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Horror

History of Exposure

Ishrat Syed and Kalpana Swaminathan write together as Kalpish Ratna. They are working on a biography of Garcia d’Orta
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The National AIDS Control Organisation has recently claimed that syphilis is close to eradication in India. While that itself is contestable, the real shocker is what the US condoned in the name of syphilis research

What really happened in Ghund?

On 1 October 2010 President Barack Obama apologised to President Álvaro Colom and the people of Guatemala for illegal medical research conducted by the United States in Guatemala during the years 1946-48.

Ghund, near Shimla, is a village in Himachal Pradesh. It is as far removed as possible—in geography, culture and climate—from Guatemala. Yet, when I read about Guatemala, it was Ghund that clamoured for notice.

Mr Obama’s apology was preliminary to a detailed enquiry by a bio-ethics committee. That investigation is now complete. The report, Ethically Impossible, is in the public domain. 1  Through the hours of anger, revulsion and despair it took me to absorb its horrific details, the question that kept troubling me was: What really happened in Ghund?

Ghund and Guatemala are united by syphilis. Not just the disease itself, but by its historic use as a tool to manipulate power.

The horror story of Guatemala is only the most recent in the catalogue of domination and destruction achieved by the use of syphilis as a weapon. Unlike biowar waged by agents of immediate destruction like smallpox and plague, the use of syphilis does not annihilate. It serves instead to create a subspecies that can conveniently be regarded as the reservoir of human evil.

Does that sound too medieval?

We saw a little of this in the final twenty years of the last century in our homophobic terror of AIDS.

We experienced much more of it in India under British rule, when, for nearly a century, Indian women were reviled as the source of syphilis and gonorrhoea, and segregated in Lock Hospitals under several infamous Contagious Diseases Acts. That story has been forgotten.

The story of Guatemala has broken now, this September, and although it happened 70 years ago, its relevance is greater than ever today as India offers itself as a willing subject for clinical trials. We are a poor country, and vulnerable. Guatemala was much poorer and even more vulnerable in 1946. Much as Ghund was in 1949.

In November 1949, Ghund was visited by a WHO team. Their purpose? To survey the population for syphilis and plan a mass treatment schedule. The team had a base in Shimla, a laboratory in Theog, and trained workers in the field. Of the 354 families surveyed in Ghund, only 80 were found free of syphilis. The afflicted were treated with penicillin, then relatively new on the market. Though the lowest possible doses were used, the results were magical.

The WHO team was baffled by the response of the cured population. The villagers, who had been confiding and co-operative earlier, now refused further blood tests. They saw no point to this, now that they were well again. They refused physical examination. On the second survey, a bare 20 per cent of index cases returned for examination and treatment. On the third survey, conducted a year after the study’s commencement, the villagers were openly hostile.

In a paper written by the team leader, John Cutler, the natives of Ghund seem a bloody-minded bunch of ignorant savages:

‘This reaction is to be expected in a group of people whose concept of disease, treatment, and results of treatment has not received the impact of scientific knowledge—even to the extent found in an illiterate population long accustomed to having physicians working among them. Such suspicion and lack of co-operation may seem incredible to the sophisticated medical mind unless the background of these medically ignorant people is understood.’

I’m not so sure.

Even allowing for the natural reluctance to undergo a blood test, our villagers seldom display hostility and belligerence towards treatments that work.

And certainly, penicillin had worked wonders. The stigma of syphilis, though hidden by clothing, is seldom far from the victim’s mind. When, for the first time, a medication heals a sore, alleviates agonising joint pain, and erases the embarrassing rash—what else can one feel but gratitude?

There are strange ways of expressing relief and gratitude, but hostility isn’t one of them. Besides refusing to get their blood tested, the villagers were also mulish prudes when it came to physical examination. The WHO people, in their two reports, seem to have exhausted their patience:

‘At examination, it was possible to strip most males to the waist so that the skin of the upper part of the body was seen, but the women could not be so examined. The people do not allow free display of the body except in very young children.’  2

John Cutler had met this attitude before. He had written angrily about it, just a year earlier, using practically the same words. He wasn’t writing about the villagers of Ghund, then. He was describing the inmates of a mental asylum (Asilo de Alienadoes) in Guatemala, where he found the women unwilling patients ‘as a result of local prejudices against male viewing of the body, even by physicians’.

Reading past Cutler’s euphemism, it is clear he thought these women plain cussed.

I can understand a mass survey for syphilis in a remote village, but what was Cutler doing examining women in a mental asylum in Guatemala?

