the tuskegee experiment summarized

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Tuskegee Experiment: The Infamous Syphilis Study

By: Elizabeth Nix

Updated: June 13, 2023 | Original: May 16, 2017

The Tuskegee experiment began in 1932, at a time when there was no known cure for syphilis, a contagious venereal disease. After being recruited by the promise of free medical care, 600 African American men in Macon County, Alabama were enrolled in the project, which aimed to study the full progression of the disease.

The participants were primarily sharecroppers, and many had never before visited a doctor. Doctors from the U.S. Public Health Service (PHS), which was running the study, informed the participants—399 men with latent syphilis and a control group of 201 others who were free of the disease—they were being treated for bad blood, a term commonly used in the area at the time to refer to a variety of ailments.

The men were monitored by health workers but only given placebos such as aspirin and mineral supplements, despite the fact that penicillin became the recommended treatment for syphilis in 1947, some 15 years into the study. PHS researchers convinced local physicians in Macon County not to treat the participants, and instead, research was done at the Tuskegee Institute. (Now called Tuskegee University, the school was founded in 1881 with Booker T. Washington as its first teacher.)

In order to track the disease’s full progression, researchers provided no effective care as the men died, went blind or insane or experienced other severe health problems due to their untreated syphilis.

In the mid-1960s, a PHS venereal disease investigator in San Francisco named Peter Buxton found out about the Tuskegee study and expressed his concerns to his superiors that it was unethical. In response, PHS officials formed a committee to review the study but ultimately opted to continue it—with the goal of tracking the participants until all had died, autopsies were performed and the project data could be analyzed.

Buxton then leaked the story to a reporter friend, who passed it on to a fellow reporter, Jean Heller of the Associated Press. Heller broke the story in July 1972, prompting public outrage and forcing the study to finally shut down.

By that time, 28 participants had perished from syphilis, 100 more had passed away from related complications, at least 40 spouses had been diagnosed with it and the disease had been passed to 19 children at birth.

In 1973, Congress held hearings on the Tuskegee experiments, and the following year the study’s surviving participants, along with the heirs of those who died, received a $10 million out-of-court settlement. Additionally, new guidelines were issued to protect human subjects in U.S. government-funded research projects.

As a result of the Tuskegee experiment, many African Americans developed a lingering, deep mistrust of public health officials and vaccines. In part to foster racial healing, President Bill Clinton issued a 1997 apology, stating, “The United States government did something that was wrong—deeply, profoundly, morally wrong… It is not only in remembering that shameful past that we can make amends and repair our nation, but it is in remembering that past that we can build a better present and a better future.”

During his apology, Clinton announced plans for the establishment of Tuskegee University’s National Center for Bioethics in Research and Health Care .

The final study participant passed away in 2004.

Tuskegee wasn't the first unethical syphilis study. In 2010, then- President Barack Obama and other federal officials apologized for another U.S.-sponsored experiment, conducted decades earlier in Guatemala. In that study, from 1946 to 1948, nearly 700 men and women—prisoners, soldiers and mental patients—were intentionally infected with syphilis (hundreds more people were exposed to other sexually transmitted diseases as part of the study) without their knowledge or consent.

The purpose of the study was to determine whether penicillin could prevent, not just cure, syphilis infection. Some of those who became infected never received medical treatment. The results of the study, which took place with the cooperation of Guatemalan government officials, were never published. The American public health researcher in charge of the project, Dr. John Cutler, went on to become a lead researcher in the Tuskegee experiments.

Following Cutler’s death in 2003, historian Susan Reverby uncovered the records of the Guatemala experiments while doing research related to the Tuskegee study. She shared her findings with U.S. government officials in 2010. Soon afterward, Secretary of State Hillary Clinton and Secretary of Health and Human Services Kathleen Sebelius issued an apology for the STD study and President Obama called the Guatemalan president to apologize for the experiments.

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Tuskegee syphilis study

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• Academia - The Tuskegee Syphilis Study: Some Ethical Reflections
• Encyclopedia of Alabama - Tuskegee Syphilis Study
• Centers for Disease Control and Prevention - The USPHS Untreated Syphilis Study at Tuskegee
• McGill University - Office for Science and Society - 40 Years of Human Experimentation in America: The Tuskegee Study
• JamesCook University Pressbooks - An Introduction to Research Methods for Undergraduate Health Profession Students - A Case Study – The Tuskegee Syphilis Experiment
• National Center for Biotechnology Information - PubMed Central - The Tuskegee syphilis study
• Tuskegee syphilis study - Student Encyclopedia (Ages 11 and up)

Tuskegee syphilis study , American medical research project that earned notoriety for its unethical experimentation on African American patients in the rural South .

The project, which was conducted by the U.S . Public Health Service (PHS) from 1932 to 1972, examined the natural course of untreated syphilis in African American men. The research was intended to test whether syphilis caused cardiovascular damage more often than neurological damage and to determine if the natural course of syphilis in black men was significantly different from that in whites. In order to recruit participants for its study, the PHS enlisted the support of the prestigious Tuskegee Institute (now Tuskegee University ), located in Macon county, Alabama . A group of 399 infected patients and 201 uninfected control patients were recruited for the program. The subjects were all impoverished sharecroppers from Macon county. The original study was scheduled to last only six to nine months.

The subjects were not told that they had syphilis or that the disease could be transmitted through sexual intercourse . Instead, they were told that they suffered from “bad blood,” a local term used to refer to a range of ills. Treatment was initially part of the study, and some patients were administered arsenic, bismuth, and mercury. But after the original study failed to produce any useful data, it was decided to follow the subjects until their deaths, and all treatment was halted. Penicillin was denied to the infected men after that drug became available in the mid-1940s, and it was still being withheld from them 25 years later, in direct violation of government legislation that mandated the treatment of venereal disease . It is estimated that more than 100 of the subjects died of tertiary syphilis .

The Tuskegee syphilis study finally came to an end in 1972 when the program and its unethical methods were exposed in the Washington Star . A class-action suit against the federal government was settled out of court for $10 million in 1974. That same year the U.S. Congress passed the National Research Act, requiring institutional review boards to approve all studies involving human subjects. In 1997 President Bill Clinton issued a formal apology for the study (see Sidebar: Presidential Apology for the Study at Tuskegee ).

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Starting in 1932, 600 African American men from Macon County, Alabama were enlisted to partake in a scientific experiment on syphilis. The “Tuskegee Study of Untreated Syphilis in the Negro Male,” was conducted by the United States Public Health Service (USPHS) and involved blood tests, x-rays, spinal taps and autopsies of the subjects.

