The Next Page / Before Tuskegee, the Guatemala Experiment: a Pitt legend's research is under scrutiny
Dr. John Cutler and Dr. Thomas Parran were giants in public health -- and at the University of Pittsburgh. They both played roles in the now-reviled 'Tuskegee Experiment,' which withheld treatment for black men with syphilis. Now a U.S. bioethics panel is
June 12, 2011 4:00 AM
Dr. John Cutler
By Torsten Ove Pittsburgh Post-Gazette
Two U.S. presidents have had to apologize for what Dr. John C. Cutler did, or helped do, in the name of science.
An esteemed professor and dean at the University of Pittsburgh from the late 1960s to 1985, Dr. Cutler died in 2003 at age 87 after spending much of his career in Pittsburgh. For decades, his reputation here had been one of pioneering medical research and dedication to improving public health around the world.
A former assistant U.S. surgeon general, he organized the final polio vaccination in the Hill District for the Allegheny County Health Department in the early 1960s, headed the population division of Pitt's Graduate School of Public Health in 1967, served as acting dean of the school in 1968 and 1969 and later helped found the Family Health Council of Western Pennsylvania.
He also established health projects in West Africa and several Third World nations and took on such missions as organizing a program that brought obstetricians from poor countries to the U.S. for training. He was a well-regarded instructor both at Pitt's Graduate School of Public Health and at the Graduate School of Public and International Affairs. Because of his accomplishments, the dean of the graduate school started a lecture series in his honor after he died. It ran until 2008, when a new dean canceled it because of "community sensitivities."
Those sensitivities concerned Dr. Cutler's role in government research at Tuskegee, Ala., in which the U.S. Public Health Service deliberately withheld treatment for syphilis for illiterate black sharecroppers from 1932 to 1972 to track the progress of the disease.
Dr. Cutler was one of the principal researchers there in the 1950s and 60s. Another man who became a Pitt luminary, Thomas Parran, oversaw the project as U.S. surgeon general from 1936 to 1948, when he left to start the Graduate School of Public Health as its first dean.
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Although Dr. Cutler defended the research at Tuskegee, President Bill Clinton apologized for it in 1997, calling it an "outrage to our commitment to integrity and equality for all our citizens."
Now, some 15 years later, a new president has apologized, this time for what Dr. Cutler did in Guatemala in the 1940s. In another Public Health Service project, also overseen by Thomas Parran, Dr. Cutler deliberately infected nearly 700 Guatemalan prisoners, mental patients and soldiers with syphilis to test the effectiveness of penicillin.
His wife, Eliese, 93 and living in Point Breeze, helped by taking hundred of photos of men's penises to document the research. She refused to discuss the project.
But Dr. Cutler's own records, uncovered in Pitt's archives by Wellesley College historian Susan Reverby while she was researching her 2009 book, "Examining Tuskegee," show that he used taxpayer dollars to pay syphilis-infected prostitutes to sleep with prisoners. When the infection rate proved insufficient, he had syphilis poured onto scrapes made on men's penises, arms and faces, or sometimes had it injected directly by spinal puncture.
The Guatemalan officials knew what was happening. Dr. Cutler, fluent in Spanish, worked with a Guatemalan doctor, Juan Funes, who had trained with the U.S. Public Health Service in New York. In exchange for access to their institutions, the Guatemalans received help from the PHS, such as penicillin and disease surveys.
But the subjects had no clue.
'What took place in Guatemala is a sobering reminder of past abuses'
In October, President Obama told Guatemalan President Alvaro Colom he was sorry.
"While I believe the research community has made tremendous progress in the area of human subjects protection," he said, "what took place in Guatemala is a sobering reminder of past abuses."
The president also told the Presidential Commission for the Study of Bioethical Issues to investigate the study and re-examine research standards. A dozen researchers have combed through 125,000 pages of records culled from various agencies and recently visited Guatemala. The report, due this summer, is also expected to include information about Dr. Cutler's experiments on federal prisoners in Indiana in 1944.
The Guatemalan government is conducting its own investigation. That report was to be completed at the end of May but still hasn't come out. The Guatemalan project has also generated a federal lawsuit brought by the descendents of the victims, who are seeking reparations. The case is pending in the District of Columbia.
