by Sam Kean
If only the science had gone as smoothly. Cutler’s research plan involved two steps. First, he’d smear fresh gonorrheal pus on several men’s penises, in the absence of prophylactics, and measure the percentage who contracted the disease that way. This would establish a baseline rate of infection. In phase two, he’d smear the pus onto men who’d been pre-treated with prophylactics, and measure the percentage in this group who contracted gonorrhea. If the percentage in the second group was significantly lower than the baseline percentage, then the prophylactics worked.
Unfortunately, Cutler never got past the first step. He spent several months smearing gonorrhea on penises (you thought your job was bad), but the men couldn’t catch the clap that way to save their lives. Without nailing down the baseline rate of infection, the study was doomed. In mid-1944, after ten futile months, PHS pulled the plug on the work, to Cutler’s immense frustration.
Still, given the prevalence of VD in the military, Cutler got a second chance. By 1946 he’d transferred to a PHS office on Staten Island, where he met Dr. Juan Funes. Funes was there on a fellowship; he normally worked for the Guatemalan government’s public-health office. The two got to talking, and when Funes heard about the demise of the Terre Haute study, he begged Cutler to visit Guatemala and continue the work on prisoners there. Funes did this for one reason—money. Guatemala had recently thrown off the yoke of the United Fruit Company, which had run the country as its personal colony for decades, a literal banana republic. The young nation was struggling to get on its feet, and just like in Tuskegee, money for public health was tight. Luring Cutler to Guatemala would bring U.S. doctors to train staff and U.S. dollars to buy equipment.
Cutler liked the proposal as well. One big flaw in the Terre Haute study had been the artificial method of exposure—having to smear pus on penises. Gonorrhea was normally transmitted during sex, and he reasoned that something about the sex act might allow the germs to spread more readily. Fortunately, prostitution was legal in Guatemala, even for prisoners. The women simply had to get checkups at public clinics—and it just so happened that Funes ran those clinics. He told Cutler that he could screen women there for STDs and channel them to the prison for research. Cutler could then run the same basic study as in Terre Haute, except the exposure method, sex, would be far more natural.
Despite the parallels to Terre Haute, the Guatemala research would differ in a few key ways. For one thing, penicillin had appeared on the scene by then, necessitating a change in protocol. Instead of the original prophylactic ointment, this time Cutler would mix up a paste of penicillin, beeswax, and peanut oil and smear that onto the men’s penises. Funes and Cutler also decided to expand the pool of subjects to include not only prisoners but soldiers in the Guatemalan army and psychiatric patients. Similarly, they decided to look beyond just gonorrhea to syphilis and chancroid.
But the biggest difference between the two studies—and what pushed the work into the realm of sinful science—was that the doctors decided not to tell the soldiers, prisoners, and psychiatric patients that they’d be infected with STDs. Instead, they’d do it secretly. Trying to explain the science behind the study, one PHS physician insisted, would only “confuse” the poor subjects, especially the native Indians who made up the majority of prisoners. In fact, just like with Tuskegee, Cutler and company not only withheld the truth but actively lied to patients, gaining their cooperation by claiming to offer “treatments” for various diseases. The contrast is stark. When infecting American citizens, Cutler felt duty-bound to secure their consent. Guatemalans didn’t warrant the same respect.
The experiments began in Guatemala City in February 1947. As planned, Funes channeled infected prostitutes to Cutler; Cutler then played pander and paired them with johns in prison. To their delight, Cutler even plied the men and women with drinks before sex. Needless to say, liquoring up research subjects wouldn’t fly nowadays, but in Cutler’s mind this made the sex more “natural” by simulating a meeting in the wild, namely a bar.