The goal was to “observe the natural history of untreated syphilis” in black populations. But the subjects were unaware of this and were simply told they were receiving treatment for bad blood. Actually, they received no treatment at all. Even after penicillin was discovered as a safe and reliable cure for syphilis, the majority of men did not receive it.

To really understand the heinous nature of the Tuskegee Experiment requires some societal context, a lot of history, and a realization of just how many times government agencies were given a chance to stop this human experimentation but didn’t.

In 1865, the ratification of the Thirteenth Amendment of the U.S. Constitution formally ended the enslavement of black Americans. But by the early 20 th century, the cultural and medical landscape of the U.S. was still built upon and inundated with racist concepts. Social Darwinism was rising, predicated on the survival of the fittest, and “ scientific racism ” (a pseudoscientific practice of using science to reinforce racial biases) was common. Many white people already thought themselves superior to blacks and science and medicine was all too happy to reinforce this hierarchy.

Before the ending of slavery, scientific racism was used to justify the African slave trade. Scientists argued that African men were uniquely fit for enslavement due to their physical strength and simple minds. They argued that slaves possessed primitive nervous systems, so did not experience pain as white people did. Enslaved African Americans in the South were claimed to suffer from mental illness at rates lower than their free Northern counterparts (thereby proving that enslavement was good for them), and slaves who ran away were said to be suffering from their own mental illness known as drapetomania.

During and after the American Civil War, African Americans were argued to be a different species from white Americans, and mixed-race children were presumed prone to many medical issues. Doctors of the time testified that the emancipation of slaves had caused the “mental, moral and physical deterioration of the black population,” observing that “virtually free of disease as slaves, they were now overwhelmed by it.” Many believed that the African Americans were doomed to extinction, and arguments were made about their physiology being unsuited for the colder climates of America (thus they should be returned to Africa).

Scientific and medical authorities of the late 19 th /early 20 th centuries held extremely harmful pseudoscientific ideas specifically about the sex drives and genitals of African Americans. It was widely believed that, while the brains of African Americans were under-evolved, their genitals were over-developed. Black men were seen to have an intrinsic perversion for white women, and all African Americans were seen as inherently immoral, with insatiable sexual appetites.

This all matters because it was with these understandings of race, sexuality and health that researchers undertook the Tuskegee study. They believed, largely due to their fundamentally flawed scientific understandings of race, that black people were extremely prone to sexually transmitted infections (like syphilis). Low birth rates and high miscarriage rates were universally blamed on STIs.

They also believed that all black people, regardless of their education, background, economic or personal situations, could not be convinced to get treatment for syphilis. Thus, the USPHS could justify the Tuskegee study, calling it a “study in nature” rather than an experiment, meant to simply observe the natural progression of syphilis within a community that wouldn’t seek treatment.

The USPHS set their study in Macon County due to estimates that 35% of its population was infected with syphilis. In 1932, the initial patients between the ages of 25 and 60 were recruited under the guise of receiving free medical care for “bad blood,” a colloquial term encompassing anemia, syphilis, fatigue and other conditions. Told that the treatment would last only six months, they received physical examinations, x-rays, spinal taps, and when they died, autopsies.

Researchers faced a lack of participants due to fears that the physical examinations were actually for the purpose of recruiting them to the military. To assuage these fears, doctors began examining women and children as well. Men diagnosed with syphilis who were of the appropriate age were recruited for the study, while others received proper treatments for their syphilis (at the time these were commonly mercury - or arsenic -containing medicines).

In 1933, researchers decided to continue the study long term. They recruited 200+ control patients who did not have syphilis (simply switching them to the syphilis-positive group if at any time they developed it). They also began giving all patients ineffective medicines ( ointments or capsules with too small doses of neoarsphenamine or mercury) to further their belief that they were being treated.

As time progressed, however, patients began to stop attending their appointments. To greater incentivize them to remain a part of the study, the USPHS hired a nurse named Eunice Rivers to drive them to and from their appointments, provide them with hot meals and deliver their medicines, services especially valuable to subjects during the Great Depression. In an effort to ensure the autopsies of their test subjects, the researchers also began covering patient’s funeral expenses.

Multiple times throughout the experiment researchers actively worked to ensure that their subjects did not receive treatment for syphilis. In 1934 they provided doctors in Macon County with lists of their subjects and asked them not to treat them. In 1940 they did the same with the Alabama Health Department. In 1941 many of the men were drafted and had their syphilis uncovered by the entrance medical exam, so the researchers had the men removed from the army, rather than let their syphilis be treated.

It was in these moments that the Tuskegee study’s true nature became clear. Rather than simply observing and documenting the natural progression of syphilis in the community as had been planned, the researchers intervened: first by telling the participants that they were being treated (a lie), and then again by preventing their participants from seeking treatment that could save their lives. Thus, the original basis for the study--that the people of Macon County would likely not seek treatment and thus could be observed as their syphilis progressed--became a self-fulfilling prophecy.

The Henderson Act was passed in 1943, requiring tests and treatments for venereal diseases to be publicly funded, and by 1947, penicillin had become the standard treatment for syphilis , prompting the USPHS to open several Rapid Treatment Centers specifically to treat syphilis with penicillin. All the while they were actively preventing 399 men from receiving the same treatments.

By 1952, however, about 30% of the participants had received penicillin anyway, despite the researchers’ best efforts. Regardless, the USPHS argued that their participants wouldn’t seek penicillin or stick to the prescribed treatment plans. They claimed that their participants, all black men, were too “stoic” to visit a doctor. In truth these men thought they were already being treated, so why would they seek out further treatment?

The researchers’ tune changed again as time went on. In 1965, they argued that it was too late to give the subjects penicillin, as their syphilis had progressed too far for the drug to help. While a convenient justification for their continuation of the study, penicillin is (and was) recommended for all stages of syphilis and could have stopped the disease’s progression in the patients.

In 1947 the Nuremberg code was written, and in 1964 the World Health Organization published their Declaration of Helsinki . Both aimed to protect humans from experimentation, but despite this, the Centers for Disease Control (which had taken over from the USPHS in controlling the study) actively decided to continue the study as late as 1969.

It wasn’t until a whistleblower, Peter Buxtun, leaked information about the study to the New York Times and the paper published it on the front page on November 16 th , 1972, that the Tuskegee study finally ended. By this time only 74 of the test subjects were still alive. 128 patients had died of syphilis or its complications, 40 of their wives had been infected, and 19 of their children had acquired congenital syphilis.