I do not know what happened in Ghund. The story of that survey was told by John Cutler, and very soon after he had wound up his operations in Guatemala. But we know what he did in Guatemala. This is that story.

Rape has only recently been recognised as a war crime. Through World War II, it was an acknowledged military diversion. Sexually transmitted diseases (syphilis and gonorrhoea) were almost an occupational hazard in the army. The United States found the number of servicemen disabled by STDs seriously unaffordable: 18,000 servicemen were disabled by STDs every day during World War I. By the end of World War II, this number had reduced considerably, largely due to the discovery of penicillin.

Dr Joseph Earle Moore, chairman of the US National Research Council Subcommittee on Venereal Diseases, wrote that he expected ‘approximately 350,000 fresh infections with gonorrhea [in the armed forces], [which] will account for 7,000,000 lost man days per year, the equivalent of putting out of action for a full year the entire strength of two full armored divisions or of ten aircraft carriers’.

A great deal was being spent already in equipping every soldier with a preventive kit. Besides condoms, these Prokits contained a syringe for urethral irrigation, the silver and mercuric compounds then in use as therapy—and later, sulfa and penicillin tablets dosed arbitrarily.

Still, syphilis continued to spread. It became necessary to push the envelope.

Prophylaxis—a vaccine, a serum, call it what you will—was the need of the hour. This didn’t seem a near possibility, but here was this wonder drug, penicillin, and very little as yet was known about how it worked.

In July 1947, The Journal of Venereal Disease Information carried this notice from a Public Health Service official, Dr John F Mahoney:

‘It has been considered impractical to work out, under postwar conditions in the United States, the solution of certain phases concerned with the prevention and treatment of syphilis. These problems are largely concerned with the development of an effective prophylactic agent for both gonorrhea and syphilis and the prolonged observation of patients treated with penicillin for early syphilis. Because of the relatively fixed character of the population and because of the highly co-operative attitude of the officials, both civil and military, an experimental laboratory in Guatemala City has been established.’

This was the first public intimation of the work being done at Guatemala.

John Cutler, accompanied by his wife Eliese, arrived in Guatemala in August 1946. He was 31. His aim was to test penicillin as a cure. This, he believed, could only be done effectively under conditions that replicated the usual way in which the disease entered the human body—sexual intercourse. Dr Cutler called it ‘Normal Exposure.’

Reading that, I was jolted back to my first day in the wards as an undergraduate student.

History taking is the first skill a doctor must learn, and the trajectory, as outlined by the textbook, begins with the weather and ends with cringe-inducing questions, the worst of which is termed ‘history of exposure’. I generally skipped that one. How could a teenager ask that of the kindly grandmother, or the harried father of five? On the rare occasion when I summoned up enough nerve, I was generally met with a look of blank incomprehension.

Dr Cutler’s experiments of ‘intentional exposure’ to syphilis were conducted on 688 persons from May 1947 to October 1948. These included prisoners, commercial sex workers and inmates of a mental asylum. The aim of these experiments was to study the efficacy of various forms of penicillin and of the prophylaxis then in use by the US Army.

The infective material used in the study was derived from two sources. Rabbits, to begin with, but Cutler wasn’t really keen on an animal source. The best study of mankind, he decided, was man. Infective material from infected human beings was the most reliable agent.

To source this ‘human passage material,’ Dr Cutler used chancres (primary sores) from patients in local hospitals. He excised these sores under local anaesthesia, ground them up, and made an emulsion. The final ‘human passage material’ often consisted of emulsions from multiple donors.

What of those donors? Chancres occur at the junction between the skin and the mucous membrane, and excising a chancre on the penis means gouging out a big chunk from it, and leaving the victim with a partial amputation. Surely, this brutal procedure at least guaranteed the donor a curative shot of penicillin? Not always. Cutler’s relentless curiosity made him withhold treatment. In his own words ‘treatment was delayed to study the healing of operative wounds in syphilitic patients’.

In the Penitentiary, 219 men were selected for ‘intentional exposure.’ This was achieved in one of two ways. In the first, a commercial sex worker was infected with the ‘human passage material.’ As gonorrhoea was also being studied alongside, the women who were chosen were infected either with gonorrhoea or syphilis. This was achieved by inserting gauze soaked in syphilitic or gonorrheal pus into the woman’s cervix.

The aim of this experiment was to ‘permit the exposure of a large group of men to infected prostitutes to determine the normal rate of infection to gonorrhea’.