Still, Cutler’s commitment to naturalness extended only so far. He apparently spied on the couples during sex, because he kept detailed records of how many minutes (or seconds) each man lasted—a proxy for exposure time. Then as soon as the men finished, he’d barge in and all but stick his nose in their crotches to examine the semen and vaginal fluid. There was no post-coital cuddling or cigarettes, either. For efficiency’s sake, the prostitutes got less than a minute between clients. One woman had to service eight men in seventy-one minutes, with no chance to wash up in between. Most of the eventual two thousand participants in the study were adults, but one prostitute was just sixteen, and some of the soldiers were as young as ten.
Despite his initial hopes, Cutler ran into the same frustrations in Guatemala as he had in Terre Haute. Even with the booze and the wham-bam sex, the men simply weren’t catching STDs at high enough rates to establish a baseline—and without a baseline, the experiments were worthless. So in his desperation, Cutler abandoned naturalistic sex and began infecting the men by hand.
It was quite the process. He first gathered some fresh venereal discharge and mixed it with nutritious beef-heart broth. Then he lured the men into his office and exposed them to this fluid in one of three ways. In the shallow exposure method, he soaked a small cotton pad in the fluid and forced it under their foreskins. (This required him, like some porno talent scout, to keep an eye out for men with meaty foreskins, which covered the pads better.) In the deep exposure method, Cutler soaked some cotton in the fluid and jammed it into the men’s urethras with a toothpick. In the abrasion method, he used the tips of syringes to scratch the head of the penis until it almost bled, then slopped fluid onto the wound. Cutler also exposed uninfected female prostitutes by inserting fluid-soaked cotton balls into their vaginas and, as he reported, swishing it around “with considerable vigor.” As if trying to ratchet up the creepiness, Cutler often invited his wife along to snap close-up photographs of people’s genitals.
Remarkably, some of Cutler’s subjects objected to these “treatments.” Rather than get his penis scraped, one psychiatric patient—who it must be said, comes off as the most sane person in the room—leapt off the table and fled; it took hospital staff hours to find him. Overall, though, Cutler was quite pleased with the artificial exposure methods, which produced baseline infection rates between 50 and 98 percent.
Cutler dutifully reported all this “progress” to his superiors in Washington, who were quite impressed. One wrote to him that “your show [!] is already attracting rather wide and favorable attention up here.” Another relayed a conversation he’d had with the U.S. surgeon general: “A merry twinkle came into his eye when he said, ‘You know, we couldn’t do such an experiment in this country.’”
Again, PHS doctors had often sacrificed lucrative careers in private practice to work in public health, and many of them came from military backgrounds to boot. In tandem, that shared background and shared sense of purpose produced a high esprit de corps within PHS ranks. Normally, a healthy esprit is a good thing. But psychologists who’ve studied group dynamics have found that teams with high cohesiveness and uniform backgrounds tend to make worse decisions than groups with more diversity of thought. In particular, uniform groups rarely question their own unethical behavior— or more precisely, fail to recognize they’re acting unethically. As far as the homogeneous PHS was concerned, Cutler was doing a bang-up job.
Still, Cutler knew on some level that his experiments had strayed into dubious territory. Even while gloating to his superiors, he stressed the need to keep everything hush-hush. Those pleas grew more insistent after April 1947, when a short article appeared in the New York Times. The piece described some experiments in Baltimore and North Carolina where scientists had exposed rabbits to syphilis and immediately given them penicillin, which seemed to prevent an infection from taking hold. The reporter noted that the work held great promise in humans—but that it would be “ethically impossible” to “shoot livin
g syphilis germs into human bodies.” Meanwhile, Cutler was doing exactly that in Guatemala. Seeing his work described as “ethically impossible” gave him no pause, though. It just reinforced his suspicion that people outside PHS ranks would make trouble, so secrecy was paramount.
Tellingly, too, historians have noted that Cutler never included himself as a research subject in his experiments. That might sound like an odd criticism, but self-experimentation was quite common in medicine through the mid-1900s. Anatomist John Hunter, for instance, deliberately gave himself gonorrhea in 1767 by injecting pus into his own penis, so he could monitor the disease day by day.4 However mad that sounds, Hunter at least had the courage to suffer for his science. Doctors were still doing such things in Cutler’s day. In fact the Nuremberg Code carves out an exemption for dangerous research as long as there’s a compelling medical need for it—and the doctors themselves serve as experimental subjects. Cutler’s work was arguably compelling, but he preferred saving his own (fore)skin and exposing others.