There was mass public outrage, and the National Association for the Advancement of Colored People launched a class action lawsuit against the USPHS. It settled the suit two years later for 10 million dollars and agreed to pay the medical treatments of all surviving participants and infected family members, the last of whom died in 2009.

Largely in response to the Tuskegee study, Congress passed the National Research Act in 1974, and the Office for Human Research Protections was established within the USPHS. Obtaining informed consent from all study participants became required for all research on humans, with this process overseen by Institutional Review Boards (IRBs) within academia and hospitals.

The Tuskegee study has had lasting effects on America . It’s estimated that the life expectancy of black men fell by up to 1.4 years when the study’s details came to light. Many also blame the study for impacting the willingness of black individuals to willingly participate in medical research today.

We know all about evil Nazis who experimented on prisoners. We condemn the scientists in Marvel movies who carry out tests on prisoners of war. But we’d do well to remember that America has also used its own people as lab rats . Yet to this day, no one has been prosecuted for their role in dooming 399 men to syphilis.

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Tuskegee Syphilis Experiment

The official title was “The Tuskegee Study of Untreated Syphilis in the Negro Male.” It is commonly called the Infamous Tuskegee Syphilis Experiment. Beginning in 1932 and continuing to 1972 the United States Public Health Services lured over 600 Black men, mostly sharecroppers in Tuskegee, Alabama, into this diabolical medical experiment with the promise of free health care. For 40 years, hundreds of African American men with syphilis went untreated, given placebos and other ineffective treatments, so that scientists could study the effects of the disease, even after there was a cure. None of the men who had syphilis were ever told they had it. Instead they were only told that they had “bad blood.” They were also never given penicillin, despite the fact that it had become a standard treatment by 1947.

The last survivor of the study died in 2004. This was not that long ago.

The Hippocratic Oath is used as a symbolic gesture that binds physicians to their patient’s well-being. Those who choose to take the oath makes an affirmation about treatment of those entrusted in their care, “I will do no harm or injustice to them.” It is commonly simply rephrased as, "First, do no harm." That was not the case with healthcare providers in Tuskegee, AL.

Below is an excerpt from an official admission of systematic racial discrimination issued by the United States President in 1997:

The President’s words confirmed the institutionally and racially discriminatory practices that have spanned not just decades as in this case, but centuries. Medical malfeasance is nothing new. Currently, amends are being made symbolically. In 2018, New York City finally removed an offensive statue from high atop a pedestal in Central Park. The statue depicted an infamous 19th-century gynecologist who experimented on enslaved women named Anarcha, Lucy and Betsey. He was part of a medical apartheid system that treated Black subjects as sub-human. He inflicted unimaginable torture because he operated under the ridiculous notion that Black people did not feel pain.

Remarkably, present day studies reveal that a frightening number of healthcare providers believe the myth that Black people have thicker skin and therefore need less pain management. The University of Virginia reported that racial bias partially explains research documenting how Black Americans are systemically undertreated for pain.

The Tuskegee Experiment was relatively recent and at least partially impacts the reactions to the current Novel Coronavirus pandemic. Black Americans have this recent example, in addition to a long history of other examples, explaining why it is reasonable to be suspicious of governmental medical information.

How the Public Learned About the Infamous Tuskegee Syphilis Study

A s the fight over reforms to the American health-care system continues this week, Tuesday marks the 45th anniversary of a grim milestone in the history of health care in the U.S.

On July 25, 1972, the public learned that, over the course of the previous 40 years, a government medical experiment conducted in the Tuskegee, Ala., area had allowed hundreds of African-American men with syphilis to go untreated so that scientists could study the effects of the disease.

“Of about 600 Alabama black men who originally took part in the study, 200 or so were allowed to suffer the disease and its side effects without treatment, even after penicillin was discovered as a cure for syphilis,” the Associated Press reported , breaking the story. “[U.S. Public Health Service officials] contend that survivors of the experiment are now too old to treat for syphilis, but add that PHS doctors are giving the men thorough physical examinations every two years and are treating them for whatever other ailments and diseases they have developed.”

By the time the bombshell report came out, seven men involved had died of syphilis and more than 150 of heart failure that may or may not have been linked to syphilis. Seventy-four participants were still alive, but the government health officials who started the study had already retired. And, because of the study’s length and the way treatment options had evolved in the intervening years, it was hard to pin the blame on an individual — though easy to see that it was wrong, as TIME explained in the Aug. 7, 1972, issue:

At the time the test began, treatment for syphilis was uncertain at best, and involved a lifelong series of risky injections of such toxic substances as bismuth, arsenic and mercury. But in the years following World War II, the PHS’s test became a matter of medical morality. Penicillin had been found to be almost totally effective against syphilis, and by war’s end it had become generally available. But the PHS did not use the drug on those participating in the study unless the patients asked for it. Such a failure seems almost beyond belief, or human compassion. Recent reviews of 125 cases by the PHS’S Center for Disease Control in Atlanta found that half had syphilitic heart valve damage. Twenty-eight had died of cardiovascular or central nervous system problems that were complications of syphilis. The study’s findings on the effects of untreated syphilis have been reported periodically in medical journals for years. Last week’s shock came when an alert A.P. correspondent noticed and reported that the lack of treatment was intentional.

About three months later, the study was terminated, and the families of victims reached a $10 million settlement in 1974 (the terms of which are still being negotiated today by descendants). The last study participant passed away in 2004.

Tuskegee was chosen because it had the highest syphilis rate in the country at the time the study was started. As TIME made clear with a 1940 profile of government efforts to improve the health of African Americans, concern about that statistic had drawn the attention of the federal government and the national media. Surgeon General Thomas Parran boasted that in Macon County, Ala., where Tuskegee is located, the syphilis rate among the African-American population had been nearly 40% in 1929 but had shrunk to 10% by 1939. Serious efforts were being devoted to the cause, the story explained, though the magazine clearly missed the full story of what was going on:

In three years, experts predict, the disease will be wiped out. To root syphilis out of Macon County, the U. S. Public Health Service, the Rosenwald Fund and Booker T. Washington’s Tuskegee Institute all joined forces. Leader of the campaign is a white man, the county health officer, a former Georgia farm boy who drove a flivver through fields of mud, 36 miles a day to medical school. Last month, deep-eyed, sunburned Dr. Murray Smith began his tenth year in Macon County. “There’s not much in this job,” said he, “but the love and thanks of the people.” At first the Negroes used to gather in the gloomy courthouse in Tuskegee, while Dr. Smith in the judge’s chambers gave them tests and treatment. Later he set up weekly clinics in old churches or schoolhouses, deep in the parched cotton fields. Last fall the U. S. Public Health Service gave him a streamlined clinic truck. The truck, which has a laboratory with sink and sterilizer, a treatment nook with table and couch, is manned by two young Negro doctors and two nurses. Five days a week it rumbles over the red loam roads. At every crossroads it stops. At the toot of its horn, through the fields come men on muleback, women carrying infants, eager to be first, proud to have a blood test. Some young boys even sneak in to get a second or third test, and many come around to the truck long after they have been cured. One woman who had had six miscarriages got her syphilis cured by Dr. Smith with neoarsphenamine. Proudly she named her first plump baby Neo.

