On April 1, close to 800 plaintiffs filed a $1 billion suit in Baltimore City Circuit Court that alleges that, in the 1940s and ’50s, doctors and medical researchers from Johns Hopkins University played a substantial role in experimenting on hundreds of Guatemalans, inoculating them with sexually transmitted diseases—including gonorrhea, syphilis, and chancroid—and using various methods to transmit the diseases to their subjects.
The lawsuit specifically alleges that, between 1945 and 1956, physicians and scientists from Johns Hopkins were involved in exposing prison inmates, psychiatric patients, prostitutes, and soldiers to the aforementioned STDs, as well as potentially infected animal fluids and tissue. The plaintiffs are threefold: direct survivors of the experiments; spouses and children of test subjects who themselves contracted venereal disease, either sexually or congenitally; and descendants who are filing wrongful death suits for parents and relatives who died from complications resulting from the experiments.
There are several pressing questions. Who, specifically, was responsible for this non-consensual experimentation on human subjects? What sort of subterfuge, if any, was used to infect so many Guatemalans? And why did it take half a century for these experiments to see the light of day?
To understand exactly who was involved in the Guatemala experiments and gauge their levels of accountability, it's important to understand the historical context out of which the experiments rose.
During World War II, STDs became a scourge for American troops. Dr. Joseph Earle Moore, chairman of the Subcommittee on Venereal Diseases for the National Research Council, estimated that gonorrhea could account for seven million lost days of work a year for the war effort, according to correspondence notes pored over by the Bioethics Commission. Army and Navy leaders, as well as prominent figures in public health agencies, agreed that the prevalence of STDs among American soldiers and the resulting lost manpower required serious attention; substantial resources, they argued, should be committed to STD research and prevention.
In addition to cotton swabs and intracutaneous injection, researchers began scarifying male subjects' penises before swabbing them with syphilis emulsions, hoping to increase transmission rates.
Moore would prove an important figure in the escalating effort for STD prophylaxis and a vital connective between various government agencies and Johns Hopkins University. He was able to win enough support from various surgeons general and health departments to go ahead with the first major STD prophylaxis research study in response to the crisis facing the troops: the Terre Haute experiments, which took place at the United States Penitentiary at Terre Haute, Indiana, and began in September 1943. The study, however, would only last 10 months. Researchers working at Terre Haute were unable to come up with a method for consistently infecting prison inmates with gonorrhea, and therefore couldn't study the disease effectively or administer potential treatments. Despite their apparent failure, the Terre Haute experiments paved the way and served as the direct antecedent for a much more sprawling, comprehensive study to follow.
At least three men played important roles in both Terre Haute and what would become known as the Guatemala Project: Moore, Dr. John F. Mahoney, and Dr. John C. Cutler.
Mahoney, the director of the Venereal Disease Research Laboratory in Staten Island, New York, had submitted the original proposal for the Terre Haute experiments to the Office of Scientific Research and Development in June of 1943. Cutler worked on-site at Terre Haute and would eventually head the experiments in Guatemala City. The pair was eager to follow up on their decidedly unfinished work at Terre Haute. Dr. Juan Funes, a Guatemalan physician who worked with Mahoney and Cutler at the VDRL on a one-year fellowship in 1945, suggested they carry out their new research in Guatemala.
How the Guatemala experiments were funded, and who, specifically, approved them, has become a matter of exigent importance now that Johns Hopkins, The Rockefeller Foundation, and Bristol-Myers Squibb face a $1 billion lawsuit. The funding streams were both intricate and convoluted, a bureaucratic labyrinth that makes agency difficult to pinpoint.
Shortly before the Guatemala proposal, the NIH Research Grants Office was created. Headed by former VDRL Associate Director Dr. Cassius J. Van Slyke, the office relied on study sections and advisory councils to review grant applications. A 2011 government report on the Guatemala experiments, "Ethically Impossible," refers to this as the "dual-review structure." In what will inevitably become a crucial point in the lawsuit, the study sections and advisory councils that approved funding were composed of both civilian scientists and government representatives.
The first group of doctors and medical officers assembled to review grant applications under the NIH Research Grants Office was the Syphilis Study Section, a 12-member team chaired by Moore, both a professor at Johns Hopkins University School of Medicine and the chair of the NRC Subcommittee on Venereal Diseases. Including Moore, four of the members were employed by Johns Hopkins at the time. The study section approved the Guatemala proposal. While it was funded through the NIH Research Grants Office, the money itself—roughly $110,000—came from the VDRL.
Cutler arrived in Guatemala City in August of 1946. His first initiative was to provide STD treatment to the Guatemalan Army using penicillin and salvarsan. In his first six months there, Cutler treated syphilis among Guatemalan soldiers, advised military doctors on prophylactic plans, and provided medical equipment and training for Guatemalan physicians. In addition, Cutler and his associates engaged in comprehensive diagnostic and serological testing among both inmates at Guatemala City Penitentiary and children. Almost 1,400 children from the Guatemala City Orphanage and other schools were used for serological testing, which included drawing blood and lumbar punctures. Serological testing was also conducted in a psychiatric hospital and leprosarium near Guatemala City.