Despite the high esprit, a few colleagues within PHS did question the Guatemala research, however tepidly. The most direct challenge involved the work with the psychiatric patients. One doctor wrote to Cutler, “I am a bit, in fact more than a bit, leery of the experiment with the insane people. They cannot give consent, do not know what is going on, and if some goody organization got wind of the work, they would raise a lot of smoke.” To be sure, he seems more concerned about bad press than harming people. But unlike hundreds of others within PHS, he at least raised objections and advised Cutler to stop.
Pictures of some of the Guatemalan women deliberately infected with STDs during an experiment by the U.S. Public Health Service. (Courtesy of the U.S. National Archives and Records Administration.)
The colleague was right to worry. Even considering all the other ethical lapses in Guatemala, Cutler’s work in the insane asylum plumbed new lows. In exchange for some pathetically modest supplies—a projector, a refrigerator, some drugs, some plates and cups—the asylum’s superintendent allowed Cutler to expose fifty psychiatric patients to STDs, including seven epileptic women who had syphilis injected into their spines. Absurdly, Cutler claimed that the women “minded the procedure so little” that they lined up “day after day” to receive the spinal injections, partly because he bribed them with cigarettes.
The most wrenching case at the asylum involved a woman named Bertha. Her age and the reason for her confinement are now lost, but in February 1948, Cutler injected syphilis germs into her left arm. She soon developed lesions and red bumps there, and her skin began peeling off. Cutler nevertheless denied her treatment for three months, and by August 23, Bertha was clearly dying. Apparently believing that he could do whatever he wanted now, Cutler proceeded to inject gonorrheal pus into her urethra, eyes, and rectum, then re-injected syphilis for good measure. Within days, Bertha was weeping pus from both eyes and bleeding from her urethra. She died August 27.
As noted before, it’s all too easy to judge people in the past by the ethical standards of today and feel superior. As the saying goes, fashions in ethics change even faster than fashions in clothing, and it should give us pause to know that people in the future will probably denounce us for things we never even thought to question. But it is fair to judge people for violating the standards of their own day, and by that measure Cutler’s “ethically impossible” work was pretty grievous. If he’d run those same experiments on Bertha in a concentration camp in Germany, he might well have been tried for war crimes.
In all PHS spent $223,000 ($2.6 million today) on Cutler’s experiments before cutting off funds in 1948. Penicillin pills cured STDs so effectively that applying prophylactic peanut oil seemed pointless. A new surgeon general was taking over anyway—one presumably less prone to “merry twinkles” over ethical lapses. As a result, Cutler packed up and left Guatemala. Perhaps inevitably, given his interest in STDs, he later joined the Tuskegee study in Alabama.
Unlike the Tuskegee doctors, who blithely published their results, Cutler never wrote a word about Guatemala. That’s partly because the research didn’t produce any new knowledge; from a public-health standpoint, there wasn’t much there. But there seems to be another, darker reason for his silence. When he left PHS in 1960, Cutler absconded with all his lab notebooks and patient charts from Guatemala, even though they were U.S. government property—a highly unusual move for a dedicated soldier like him. No one knows why he took them, but it sure smells like a cover-up, to prevent anyone else from finding out about the research. Amazingly, no one did until 2005, when historian Susan Reverby came across the notebooks at the University of Pittsburgh, where Cutler taught after leaving PHS. Had Reverby not unearthed them, and heroically gone through all ten thousand pages, they’d likely still be secret today.5
Cutler wasn’t alive to see his research exposed; he died in 2003. So what sort of work had he done after Guatemala? Besides Tuskegee, he did stints in Haiti and India to help provide healthcare for women. He arranged fellowships for gynecologists and obstetricians in developing nations to train in the United States, so they could return home and save women’s lives. He also condemned the moral panic surrounding AIDS in the 1980s, refusing to demonize victims for being gay.