In the years following the disclosure, the Tuskegee study became a byword for the long and complicated history of medical research of African Americans without their consent. In 1997, President Bill Clinton apologized to eight of the survivors. “You did nothing wrong, but you were grievously wronged,” he said. “I apologize and I am sorry that this apology has been so long in coming.” As Clinton noted, African-American participation in medical research and organ donation remained low decades after the 1972 news broke, a fact that has often been attributed to post-Tuskegee wariness.

In 2016, a National Bureau of Economic Research paper argued that after the disclosure of the 1972 study, “life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women.” However, many experts argue that the discrepancy has more to do with racial bias in the medical profession.

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Article contents

The tuskegee syphilis study.

• Susan M. Reverby Susan M. Reverby Women's and Gender Studies, Wellesley College
• https://doi.org/10.1093/acrefore/9780199329175.013.1032
• Published online: 22 November 2022

Between 1932 and 1972, the US Public Health Service (PHS) ran the Tuskegee Study of Untreated Syphilis in the Male Negro in Macon County, Alabama, to learn more about the effects of untreated syphilis on African Americans, and to see if the standard heavy metal treatments advocated at the time were efficacious in the disease’s late latent stage. Syphilis is a sexually transmitted infection and can be passed by a mother to her fetus at birth. It is contagious in its first two stages, but usually not in its third late latent stage. Syphilis can be, although is not always, fatal, and usually causes serious cardiovascular or neurological damage. To study the disease, the PHS recruited 624 African American men, 439 who were diagnosed with the latent stage of the disease and 185 without the disease who were to act as the controls in the experiment. However, the men were not told they were to participate in a medical experiment nor were they asked to give their consent to be used as subjects for medical research. Instead, the PHS led the men to believe that they were being treated for their syphilis by the provision of aspirins, iron tonics, vitamins, and diagnosis spinal taps, labeled a “special treatment” for the colloquial term “bad blood.” Indeed, even when penicillin became widely available by the early 1950s as a cure for syphilis, the researchers continued the study and tried to keep the men from treatment, however not always successfully.

Although a number of health professionals raised objections to the study over the years, while—thirteen articles were published in various medical journals, it continued unobstructed until 1972, when a journalist exposed the full implications of the study and a national uproar ensued. The widespread media coverage resulted in a successful lawsuit, federal paid health care to the remaining men and their syphilis-positive wives and children, Congressional hearings, a federal report, and changes to the legislation concerning informed consent for medical research. The government officially closed the study in 1972. In 1996, a Legacy Committee requested a formal apology from the federal government, which took place at the White House on May 16, 1997.

Rumors have surrounded the study since its public exposure, especially the beliefs that the government gave healthy men syphilis, rather than recruiting men that had the disease already, in order to conduct the research, and that all men in the study were left untreated decade after decade. In its public life, the study often serves a metaphor for mistrust of medical care and government research, memorialized in popular culture through music, plays, poems, and films.

• untreated syphilis
• medical research
• US Public Health Service
• African Americans

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date: 07 September 2024

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About the USPHS Syphilis Study

Where the Study Took Place

The study took place in Macon County, Alabama, the county seat of Tuskegee referred to as the "Black Belt" because of its rich soil and vast number of black sharecroppers who were the economic backbone of the region. The research itself took place on the campus of Tuskegee Institute.

What it Was Designed to Find Out

The intent of the study was to record the natural history of syphilis in Black people. The study was called the "Tuskegee Study of Untreated Syphilis in the Negro Male." When the study was initiated there were no proven treatments for the disease. Researchers told the men participating in the study that they were to be treated for "bad blood." This term was used locally by people to describe a host of diagnosable ailments including but not limited to anemia, fatigue, and syphilis.

Who Were the Participants

 A total of 600 men were enrolled in the study. Of this group 399, who had syphilis were a part of the experimental group and 201 were control subjects. Most of the men were poor and illiterate sharecroppers from the county.

What the Men Received in Exchange for Participation

The men were offered what most Negroes could only dream of in terms of medical care and survivors insurance. They were enticed and enrolled in the study with incentives including: medical exams, rides to and from the clinics, meals on examination days, free treatment for minor ailments and guarantees that provisions would be made after their deaths in terms of burial stipends paid to their survivors.

Treatment Withheld

There were no proven treatments for syphilis when the study began. When penicillin became the standard treatment for the disease in 1947 the medicine was withheld as a part of the treatment for both the experimental group and control group.

How/Why the Study Ended

On July 25, 1972 Jean Heller of the Associated Press broke the story that appeared simultaneously both in New York and Washington, that there had been a 40-year nontherapeutic experiment called "a study" on the effects of untreated syphilis on Black men in the rural south.

Between the start of the study in 1932 and 1947, the date when penicillin was determined as a cure for the disease, dozens of men had died and their wives, children and untold number of others had been infected. This set into motion international public outcry and a series of actions initiated by U.S. federal agencies. The Assistant Secretary for Health and Scientific Affairs appointed an Ad Hoc Advisory Panel, comprised of nine members from the fields of health administration, medicine, law, religion, education, etc. to review the study.

While the panel concluded that the men participated in the study freely, agreeing to the examinations and treatments, there was evidence that scientific research protocol routinely applied to human subjects was either ignored or deeply flawed to ensure the safety and well-being of the men involved. Specifically, the men were never told about or offered the research procedure called informed consent. Researchers had not informed the men of the actual name of the study, i.e. "Tuskegee Study of Untreated Syphilis in the Negro Male," its purpose, and potential consequences of the treatment or non-treatment that they would receive during the study. The men never knew of the debilitating and life threatening consequences of the treatments they were to receive, the impact on their wives, girlfriends, and children they may have conceived once involved in the research. The panel also concluded that there were no choices given to the participants to quit the study when penicillin became available as a treatment and cure for syphilis.

