose focus that year was “400 years – 1619 to 2019: Ethics of Reparations and Reconciliation.” Descendants, scholars, policy folks, spiritual leaders, practitioners, and others gathered to learn, discuss, grieve, and for some, heal.
We are launching Public Health is Political at this memorial point because in many ways, the Public Health Service Syphilis Study is the first major account of maltreatment by public health entities to come to light and is foundational to bioethics and current research regulation in the United States. Since the end of the study and the apology, much of how we practice has changed for the better and nearly every public health student has at least heard about this study. But, in order for true reconciliation, we must change the conditions and belief systems that allowed for these experiments to occur at all.
We caution readers against using the violence that has happened and continues to happen at the hands of public health, PHS, and other public health entities to discredit them entirely. Instead, we encourage readers to be critical of the field and understand that if the conditions do not change that allowed these harms in the first place, then public health researchers and practitioners are perpetually susceptible to them happening again in different ways. This is an incomplete analysis and further investigation is warranted.
What were the conditions that allowed for such experiments and how do they show up today?
We can begin understanding this by going back to the birth of Tuskegee, Alabama. Tuskegee was founded in 1833 by General Thomas Simpson Woodward who worked under President Andrew Jackson. Part of Jackson’s Indian termination efforts (ex. Indian Removal Act of 1830), involved removing Muscogee peoples from the territory that is now Georgia and Alabama to enable the states to “advance rapidly in population, wealth, and power.” The wealth, of course, came from enslaved Africans forced to work the cotton plantations that the land was developed for.
In addition to the efforts to exterminate Muscogee peoples, the Voices of Our Fathers Newsletter, Dr. Ruben C. Warren writes, “three major historical occurrences set forth the context for the [Tuskegee] Study: the Middle Passage which ushered in the enslavement of Africans in the Western Hemisphere; chattel slavery, which further devalued Black bodies, attempted to totally deconstruct Black culture and Black life, rendering Black people as less than human and; the American Eugenics Movement, which provided a class basis and then a class and race basis for further devaluing and rendering Black people as less than human.” These three major historical occurrences are rooted in white supremacy and heteropatriarchy, which are the belief systems that justify these occurrences. Because of these belief systems and their resulting systems of power are alive and well, the opportunity for violence to occur at the hands of public health practitioners remains. It is important to note that everything that happened with this study is racism, but it is not enough to name that, we must understand what belief systems racism is rooted in and the mechanisms by which racism operates. Thus, the focus on white supremacy, heteropatriarchy, the Middle Passage, chattel slavery, and eugenics. With this understanding, we can compare past and current conditions and understand where the belief systems exist and how to struggle against them so that we can operate in ways that reaffirm life and our responsibility to each other within our profession.
Beyond the dehumanization of Black men and the belief that they were less than human- due to the Middle Passage and chattel slavery, racial capitalism created the circumstances such that the men in this study were vulnerable to exploitation and coercion by PHS researchers because they were deprived of money, opportunity, and healthcare access. Study participants who were mostly poor sharecroppers were promised free medical care and burials in exchange for their bodies and for some, their lives. One PHS researcher, Oliver Wegner wrote, “we have no further interest in these patients until they die.” The free burials coerced the men in the study to come to the hospital when sick and the families to hand over their loved ones body for autopsy, which was necessary in order to receive the burial benefits. Wegner stated, “If the colored population become aware that accepting free hospital care means a postmortem every darkey will leave Macon County.” Today, people are still impacted by racism and discrimination at all levels, still poor, and still do not have access to healthcare. Clinical research trials are a mechanism for some people to get any medical treatment at all. Additionally, in cities that are oversaturated with research and overtaken by universities, joining clinical trials serves as the main form of income for some people and their families.
Violence in experimentation still exists in public health and the belief systems that underpin them have not changed since the PHS syphilis study at Tuskegee. Beliefs that some people are less than, are disposable, and can be sacrificed plays out in many ways in public health. Utilitarian exploitation refers to the exploitation of a person or a group of people for the “greater good.” Sacrifice for the sake of knowing, innovation, modern medicine, and “the greater good” despite all we have theoretically learned from the abuse and exploitation of Henrietta Lacks and syphilis experiments on Guatemalans is a logic of violence we need to be actively resisting. We have seen this as recently as 2013, when California’s Department of Corrections and Rehabilitation oversaw 144 cases of illegal sterilization of incarcerated women. Forced sterilization of Native women was also common practice for the Indian Health Service, under PHS, well into the 1970s and was also carried out against other communities as part of the eugenics movement.
This is just a snapshot of the conditions, practices, and belief systems that are ever present in our society and public health discipline. These are so normalized that had someone not leaked the PHS Syphilis Study to the press in 1972 they may have continued well into who knows when. If we do not look for these patterns or signs of these belief systems in our work, we will continue committing acts of violence when we are supposed to know better. As public health practitioners, we also have a responsibility to support political and economic structures that create the conditions to sustain health and wellbeing. For example, we must ensure that all people have access to free and high quality medical care. This can be done by expanding Medicaid, ending the privatization of health insurance and medical care facilities, and increasing the opportunities for nationalized health care. Additionally, we must work towards a future where fundamental necessities are not tied to wage labor. For example, free housing, food, education, burials, etc.
Syphilis, though preventable and curable, remains a pressing public health issue and so do the systems of power that keep it as such. Now, federal funding cuts, more attacks on reproductive health, increasing privatization of all services and goods, attempts to substantially cut Medicaid and other programs, the increasing dehumanization of specific people, and censorship and rewriting of history, are exacerbating the issues that will ultimately cause increased morbidity and mortality. Our intention is that Public Health is Political can be a place to interrogate these conditions, systems, and patterns and to instill hope so that we can create effective pathways to a better world.
On this day, the memorial of Clinton’s apology, we remember and mourn the Black men who were exploited, violated, and maimed by the PHS syphilis experiments, their loved ones, and the broader impacted community. We commit to actively resisting the systems of power and their associated belief systems that created the conditions for these experiments for a different public health.
Authored by Deionna Vigil
Deionna Vigil is the Co-Editor of Public Health is Political.