In light of these developments, it's clear that Dr. Cutler's legacy, and to a lesser extent that of Dr. Parran, has been irreparably tarnished.
It's happened before with big names in research. The most recent example is Cornelius Rhoads, a famed Rockefeller Institute pathologist who in 1931 was conducting research in Puerto Rico. One night he wrote an angry letter, apparently after his car had been vandalized, in which he insulted Puerto Ricans as "degenerate" and claimed he had killed eight of them and "transplanted cancer into several more."
He later said he was joking to blow off steam, but in 2003 the American Association for Cancer Research stripped his name from an annual award given to young researchers.
'We couldn't do such an experiment in this country'
Dr. Parran, who founded the Graduate School of Public Health at Pitt with a grant from Andew Mellon, was a major figure in medicine.
Appointed U.S. surgeon general in 1936 by President Franklin Roosevelt, he was considered the world's authority on public health. His 1937 book, "Shadow on the Land," was groundbreaking for its frank discussion of syphilis at a time when such things were talked about in whispers.
He came to Pitt with much fanfare and built the school of public health into a nationally recognized institution, recruiting its first generation of faculty from the PHS, including his former deputy surgeon general, James Crabtree. The building that houses the school was renamed Parran Hall in his honor in 1969, the year after he died.
Yet as correspondence from the Cutler files indicates, during his days as surgeon general, Dr. Parran was fully aware of what was happening in Guatemala and Tuskegee.
G. Robert Coatney, a malaria expert who visited the Guatemala project in 1947, briefed Dr. Parran on it. In a to letter Dr. Cutler, he wrote: "As you well know, [Dr. Parran] is very much interested in the project and a merry twinkle came into his eye when he said, 'You know, we couldn't do such an experiment in this country.' "
Dr. Cutler tried to keep a lid on what he was doing for fear of ruining the research. In one letter, he warned that "a few words to the wrong person here, or even at home, might wreck it or parts of it ... "
In another letter, he admitted to "double talk" in not telling his subjects that the inoculum he was using contained syphilis.
Those familiar with the records and the history of medical research, however, caution that the project has to be evaluated in the proper historical context. For one thing, medical research had few hard-and-fast rules in the first half of the century, especially regarding informed consent.
According to University of Wisconsin medical historian Susan Lederer, who in March joined Ms. Reverby for a symposium at Pitt to discuss the Cutler research, the guidelines tended to be stricter for more serious diseases. An example, she said, is the U.S. Army Yellow Fever study conducted in Cuba in 1900 by Walter Reed, who developed a contract between the subjects and the investigators that required written consent.
But other studies involving less lethal diseases were conducted without any rules beyond those imposed by a researcher's moral compass. Ms. Lederer notes, for example, that the term "volunteer" was typically used as a synonym for research subject, "with no special meaning intended regarding the decision of the participants to join in an experiment."
The history of U.S. research contains many unsettling stories, most involving vulnerable populations such as prisoners, mental patients, poor blacks and even children:
• In 1906, Harvard professor Richard Strong infected prisoners in the Philippines with cholera, compensating them with cigars and cigarettes. Thirteen died. During the Nuremberg trials after World War II, German doctors accused of conducting barbaric experiments cited this study as a defense, saying Americans were guilty of the same practices.
• In 1914, Dr. Joseph Goldberger, a PHS doctor, convinced the governor of Mississippi to let him experiment on prisoners to induce pellagra, a debilitating disease he believed was caused by poor diet. He fed the men cornbread, yams, grits and rice and proved his theory. In exchange, the governor kept a promise to pardon the prisoners. German doctors cited this experiment at Nuremberg, too.
• In 1919, Dr. Leo L. Stanley, the doctor at San Quentin prison in California, tried to reverse the aging process in older prisoners by implanting ram testicles into them. He ground up the testicular material and injected the substance into their lower abdomens. He claimed the injections enhanced their virility.