Reviewing the results of the research the panel concluded that the study was "ethically unjustified." The panel articulated all of the above findings in October of 1972 and then one month later the Assistant Secretary for Health and Scientific Affairs officially declared the end of the Tuskegee Study.

Class-Action Suit

In the summer of 1973, Attorney Fred Gray filed a class-action suit on behalf of the men in the study, their wives, children and families. It ended a settlement giving more than $9 million to the study participants.

The Role of the US Public Health Service

In the beginning of the 20th Century, the U.S. Public Health Service (PHS) was entrusted with the responsibility to monitor, identify trends in the heath of the citizenry, and develop interventions to treat disease, ailments and negative trends adversely impacting the health and wellness of Americans. It was organized into sections and divisions including one devoted to venereal diseases. All sections of the PHS conducted scientific research involving human beings. The research standards were for their times adequate, by comparison to today's standards dramatically different and influenced by the professional and personal biases of the people leading the PHS. Scientists believed that few people outside of the scientific community could comprehend the complexities of research from the nature of the scientific experiments to the consent involved in becoming a research subject. These sentiments were particularly true about the poor and uneducated Black community.

The PHS began working with Tuskegee Institute in 1932 to study hundreds of black men with syphilis from Macon County, Alabama.

Compensation for Participants

As part of the class-action suit settlement, the U.S. government promised to provide a range of free services to the survivors of the study, their wives, widows, and children. All living participants became immediately entitled to free medical and burial services. These services were provided by the Tuskegee Health Benefit Program, which was and continues to be administered by the Centers for Disease Control and Prevention in their National Center for HIV, STD and TB Prevention.

1996 Tuskegee Legacy Committee

In February of 1994 at the Claude Moore Health Sciences Library in Charlottesville, VA, a symposium was held entitled "Doing Bad in the Name of Good?: The Tuskegee Syphilis Study and Its Legacy." Resulting from this gathering was the creation of the Tuskegee Syphilis Study Legacy Committee which met for the first time in January 18th & 19th of 1996.  The committee had two goals; (1) to persuade President Clinton to apologize on behalf of the government for the atrocities of the study and (2) to develop a strategy to address the damages of the study to the psyche of African-Americans and others about the ethical behavior of government-led research; rebuilding the reputation of Tuskegee through public education about the study, developing a clearinghouse on the ethics of scientific research and scholarship and assembling training programs for health care providers. After intensive discussions, the Committee's final report in May of 1996 urged President Clinton to apologize for the emotional, medical, research and psychological damage of the study. On May 16th at a White House ceremony attended by the men, members of the Legacy Committee and others representing the medical and research communities, the apology was delivered to the surviving participants of the study and families of the deceased.

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AP exposes the Tuskegee Syphilis Study: The 50th Anniversary

This 1950’s photo made available by the National Archives shows a man included in a syphilis study in Alabama. For 40 years starting in 1932, medical workers in the segregated South withheld treatment for Black men who were unaware they had syphilis, so doctors could track the ravages of the illness and dissect their bodies afterward. (National Archives via AP)

In this 1950’s photo made available by the National Archives, a man included in a syphilis study has blood drawn in Alabama. For 40 years starting in 1932, medical workers in the segregated South withheld treatment for Black men who were unaware they had syphilis, so doctors could track the ravages of the illness and dissect their bodies afterward. (National Archives via AP)

This image made available by the U.S. National Archives shows part of a 1940-dated document describing procedures for the distribution of autopsy results from subjects of the Tuskegee Syphilis Study conducted by the U.S. government. For 40 years starting in 1932, medical workers in the segregated South withheld treatment for Black men who were unaware they had syphilis, so doctors could track the ravages of the illness and dissect their bodies afterward. (National Archives via AP)

FILE - In this 1950’s photo made available by the National Archives, men included in a syphilis study stand for a photo in Alabama. For 40 years starting in 1932, medical workers in the segregated South withheld treatment for Black men who were unaware they had syphilis, so doctors could track the ravages of the illness and dissect their bodies afterward. (National Archives via AP, File)

FILE - In this 1950’s photo released by the National Archives, a man included in a syphilis study has blood drawn by a doctor in Tuskegee, Ala. For 40 years starting in 1932, medical workers in the segregated South withheld treatment for Black men who were unaware they had syphilis, so doctors could track the ravages of the illness and dissect their bodies afterward. Finally exposed in 1972, the study ended and the men sued, resulting in a $9 million settlement. (National Archives via AP)

Lillie Tyson Head holds a photograph of her late parents, Freddie Lee and Johnnie Mae Neal Tyson, at her home in Wirtz, Va., on Saturday, July 23, 2022. Freddie Tyson was part of the infamous “Tuskegee Study,” in which hundreds of Black men in Alabama went untreated for syphilis for decades so federal government researchers could record the disease’s affects on the body. Head says her mother was later tested, and did not have the disease. (AP Photo/Allen G. Breed)

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WASHINGTON (AP) — EDITOR’S NOTE — On July 25, 1972, Jean Heller, a reporter on The Associated Press investigative team, then called the Special Assignment Team, broke news that rocked the nation. Based on documents leaked by Peter Buxtun, a whistleblower at the U.S. Public Health Service, the then 29-year-old journalist and the only woman on the team, reported that the federal government let hundreds of Black men in rural Alabama go untreated for syphilis for 40 years in order to study the impact of the disease on the human body. Most of the men were denied access to penicillin, even when it became widely available as a cure. A public outcry ensued, and nearly four months later, the “Tuskegee Study of Untreated Syphilis in the Negro Male” came to an end. The investigation would have far-reaching implications: The men in the study filed a lawsuit that resulted in a $10 million settlement , Congress passed laws governing how subjects in research studies were treated , and more than two decades later President Bill Clinton formally apologized for the study, calling it “shameful.”

Today, the effects of the study still linger — it is often blamed for the unwillingness of some African Americans to participate in medical research.

In observance of the 50th anniversary of Heller’s groundbreaking investigation, the AP is republishing the original report and a recent interview with her and others on how the story came together.

For 40 years the U.S. Public Health Service has conducted a study in which human guinea pigs, denied proper medical treatment, have died of syphilis and its side effects.

The study was conducted to determine from autopsies what the disease does to the human body.

PHS officials responsible for initiating the experiment have long since retired. Current PHS officials, who say they have serious doubts about the morality of the study, also say that it is too late to treat syphilis in any of the study’s surviving participants.

