Saturday, October 02, 2010

John Cutler and the Guatemala Syphilis Research Program

There is considerable publicity today about a research project conducted in Guatemala in 1946-1948. The research studied the process of infection by syphilis (with the intent of eventually finding better ways to prevent infection) and two other sexually transmitted diseases (STDs). It also studied the accuracy of blood tests for syphilis infection. The project was collaborative, supported by the U.S. Public Health Service and National Institutes for Health and various agencies of the government of Guatemala. Hundreds of human subjects were subjected to experimental procedures during the research, drawn from people in jail, in asylums, and in the military. While consent was obtained from institutional officials, even during the research there was concern that informed consent may not have been obtained from all of the subjects. The U.S. Secretaries of State and Health and Human Services have publicly apologized for the the U.S. role in the research.

Here are links to articles in:
I think both articles are inaccurate in some respects. Both are based primarily on a report by Susan M. Reverby, a historian. Here are the source materials:
I find Reverby's paper to inject adjectives giving the author's emotional response to the material covered, rather than a more straight-forward account of the events.

There is a brief report from the U.S. Centers for Disease Control on the archival materials relating to the study *used as the basis for the Reverby report). The CDC report concludes on the ethics of the study:
The design and conduct of the studies was unethical in many respects, including deliberate exposure of subjects to known serious health threats, lack of knowledge of and consent for experimental procedures by study subjects, and the use of highly vulnerable populations.
I concur that the study would not have been approved under current standards for ethical review. On the other hand, the project was approved by the relevant authorities of the time in both the United States and Guatemala. Ethics change with time, and scientists believed they were acting ethically in the 1940s doing things which we now see as unethical.

John C. Cutler

The main protagonist in the Reverby paper and newspaper articles in John Cutler. His papers are archived at the University of Pittsburgh and were the basis of the Reverby article. I knew John Cutler, having worked with him for some months in 1977 when he volunteered to help with a policy study on which I was employed. I found him to be a devoted public health professional, strongly concerned with improving world health. His career included service as Deputy Director of the Pan American Sanitary Bureau/Pan American Health Organization (the Western Hemisphere branch of the World Health Organization) and Assistant Surgeon General of the U.S. Public Health Service, as well as professor of public health at the University of Pittsburgh and chair of its Department of Health Administration. Here are:
Some Comments on Syphilis

Syphilis remains a significant public health problem. According to the CDC, more than 36,000 cases were reported in the United States during the most recent year for which data have been compiled. Since under-reporting is often a problem for STDs, there were probably more cases; there are many more cases in other parts of the world.

The primary stage of the disease is usually marked by the appearance of a single sore. Skin rash and mucous membrane lesions characterize the secondary stage. Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. 

The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear. Without treatment, the infected person will continue to have syphilis even though there are no signs or symptoms; infection remains in the body. This latent stage can last for years. The late stages of syphilis can develop in about 15% of people who have not been treated for syphilis, and can appear 10–20 years after infection was first acquired. In the late stages of syphilis, the disease may subsequently damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.
Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are needed to treat someone who has had syphilis for longer than a year.
Comments on the Controversy

The world would be a better place if researchers in the past had in fact discovered better ways to prevent syphilis transmission, and it seems to me that it might have been possible to do so even with the tools available in the 1940s and 1950, had research been prosecuted with more vigor. 

In spite of the fearsome reputation of syphilis, the risks to people experimentally infected with the agent of the disease might be deemed acceptable if those people who in fact were infected were promptly diagnosed and treated.

There is a major difference between the Tuskegee study which observed untreated people with syphilis for some 40 years and the Guatemala study which was designed to promptly treat any subject who was in fact infected. In the former case, the subjects might well have had complications of the disease which could have been prevented, while promptly treated early infection is not nearly as dangerous. (Unfortunately, for reasons not given in the discussions I read, many infected subjects were not treated with penicillin; a very large portion of the subjects in the research appear to have died!)

The Reverby paper and the derivative newspaper articles seem to assume that since the project received funding from the United States government and since Cutler was in residence in Guatemala during the research period, the United States dominated the project. I wonder about that assumption.

The primary Guatemalan collaborator in the project was Dr. Juan Funes, chief of the VD control division of the Guatemalan Sanidad Publica. Funes was the author of the major report on the research, published in the Bulletin of the Pan American Sanitary Bureau. (This Bulletin is now a respected international journal, and publication of the results of research conducted under sponsorship of the Pan American Sanitary Bureau in Spanish in its scientific journal seems quite appropriate.)

Dr. Cutler was a young scientist; he graduated from medical school in 1941 and joined the Public Health Service in 1942, four years before the beginning of this research project. Dr. Funes was not only a division chief in the Guatemalan Ministry of Public Health, but had received training from the U.S. Public Health Service. My experience in Latin American public health research and my experience collaborating with John Cutler leads me to assume that the collaboration on the syphilis project may well have been between equals.


John Daly said...

Before you think too badly of John Cutler for his work in Guatemala in the 1940s, recall some other people who had what we would now see as ethical lapses. Thomas Jefferson not only owned slaves, but apparently fathered a child by one of those slaves. Abraham Lincoln thought Africans congenitally inferior to Europeans, and freed the slaves in the Emancipation Proclamation only in areas still under control of the Confederacy, doing so primarily to cripple the Confederate economy.

Recall too that John Cutler, through his research was a principle inventor of what became the standard test to diagnose syphilis. His research paid off!

I wonder how many of his current critics have a career that would compare with his half century devoted to promoting public health, or would have any accomplishment to compare with that of the development of the diagnostic test for a major disease, one that could when diagnosed be reliably cured with antibiotics.

John Daly said...

Reverby in her paper suggests that Cutler was guilty of racism in suggesting that native Americans might show differing blood serum responses to syphilis infection than European Americans.

Actually, it is well established that different population groups show differing responses to the same disease. Think of how lethal diseases from the Eurasian region such as measles, mumps and flu were in the Americas after Europeans reached Americans shores and brought the diseases for the first time to America.

It is believed that syphilis and the closely related disease of yaws were limited to the Americas before Columbus, and may have been endemic in American populations. If so, would it not have been possible that native Americans would have evolved resistance to those diseases, and thus have responded differently to them than would have European Americans?