Cutler would not begin intentionally infecting Guatemalans with STDs until about six months later, in February of 1947. His first major study group would be the Guatemalan Army—the same army Cutler had, in the preceding months, treated with penicillin—scarce and coveted in the city—and drew up an STD prevention plan for.
In total, 446 psychiatric patients were intentionally exposed to syphilis between May of 1947 and October of 1948; 71 patients in the psychiatric hospital died during the experiments.
In Cutler's first experiment with Army soldiers, he sought to infect them with gonorrhea through what is referred to as "normal exposure"—i.e. sexual intercourse. He did this by recruiting at least four commercial sex workers who presented with gonorrhea and were referred to him by the Venereal Disease and Sexual Prophylaxis Hospital; later, he would intentionally inoculate sex workers with gonorrhea while continuing the normal exposure experiments. Research notes suggest that some of the sex workers were paid $25 for their participation in the experiment. Ultimately, only five out of 93 men contracted gonorrhea from a total of 138 intentional exposures. Just as in Terre Haute, consistent and effective inoculation was elusive.
With normal exposure proving ineffective, Cutler turned to the "artificial exposure" method with Guatemalan soldiers. For this method, researchers rub a swab or toothpick covered in gonorrheal pus directly on the penis. For what researchers referred to as "deep inoculation," the toothpick was wrapped in cotton and inserted directly into the male's urethra. Artificial inoculation proved much more effective, with subjects contracting gonorrhea anywhere from 50 to 98 percent of the time, depending on whether they received superficial or deep inoculation. Of the 518 soldiers who were intentionally exposed to gonorrhea, available records only show 237 receiving treatment. This does, however, conflict with Cutler's own 1952 report, “Experimental Studies in Gonorrhea,” in which he claims all infected subjects were treated with penicillin injections.
The other main focus of Cutler's research in Guatemala City was syphilis. Like gonorrhea, syphilis was seen as a major crisis in military medicine, and there was urgency, or at least strong motivation, within the Committee on Medical Research, the VDRL, and the U.S. government to find better prophylaxis for it. In addition, Cutler was eager to test the effectiveness of a prophylactic pioneered by Mahoney and Dr. Richard C. Arnold: the arsenical agent orvus-mapharsen. Mahoney and Arnold had proved orvus-mapharsen effective in treating STDs in rabbits, but had wanted to test the treatment on human subjects. Cutler seized on just such an opportunity in Guatemala.
Cutler's first experiments with syphilis while in Guatemala City took place in the city's Central Penitentiary. Many of the inmates were indigenous Guatemalans, and Cutler's letters to Arnold suggest that, because of this, he did not feel responsible for explaining the experiments to them. In another letter to Mahoney, Cutler explained that "the work in the prison ... will have to be carried out as a scheme of prophylaxis for everyone."
The syphilis experiments in the penitentiary followed a trajectory similar to the gonorrhea experiments with the Guatemalan Army: Cutler and his researchers first attempted to infect subjects through normal exposure, but when complications emerged, they turned to artificial. With the prisoners, Cutler administered injections of syphilitic material that resulted in a transmission rate of 96.8 percent. Despite some success from artificial inoculation, work at the penitentiary was difficult as inmates were often recalcitrant and weary of the constant blood draws.
Although in later reports Cutler portrayed his decision to move to the National Mental Health Hospital in Guatemala City as a response to the challenging circumstances in the prison, Cutler's work in the hospital began in May of 1947, roughly contemporaneous to his artificial exposure work in the prison.
This time bypassing the normal exposure via sex workers phase of the study entirely, Cutler started with artificial inoculation in the mental hospital. As Susan M. Reverby, who first uncovered the Guatemala experiments around 2005 while researching at the University of Pittsburgh, explained in her article "'Normal Exposure' and Inoculation Syphilis: A PHS 'Tuskegee' Doctor in Guatemala, 1946-1948," for researchers in the Guatemala study, "the cooperation was sought with the institution, not with the subject-inmates or their families. And the best way to gain that cooperation was by offering supplies." Cutler provided the institution with a film projector, a refrigerator, and anti-convulsant drugs, in addition to compensating subjects with cigarettes.
In the National Mental Health Hospital, Cutler employed a wider array of inoculation methods. In addition to cotton swabs and intracutaneous injection, researchers began scarifying male subjects' penises before swabbing them with syphilis emulsions, hoping to increase transmission rates. They also experimented with cisternal punctures; in that procedure, a needle is injected into the back of the skull, into the cisternal magna, to withdraw a sample of spinal fluid. Cutler performed cisternal punctures on hundreds of psychiatric patients. Seven of these subjects, all women described as severe epileptics, were injected with syphilis via cisternal puncture: After the spinal fluid was removed, syphilitic emulsions were injected into the cisternal magna.