But PHS doctors say they are rendering whatever other medical services they can now give to the survivors while the study of the disease’s effects continues.

The experiment, called the Tuskegee Study began in 1932 with about 600 black men mostly poor and uneducated, from Tuskegee, Ala., an area that had the highest syphilis rate in the nation at the time.

One-third of the group was free of syphilis; two-thirds showed evidence of the disease. In the syphilitic group, half were given the best treatment known at the time, but the other half, about 200 men, received no treatment at all for syphilis, PHS officials say.

As incentives to enter the program, the men were promised free transportation to and from hospitals, free hot lunches, free medicine for any disease other than syphilis and free burial after autopsies were performed.

The Tuskegee Study began 10 years before penicillin was discovered to be a cure for syphilis and 15 years before the drug became widely available. Yet, even after penicillin became common, and while its use probably could have helped or saved a number of the experiment subjects, the drug was denied them, Dr. J.D. Millar says.

He is chief of the venereal disease branch of the PHS’s Center for Disease Control in Atlanta and is now in charge of what remains of the Tuskegee Study. Dr. Millar said in an interview that he has serious doubts about the program.

“I think a definite serious moral problem existed when the study was undertaken, a more serious moral problem was overlooked in the post-war years when penicillin became available but was not given to these men and a moral problem still exists,” Dr. Millar said.

“But the study began when attitudes were much different on treatment and experimentation. At this point in time, with our current knowledge of treatment and the disease and the revolutionary change in approach to human experimentation, I don’t believe the program would be undertaken,” he said.

Syphilis, a highly contagious infection spread by sexual contact, can cause if untreated, bone and dental deformations, deafness, blindness, heart disease and central nervous system deterioration.

No figures were available on when the last death occurred in the program. And one official said that apparently no conscious effort was made to halt the program after it got under way.

A 1969 CDC study of 276 treated and untreated syphilitics who participated in the Tuskegee Study showed that seven had died as a direct result of syphilis. Another 154 died of heart disease.

CDC officials say they cannot determine at this late date how many of the heart disease deaths were caused by syphilis or how many additional deaths could be linked to the disease.

However, several years ago an American Medical Association study determined that untreated syphilis reduces life expectancy by 17 per cent in black men between the ages of 25 and 50, a precise description of the Tuskegee Study subjects.

Don Prince, another official in the venereal disease branch of CDC, said the Tuskegee Study had contributed some knowledge about syphilis, particularly that the morbidity and mortality rate among untreated syphilitics were not as high as previously believed.

Like Dr. Millar, Prince said he thought the study should have been halted with penicillin treatment for participants after World War II.

“I don’t know why the decision was made in 1946 not to stop the program,” Prince said. “I was unpleasantly surprised when I first came here and found out about it. It really puzzles me.”

At the beginning of 1972, according to CDC data, 74 of the untreated syphilitics were still living. All of them, Dr. Millar said, were men who did not suffer any potentially fatal side effects from their bouts with the disease.

Some of them received penicillin and antibiotics in past years for other aliments, Prince said, but none has ever received treatment for syphilis. Now, both men agree, it’s too late

Recent reviews of the Tuskegee Study by the CDC indicate that treatment now for survivors is medically questionable, Dr. Millar said. Their average age is 74 and massive penicillin therapy, with possible ill side effects, is deemed too great a risk to individuals, particularly for those whose syphilis is now dormant.

However, Dr. Millar, added there was a point in time when survivors could have been treated with at least some measure of success.

“The most critical moral issue about this experiment arises in the post-war era, the years after the end of World War II when penicillin became widely available.

“I know some were treated with penicillin for other diseases and then dropped from the program because the drug had some positive effect on the primary disease (syphilis). Looking at it now, one cannot see any reason they could not have been treated at that time.”

What Newly Digitized Records Reveal About the Tuskegee Syphilis Study

The archival trove chronicles the extreme measures administrators took to ensure Black sharecroppers did not receive treatment for the venereal disease

Caitjan Gainty, The Conversation

In 1972, a whistleblower revealed that the United States Public Health Service (USPHS) had withheld syphilis treatment from hundreds of Black men as part of a 40-year study observing the natural course of the disease. The experiment’s subjects—the majority of whom were sharecroppers from rural Alabama—believed they were undergoing treatment for “bad blood,” a colloquial name then used for a host of conditions, including venereal diseases. Instead, they received placebos and inadequate medical care, even after penicillin emerged as an effective, readily available treatment for syphilis in the mid-1940s.

The Tuskegee syphilis study , as the experiment is often called today, began in 1932 with the recruitment of 600 Black men, 399 with syphilis and 201 without, to serve as the control group. Initially intended to run for six months, the study continued for decades. Unwitting participants lured in by the promise of free medical care, hot meals and burial insurance returned regularly for aspirin, tonics, blood draws and the occasional spinal tap. But none of these treatments does any good for syphilis, and 128 of the men ultimately died of the disease or complications related to it.

When news of the study broke, Chuck Stone , a journalist and former Tuskegee Airman , responded with an impassioned editorial, writing, “It either takes a tough constitution or a rancid morality to sit quietly by and watch 200 men die without doing anything about it. I call it genocide. Have you got a better name for it?”

Historians have had decades to pore over the study’s archives. Now, the National Library of Medicine has made a collection of those documents available for public viewing online . Anyone with an internet connection can read the primary source material—hundreds of pages of administrative records, letters and meeting minutes.

No one would expect the portrait this collection paints to be pretty or redemptive. Indeed, the study has gone down in the annals of American history as one of the most notorious, but by no means only, examples of medicine at its most prejudicial, virulent and unethical. Even with this knowledge, it is galling to read about the lengths USPHS doctors went to to ensure their patients were denied treatment.

Immobile and malleable

A 1948 history of the study makes it clear that the choice to set the experiment in the Deep South was deliberate. As the paper notes, the study followed a broader survey of syphilis in the still deeply segregated region. Sponsored by the Julius Rosenwald Fund , this earlier program aimed to assess the prevalence of the disease in several Southern counties and make sensible plans for its treatment—a starkly different goal than the Tuskegee experiment. The USPHS drew on this data to identify Macon County, Alabama, the surveyed area with the highest prevalence rate of syphilis, as the right place for a new study. Macon County also had high poverty rates and low education rates, ensuring the experiment’s subjects would be both immobile and malleable.

Another contributing factor was the presence of the venerable Tuskegee University, a historically Black college then known as the Tuskegee Institute, which had the facilities necessary to carry out the autopsies and lab work the study required.