Dr Cutler’s superiors expressed concern over the frenetic pace of the ‘normal exposure.’ One woman was subjected to eight men over 71 minutes. Yes, Cutler was there with a stopwatch, and his wife with a camera. None of its prisoners had volunteered for the study, nor was the implication explained to them. Of the 219 men who underwent ‘intentional exposure’, only 92 received any kind of treatment.

When ‘normal exposure’ did not result in an infection, Cutler resorted to ‘artificial inoculation.’ This was either superficial or deep, the infective material introduced on a swab.

Two months into this study, on 27 April 1947, Waldemar Kaempffert, science editor of The New York Times, published this note under the title Syphilis Preventive:

‘Drs. Harry Eagle, Harold J. Magnuson and Ralph Fleischman of the United States Public Health Service, the Johns Hopkins School of Hygiene and the University of North Carolina have discovered that small doses of penicillin, injected within a few days after exposure, prevent syphilis from developing. The case holds good for rabbits, but no tests on human beings have yet been made. To settle the human issue quickly it would be necessary to shoot living syphilis germs into human bodies, just as Dr Eagle shot them into rabbits. Since this is ethically impossible, it may take years to gather the information needed.

W.K.’

John Cutler reacted to this with anxiety. He wrote to his senior colleagues and expressed the need for secrecy about the experiments in Guatemala. But his investigative zeal was in no way deterred.

In September 1947, Cutler was experimenting with ‘normal exposure’ followed by ‘artificial inoculation’ ‘while the penis was still partially engorged and while the fluid of the ejaculate was at the meatus’. These inoculations were performed to ‘simulate more nearly the natural conditions’. He also conducted ‘artificial inoculation’ in patients where ‘normal exposure’ had failed to produce signs of syphilis. He injected syphilitic material into the foreskins and arms of these men, and produced infection in most of them.

Dr Cutler’s experiments in the Guatemala Army continued till July 1948. The Psychiatric Hospital, the Asilo de Alienadoes, was his next arena of ‘research,’ where inmates were ‘intentionally exposed’ to gonorrhoea. Berta was one of these.

In February 1948, Berta was injected with syphilis in her arm. Within a month, she developed signs of infection, but was given no treatment for the next three months.

On 23 August, Dr Cutler noted that Berta looked close to death.

Immediately, he injected her with both gonorrheal pus and syphilitic material from another patient. Berta received these injections into her urethra, rectum and eyes. In a few days, her eyes were painfully infected, and she was bleeding from the urethra. She died four days after this ‘experiment.’

Curious too about the ability of the spirochete to penetrate into the mucosa of the gastro-intestinal system, to test ‘the problem of oral contagion through kissing and oro-genital sexual contacts’, ‘[a] mixture of testicular tissue and supernatant fluid was well mixed. One cc of this mixture was placed in a small beaker to which was added 20 ccs of distilled water. The patient was given the dose to swallow...’

To determine the effectiveness of the blood-brain barrier in repelling the spirochete, Treponema pallidum was injected ‘directly into the central nervous system’.This required a cisternal puncture, where spinal fluid is withdrawn from the back of the skull (close to the brain stem, and hence specially precarious) and syphilitic emulsions injected into the spinal canal. These were done in 1955 on ‘deteriorated and debilitated epileptics’.

Not surprisingly, this resulted in paraplegia, meningitis, and one death. Dr Cutler claimed this procedure was so popular that patients queued up for it, eager to claim their ‘reward’ of two packs of American cigarettes.

US Public Health Service officials had some qualms about ‘experimenting on the insane’, but advised Cutler ‘your first study could be done in a short time and none would be the wiser. In the report, [we] see no reason to say where the work was done and the type of volunteer’.

Eventually, 446 psychiatric patients were entered for ‘intentional exposure’ to syphilis:  of these, 294 were treated. The patients were not informed about what was being done to them. Dr Cutler wrote: ‘… as you can imagine we are all holding our breaths, and we are explaining to the patients and others concerned with but a few key exceptions that the treatment is a new one utilizing serum followed by penicillin. This double talk keeps me hopping at times’.

There was active resistance to these procedures. One patient fled after his penis was scarified for ‘artificial inoculation.’ Dr Cutler’s justification for this is a masterpiece of semantic prevarication:

‘Studies on human inoculation with syphilis demonstrated the value of intact, healthy skin and mucous membrane in preventing infection.’

From this description, could you have guessed what Cutler actually did?