• In 1939, University of Iowa speech pathologist Wendell Johnson oversaw a study in which children at an orphans' home were belittled to induce stuttering. The idea was to see if stuttering was a learned behavior. The research, later known as the "monster study," resulted in a lawsuit that was settled in 2007 for $925,000. The university apologized in 2001, although the building housing the speech department remains named for Dr. Johnson.
• In the 1960s, two experiments caused a national scandal. In 1963, Chester Southam injected live cancer cells into 22 elderly patients at the Jewish Chronic Disease Hospital in Brooklyn, N.Y. At the Willowbrook Hospital on Staten Island, Saul Krugman and Robert McCollum injected live hepatitis into retarded children.
'In the interest of the total society'
So, was Dr. Cutler's research an aberration?
The Guatemala study took place at a critical time for medical ethics because the Nuremberg trials had just concluded, leading to the development of the Nuremberg Code of principles to protect human subjects.
But, as Ms. Reverby writes in "Examining Tuskegee," most American doctors did not see Nuremberg as relevant to them: "The horrors of the experiments under the Nazis became thought of as Nazi science, not science."
There were other factors at work, too. The Public Health Service was an outfit built on a military model whose officers were seen -- and saw themselves -- as noble figures battling disease around the world.
The uniformed doctors, all white men with an elite mindset, enjoyed an esprit de corps bolstered by the danger and romance of their work. They often contracted the diseases they studied and even maintained a "Killed in Action" list.
That kind of devotion, Ms. Reverby writes, "created a sense that martyrdom in the name of science had become expected and necessary."
Dr. Cutler was very much a part of this world.
Born in Cleveland in 1915, he graduated from Western Reserve University Medical School in 1941 and joined the service a year later. He and Eliese, who never had children, traveled from post to post as he waged war on syphilis.
It's difficult to understand now, but before the age of antibiotics the disease was a worldwide scourge. An entire medical industry had been set up to combat it. At PHS, research trumped all.
Dr. Cutler justified his role in Tuskegee in a matter-of-fact way, likening the study to sending men into combat to protect the national interest.
"Some will die," he said in "The Deadly Deception," a NOVA documentary that aired on PBS in 1993. "It's in the interest of the total society. These men in Tuskegee helped us learn how to treat syphilis among blacks. They were serving their race."
To him, clearly, the purity of the science is what mattered; he couldn't seem to understand why he was being questioned.
"It was important that they were supposedly untreated, and it would be undesirable to go ahead and use large amounts of penicillin to treat the disease, because you'd interfere with the study."
One of his colleagues at Tuskegee, Sidney Olansky, also defended the research on "Primetime Live" in 1992. As a result, Emory University Medical School in Atlanta, where he had taught, changed its mind about naming its dermatology library after him.
"These things have a long memory," said Ms. Lederer, the medical historian.
'Thought they were doing good science against a dreadful disease'
No one knows if Dr. Cutler defended his Guatemala project in the same way. The results were never published and the experiment shut down in 1948, after which he moved on to do syphilis research with Dr. Olansky on inmates at Sing Sing prison in New York.
But there is evidence that he and his colleagues knew they were on shaky ethical ground.
The lawsuit brought by the Guatemalans, for example, says that the PHS left the U.S. to avoid scrutiny after a debate by the National Research Council over the ethics of a 1944 PHS study involving Dr. Cutler at the federal penitentiary in Terre Haute, Ind., in which prisoners were infected with gonorrhea.
Dr. Cutler's correspondence seems to bolster a need for secrecy.
In one 1947 letter to his boss, J.F. Mahoney, he wrote: "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. ... We are just a little bit concerned about the possibility of having anything said about our program that would adversely affect its continuation."
In her talk at Pitt, Ms. Reverby said the Guatemala revelations generated so much interest because the story tapped into the perfect elements of medical scandal: sex, a secret find and "underlying distrust" of the medical establishment, especially now that more than half of U.S. research is done overseas.
But Ms. Reverby also urged a sense of perspective.
"Cutler and his colleagues thought they were doing really good science against a really dreadful disease," she said. "I think it's incredibly dangerous to see Cutler as a monster, like [Nazi doctor Joseph] Mengele, and not understand the broader institutional support for what he's doing."