Always a hurdle was a 1927 Alabama state statute that required medical personnel to report and treat all cases of syphilis. But enforcement of this statute was so lax that the experiment could have continued unimpeded had it not been for the 1942 draft, which led the local Selective Service Board to unmask the syphilitic status of the study’s subjects. The board’s charge was to evaluate individuals for military service, a process that required testing for venereal diseases and mandatory treatment for those affected.

R.A. Vonderlehr, the assistant surgeon general and one of the originators of the study, jumped into action to prevent the subjects from receiving treatment. He wrote urgently to local health officer Murray Smith, asking him to pull some strings to get the study subjects exempted.

“I would suggest that you confer with the chairman of the local Selective Service Board,” Vonderlehr wrote. “I believe he is an old friend of yours, and I would inform him of all the circumstances connected with the study. It is entirely probable that … he will cooperate with you in the completion of the investigation.”

Smith made good use of his social connections, managing to get the 256 remaining syphilitic subjects exempted from treatment. Likewise, when the same matter reached D.G. Gill, director of the Alabama Department of Health’s Bureau of Preventable Diseases, he requested Vonderlehr’s advice on whether to “make an exception of these few individuals” to avoid “encroaching on some of your study material.”

Effective treatment denied

Even in the postwar period, when penicillin became widely available, replacing the arguably ineffective and dangerous arsenic-based syphilis treatments that had preceded it, the study ploughed ahead , still more committed to documenting the disease than treating its sufferers. There was nothing unwitting about this denial of treatment.

Indeed, the archive shows that subjects were explicitly and repeatedly lied to for decades so they wouldn’t seek treatment for syphilis on their own. Even the form letters they received bore the hallmarks of a scam. They were invited to a “special examination” with government doctors waiting to give them “special attention” to “find out how you have been feeling and whether the treatment has improved your health.” Some of these notes were signed by Smith, who was designated just below his signature as a “special expert” to the USPHS.

And then there were the spinal taps , which were widely hated by the study subjects for the severe headaches they caused and because the men worried the procedure “robbed [them] of their procreative powers (regardless of the fact that I claim it stimulates them),” wrote physician Austin V. Deibert in a 1939 letter to Vonderlehr. 

Deibert told Vonderlehr the USPHS might have to  cancel the spinal taps  for the sake of the study’s continuation. “All in all and with no attempt at humor,” he said, he was the one with the real “headache.”

Neither World War II nor the early civil rights movement seemed to move the subsequent generations of study staff and administrators. The study was widely known in medical circles, thanks to the dozen or so articles on its findings published in prominent journals. Though outsiders started criticizing the experiment in the 1950s and ’60s, these dissenting voices were few and far between.

The first confirmed critique of the study from outside the USPHS arrived in a 1955 letter written by physician Count Gibson , who had heard a USPHS official explicitly state that the study’s subjects were not informed that treatment was being withheld.

Though Gibson was reportedly unsatisfied with the response he received, his colleagues urged him not to pursue the issue for fear that speaking out against these very powerful men might jeopardize his own career. He let it drop. In 1964, cardiologist Irwin Schatz voiced similar concerns, writing a letter that also questioned the study’s ethics. He never received a reply.

Concerns waved off

Indeed, the study directors continued to wave off concerns. As a set of meeting minutes from 1965 put it, “Racial issue was mentioned briefly. Will not affect the study. Any questions can be handled by saying these people were at the point that therapy would no longer help them. They are getting better medical care than they would under any other circumstances.”

In 1970, Anne R. Yobs, a co-author of one of the published papers, acknowledged that the research should come to an end. In a letter to the director of the Centers for Disease Control, she recommended closing the study, not because the charges of racism and unethical practice that had started to pour in were merited, but rather because “changes at the program level … in sensitivity to (potential) criticism” had forced administrators’ hands.

The study had become “an increasingly emotionally charged subject,” preventing “a rational appraisal of the situation,” wrote James B. Lucas, assistant chief of the USPHS’ Venereal Disease Branch, in a memo that same year.

By 1972, Peter Buxtun , a USPHS venereal disease officer who had spoken out against the study within the organization for years to no avail, had had enough. He went to the press.

Jean Heller, an Associated Press journalist, broke the story that July. A few months later, an ad hoc committee organized to evaluate the study finally ended it .

The Tuskegee study’s legacy has reverberated across the decades. In 1974, the NAACP successfully sued the federal government for $10 million, distributing the settlement money to the study subjects and their surviving family members. In 1997, President Bill Clinton publicly apologized to the men, acknowledging that what the USPHS had done was “deeply, profoundly, morally wrong.”

The study has had a material impact on medical outcomes within the African American community more broadly. Over the past several decades, researchers have connected the experiment to lower life expectancy among Black men due to broken trust in the health care system. More recently, the Covid-19 pandemic and subsequent vaccination efforts reignited discussions around Tuskegee’s impact on medical mistrust . Susan Reverby, the preeminent historian of the Tuskegee syphilis study, argues that the experiment’s legacy is far more complex than commonly stated, in no small part because of how it has been viewed historically. She notes that tying medical skepticism directly to Tuskegee erroneously suggests that the “reason for mistrust happened a long time ago,” thus turning attention away from the structural racism of today. As historian Alice Dreger succinctly puts it, “African Americans who distrust the health care system see plenty of reasons all around them to do so. They don’t have to look back 40 years.”

Perhaps, in this light, the most important takeaway from these digitized documents is not the starkly racist, unethical enterprise they so vividly record. It’s easy to condemn Vonderlehr, Smith, Yobs, Deibert and the countless others in the story whose actions are deeply troubling. But it’s more useful to observe how professional credentials and networks, philanthropic funding, warped notions of the greater good, and devotion to the scientific method provide cover to racism—and even prop it up. For it is often in these more quotidian spaces of life that racism in medicine persists .

This article is published in partnership with the Conversation under a Creative Commons license. Read the Conversation’s version .

Caitjan Gainty is a historian of 20th-century medicine and technology at King’s College London. She initially trained in public health and worked for several years in health care research before returning to academia to pursue a PhD in the history of medicine, which she received in 2012.

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The Lasting Fallout of the Tuskegee Syphilis Study

A recent paper provides evidence that the Tuskegee Syphilis Study reduced the life expectancy of African-American men.

A new paper provides evidence that the Tuskegee Syphilis Study reduced the life expectancy of African-American men —though the Tuskegee Syphilis Study ended decades ago. What was the Tuskegee Syphilis Study and why did it have lasting reverberations?