‘The foreskin was retracted and the glans placed on a stretch over the forefinger of the left hand of the physician. Using the long end of a 20 gauge, long-bevel hypodermic needle held in the right hand, the dorsal surface of the glans just distal to the coronal sulcus was lightly abraded over an area of about 2 x 5 mm. We tried to stop the abrasion short of drawing blood or serum, barely removing the surface layer, but not infrequently small bleeding points could be noted. The abraded area was covered with ... a cotton pledget soaked in Treponema pallidum.’

On 17 February 1947, G Robert Coatney, a PHS malariologist, wrote Dr Cutler about Surgeon General Thomas Parran’s interest in his work.

‘I saw Doctor Parran on Friday [14 February] and he wanted to know if I had had a chance to visit your project. Since the answer was yes, he asked me to tell him about it and I did so to the best of my ability. He was familiar with all the arrangements and wanted to be brought up to date on what progress had been made. As you well know, he 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.’’

General Parran retired in July 1948. He had enthusiastically supported Cutler’s experiments. With his mentor gone, it was time for Cutler to wind up.

In 1932, twelve years before Guatemala, a group of African Americans actually suffering from syphilis in Macon County, Alabama, were enrolled in a study that has become a byword in medical infamy: the PHS Tuskegee Syphilis Study. Macon County was chosen because syphilis had a prevalence rate of 39.5 per cent among its African-American population. The men chosen for this study, many of them illiterate, were told they would be treated for ‘bad blood.’ The phrase was a dumbed down version of the white supremacist credo that African-Americans were a ‘syphilis-soaked race’ and that syphilis was ‘biologically different’ in African Americans. Cutler echoed this opinion with regard to Guatemalans whom he dismissed as ‘Indians.’ Not surprising then that Cutler was inducted into the Tuskegee Study.

For forty years, the men in the Tuskegee Study trusted that they were being treated. They were not. They were given placebos and monitored for the manifestations and progression of the disease. Poor, uneducated, and ignorant of the nature of their disease, they continued to suffer. Many died. The whistle was finally blown in 1972, almost thirty years into penicillin’s career as an anti-syphilitic—but I’m getting ahead of the story.

Tuskegee became a scandal when the reporter Jean Heller broke the story for The New York Times on 26 July 1972.

John Cutler’s role in the Guatemalan experiments was discovered entirely serendipitously after his death on 8 February 2003, when Susan Reverby, Professor of History, Wellesley College, began researching his papers in connection with the Tuskegee Study.

Today, as we flinch at the horrors this man perpetrated, it seems to me we cannot see the forest for the trees. This story is much bigger than John Cutler. Presi- dent Obama apologised for a much larger wrong that syphilis has been employed in the commission of since it first emerged as a human illness, in 1493.

Syphilis, since its emergence in the 15th century, has been an exponential school for scandal. It was that story I meant to tell. But Guatemala is in the here-and-now for us, in particular, and not just because of Ghund.

The most ironic fact in this horror show of Guatemala is that while John Cutler and his team were committing the worst of crimes, the Nuremburg Trials were in progress in Europe.

The Prosecution’s opening on 6 December 1946 accused the Nazis of ‘murders, tortures and other atrocities committed in the name of medical science … to their murderers, those wretched people were not individuals at all. They came in wholesale lots and were treated as animals.’

The Nazis, in their defence, cited American experiments, which were just as horrific as those they were accused of.

No, the Guatemala study was still not public knowledge. But Dr Leo Alexander, the Medical Consultant, hurriedly drew up a code of ethics that soon became known as the Nuremberg Rules.

The US Public Health Service cannot claim ignorance of these rules. Every one of them was flouted in the Guatemalan experiments conducted between 1946 and 1948.

And, what really happened in Ghund in 1949?

Perhaps we shall never know. But it is necessary to understand that governments tacitly or unknowingly support methods of medical research that manipulate and subjugate populations. It has been done right here in India, in the scandalous Lock Hospitals of the British Raj. But that’s another story, a tale I have yet to tell. 

Bombay surgeons Ishrat Syed and Kalpana Swaminathan write together as Kalpish Ratna. Their novel, The Quarantine Papers, was published by HarperCollins India in January 2010

1. The report Ethically Impossible: STD Research in Guatemala from 1946 to 1948 can be accessed at http://www.bioethics.gov/cms/sites/default/files/Ethically-Impossible_PCSBI.pdf

2. Mass Treatment of Syphilis in an Indian Province: Report of the World Health Organization Venereal Disease Demonstration Team in the Ghund Area of the Himachal Pradesh, India. (Bull. World Hlth. Org., 1952)