One of the most well-documented subjects at the psychiatric hospital was a patient named Berta, injected with syphilis in February of 1948. As she went untreated for months after the initial injection, Berta’s health deteriorated, with lesions on her arms and legs and atrophying skin. After six months, she appeared moribund. Upon observing this, Cutler proceeded to put gonorrheal pus into her eyes, urethra, and rectum. He also infected her with syphilis for a second time. Over the next few days, Berta's eyes started to pus and she bled from her urethra. Four days after Cutler re-infected her, she died.
In total, 446 psychiatric patients were intentionally exposed to syphilis between May of 1947 and October of 1948. Although records to not indicate any relationship between mortality and testing, 71 patients in the psychiatric hospital died during the experiments.
Cutler left Guatemala in December 1948. Whether or not he submitted any reports on the STD studies to his superiors, the VDRL, or any other government agency remains unknown. While he wrote three separate final reports on syphilis, gonorrhea, and chancroid, it is unclear whether the reports were shown to anyone. In 1990, Cutler donated all the records of the Guatemala experiments to the University of Pittsburgh, where he served as dean of the Graduate School of Public Health from 1968 to 1969. The final reports—and the truth of what researchers from the PHS did in Guatemala City from 1946 to 1948—would languish untouched in the school’s archives for another 13 years.
In 2003, Wellesley professor Susan Reverby began searching through the University of Pittsburgh archives while conducting research for a book on the infamous Tuskegee Study in Alabama. She sought permission from the Graduate School of Public Health to look through Cutler's records, as he had played a role in the syphilis experiments in Tuskegee. Sometime around 2005, she stumbled upon Cutler's reports on Guatemala. In May 2010, Reverby shared her discovery with the American Association for the History of Medicine, and later notified the Centers for Disease Control and Prevention. In October of that year, President Obama called the president of Guatemala at the time, Álvaro Colom, and apologized for the incident. Then-Secretary of State Hillary Clinton later issued an apology to the Guatemalan government and those affected by the medical experiments. While the secrecy of the experiments had finally ended after 62 years, its tortuous litigation was just about to begin.
There is no doubt of the crimes themselves and their cruelty, inhumanity, and generations-spanning wounds, but conclusively determining who exactly is responsible can rapidly become an exercise in opacity.
In March 2012, a group of Guatemalan plaintiffs filed a class-action lawsuit against the U.S. for damages stemming from the experiments. The case was eventually thrown out, with the U.S. District Court for the District of Columbia finding that the government has immunity from liability for harm suffered outside the U.S. Now, a little more than three years later, the much larger lawsuit of 774 plaintiffs is instead fingering private institutions.
But aside from the indisputable truth of the atrocities suffered under the PHS study led by Cutler, do the plaintiffs have a case? In other words, in filing suit against Johns Hopkins, the Rockefeller Foundation, and Bristol-Myers Squibb, does the lawsuit get the accountability right?
The government agency infrastructure that funded, approved, and carried out the experiments in Guatemala is labyrinthine. The VDRL, part of the PHS, conceived of and proposed the research in Guatemala. The VDRL submitted a proposal for the Guatemala study to the Syphilis Study Section panel, housed under the NIH Research Grants Office. The Syphilis Study Section consisted of 12 men, four of whom held positions at Johns Hopkins. The suit alleges that Johns Hopkins and the Rockefeller Foundation "helped design, support, develop, encourage, and finance, and participated in and benefited from the Guatemala Experiments.” Moreover, "in concert with others, Johns Hopkins created and designed the Guatemala experiments; approved and recommended them for funding; oversaw, monitored, encouraged, directed, and aided and abetted them while they were ongoing; and helped conceal their unethical, moral, and tortious nature."
Archival documents and government reports, including and especially the report commissioned by Obama and produced by the Bioethics Commission, paint a more nuanced picture. The men primarily responsible for actually carrying out the Guatemala experiments include Cutler, a medical officer for the PHS; Mahoney, head of the VDRL lab in Staten Island, to whom Cutler reported during the experiments; and Dr. Richard Arnold, a medical officer posted at the VDRL. The project has been described as a collaboration between the PHS, the VDRL, the NIH, and the Pan American Sanitary Bureau.
Interestingly, the suit alleges that Johns Hopkins essentially monopolized the panels that approved STD research funding, "influencing and controlling these entities" so that the university could direct the flow of funds toward its own research projects. But based on reports, correspondence, and Cutler's University of Pittsburgh files, it's unclear how active the Syphilis Study Section—the entity with by far the strongest ties to Johns Hopkins—was in the ongoing activities in Guatemala City.
The U.S. government’s medical experimentation in Guatemala in the 1940s appears to be another example of the frustrating tension that emerges when sorting out a historical atrocity: There is no doubt of the crimes themselves and their cruelty, inhumanity, and generations-spanning wounds, but conclusively determining who exactly is responsible can rapidly become an exercise in opacity.
When reviewing accounts of the experiments, month by month, blow by blow, what emerges above all is the portrait of a single man—Dr. John C. Cutler—whose ambitions seemed to laugh in the face of the Hippocratic Oath and who exploited the most vulnerable human beings at his disposal with a sort of obsessive, myopic frenzy. Alas, the question that rises out of his sinister narrative and snakes itself around the lawsuit is both vexing and unavoidable: Who should pay for this man's sins?