Sound familiar? Apologies for the rhetorical ploy, but the seemingly heroic doctor at the beginning of this section—the one who championed women and minorities—was the same man who ran the Guatemala study. If the only details you knew about Cutler came from his obituary, before the Guatemala work was exposed, you’d think he was Albert Schweitzer.
So how can these two Cutlers be the same person? Perhaps he repented after leaving Guatemala, and dedicated his life to doing better. Perhaps he buried all memory of it, and refused to admit he’d done anything wrong. Perhaps he still subscribed to the crude utilitarianism that as long as you were trying to help enough people overall—humankind in the abstract—you could sacrifice actual human beings along the way. (Well into the 1990s, Cutler defended the Tuskegee study on those very grounds.) Or perhaps the attempt to square Cutler One and Cutler Two misses the point. It’s tempting to lump the Guatemala Cutler in with Joseph Mengele and other Nazi doctors—to dismiss him as another sicko. It’s much harder to do so when we acknowledge all the good he did later. Perhaps, in the end, there is no satisfying way to reconcile the two John Cutlers.6
Because the Guatemala experiments were hushed up for so long, Tuskegee ended up casting a darker shadow on medical science. But as research becomes more international, sad echoes of both cases have sounded across the globe.
One controversy involved malaria vaccines. Most infectious diseases are caused by viruses or bacteria. Malaria is caused by a protozoan, a tiny but sophisticated creature with a complex life cycle. That complexity has hindered vaccine development for decades, exacerbating what’s arguably the world’s biggest health problem: the disease strikes 200 million people every year.
In the late 2010s, a promising new malaria vaccine appeared, and the World Health Organization (WHO) began testing it in Malawi, Ghana, and Kenya. To be sure, this vaccine, called Mosquirix, wasn’t perfect. In children under seventeen months old, it cut malaria rates by only one-third. Compared to control groups, it also increased the risk of meningitis by ten times and, for mysterious reasons, doubled the overall fatality rates of girls. Still, even taking those dangers into account, Mosquirix has the potential to save well over a hundred thousand lives in Africa alone every year.
The deployment of the vaccine, however, struck many critics as underhanded. Bureaucratically, WHO classified the vaccination program as a “pilot introduction” instead of a “research activity,” seemingly to avoid the red tape and extra oversight that official “research” requires. Worse, officials didn’t inform parents about the meningitis risk or increased fatality rates for girls. Instead, when parents showed up at clinics to vaccinate their children for other diseases, a doctor would simply ask them if they wanted a malaria vaccine as well. No one e
ven told them that Mosquirix was experimental. WHO defended its methods by noting that parents could opt out if they chose. WHO also argued that it had gained “implied consent” by providing information to the communities beforehand about vaccines in general. But critics countered that implied consent fell well short of the “informed consent” that most research requires. As one bioethicist argued, “Implied consent is no consent at all.”
As of now, this research—and the arguments over it—are still ongoing. But however iffy this all looks, the fundamental debate comes down to this: If the WHO’s shortcuts speed up the introduction of the vaccine and spare a few hundred thousand lives, will the ethical sleight-of-hand have been worth it?
An even trickier case involved AIDS drugs in Uganda in the 1990s. HIV-positive women have a one-quarter chance of passing the virus to their children during pregnancy. Certain drugs can cut that rate substantially, but the drugs were too expensive for most Africans to buy—$800 per person. In addition, the treatment regimen was complicated, involving both pills and shots from healthcare workers, for both the pregnant mother and the child after birth. In response, international health officials decided to test a shorter, simpler version of the regimen in Uganda. Half the pregnant women in the study received a short course of the drug AZT, while half received an inert placebo pill as a control. Scientists then compared infection rates in the two groups to see whether the short course worked.