The now-infamous 1932 Tuskegee Syphilis Study  was conducted by the U.S. Public Health Service in Macon County, Alabama. During the experiment 600 impoverished black men were studied, 399 of whom had syphilis that went untreated although the health care practitioners knew of their illness. The men were never educated about syphilis, were never told of their status or treated, although treatments did exist; they were merely told they were being seen for “bad blood.” The men underwent painful procedures like spinal taps under the guise of “free healthcare,” and were “compensated” with meals and burial insurance. The intent of the study was never even to actually help the patients, but rather to examine the course of untreated dormant syphilis in black men.

Men in the study were not allowed to access other treatment services in the area. Not only did the syphilis harm the men, many of their wives and even some of their children contracted the disease. Despite the fact that codes like the Nuremberg Code of ethics was created during the Tuskegee study, and that by 1947 penicillin had become a standard, effective treatment for syphilis, the experiment continued. The study was initially intended to be six months but continued until 1972.  It did not provide as much insight on syphilis research as it did about racism in health research.

Decades after the Tuskegee Syphilis study health statistics continue to illustrate the lack of trust black Americans have for healthcare professionals. Looking at the context and history of the beliefs can help us make sense of the trends. In the 1990s a notable chunk of the African American community believed that the government created AIDS . A 1997 study illustrated cited 32.1% of the black women surveyed agreed with a statement that scientists were not trustworthy . This significantly deviates from the 4.1 % of white women in the study who agreed with the aforementioned statement. This was despite the fact that over 80% of women surveyed recognized the benefits of medical research for society. The newer findings  delve specifically into how this mistrust of the health profession has had negative impacts on black people’s health.

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While tenets of equity in healthcare research appear to be universal , there is a long history of disparity when it comes to the distribution and quality of healthcare amongst individual people. The Hippocratic oath  compels new doctors to make blanket commitments to ethics and accountability while serving humanity regardless of gender, race, religion, political affiliation, sexual orientation, nationality, or social standing . And yet this oath belies a legacy of racism in medicine.

Communities that have experienced such painful histories of being used as lab rats understandably may not be inclined to engage with healthcare providers. Beneficence and non-maleficence are cornerstones of health care provision, at least if you look at codes we like to think all healthcare providers adhere to. But fidelity was not upheld with Tuskegee and the ripple effect is evident today. Oaths do not guarantee an obligation to morality or veracity in healthcare, people do.

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TUSKEGEE AND THE HEALTH OF BLACK MEN *

Marcella alsan.

Stanford University, NBER and BREAD

Marianne Wanamaker

University of Tennessee, NBER and IZA

Associated Data

JEL Codes: I14, O15 For forty years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black males with syphilis despite the availability of effective treatment. The study’s methods have become synonymous with exploitation and mistreatment by the medical profession. To identify the study’s effects on the behavior and health of older black men, we use an interacted difference-in-difference-in-differences model, comparing older black men to other demographic groups, before and after the Tuskegee revelation, in varying proximity to the study’s victims. We find that the disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women.

I. Introduction

The Tuskegee Study became a symbol of their mistreatment by the medical establishment, a metaphor for deceit, conspiracy, malpractice, and neglect, if not outright genocide. Corbie-Smith et al. (1999)

African-American men have the worst health outcomes of all major ethnic, racial, and demographic groups in the United States. 1 Although recent trends have shown signs of improvement, particularly at younger ages, the gradients for older men are still sobering; the expectation of life for black men at age 45 is three years less than for their white male peers and five years less than for black women ( Murphy 2013 ). Compared to other demographic groups, black men have higher death rates from chronic conditions such as HIV/AIDS, heart disease, and cancer, including lung, prostate, and colon ( Kaiser Family Foundation 2007 ). Many factors contribute to such disparities, including lower income and education, lack of health insurance, and higher rates of disengagement from the labor force. But socioeconomic status is not fully determinant of these gaps ( Adler et al. 1993 ; Cutler, Lleras-Muney, and Vogl 2011 ) and a growing qualitative literature suggests that mistrust of healthcare institutions partially contributes to these inequities. Yet empirical evidence on the causal role of medical mistrust for racial health disparities remains thin.

This study uses the historical disclosure of an unethical and deadly experiment, the Tuskegee Study of Untreated Syphilis in the Negro Male (TSUS), to identify the relationship between medical mistrust and racial disparities in health-related behaviors and health outcomes. For 40 years, between 1932 and 1972, the U.S. Public Health Service (PHS) followed hundreds of poor, black men in Tuskegee, Alabama, the majority of whom had syphilis, for the stated purpose of understanding the natural course of the disease. The men were denied highly effective treatment for their condition (most egregiously, penicillin, which became standard of care by the mid-1940s) and were actively discouraged from seeking medical advice from practitioners outside the study ( Brandt 1978 ). Participants were subjected to blood draws, spinal taps, and, eventually, autopsies by the study’s primarily white medical staff. Survivors later reported that study doctors diagnosed them with "bad blood" for which they believed they were being treated. Compensation for participation included hot meals, the guise of treatment, and burial payments. News of the Tuskegee Study became public in 1972 in an exposé by Jean Heller of the Associated Press, and detailed narratives of the deception and its relationship to the medical establishment were widespread. By that point, the majority of the study’s victims were deceased, many from syphilis-related causes.

In the years following 1972, journalists, social scientists, and medical researchers have repeatedly pointed to the Tuskegee experiment as a reason African-Americans remain wary of mainstream medicine. For example, as HIV disproportionately ravaged black communities in the U.S., a number of observers conjectured that the Tuskegee Study’s legacy had hampered public health education efforts in the black community, contributing to the epidemic’s spread ( Gaston and Alleyne-Green 2013 ). A recent resurgence of tuberculosis in Marion County, Alabama is similarly attributed ( Blinder 2016 ). Qualitative research aimed at understanding the reluctance of black men, in particular, to participate in medical research or engage in preventive care often produces unprompted reference to Tuskegee ( Corbie-Smith et al. 1999 ). In sum, the Tuskegee Study is an often-cited contributor to delays and avoidance in care seeking, wariness of public health campaigns, low participation in clinical trials, and overall worse health indicators among black men.

To empirically investigate whether the study’s disclosure contributed to racial disparities in health and healthcare utilization in the years following 1972, we rely on a variety of survey and administrative data, including measures of trust in doctors from the General Social Survey (GSS) ( Smith et al. 2015 ), health seeking behavior reported in the National Health Interview Survey (NHIS) ( Minnesota Population Center 2012 ), and mortality data available by race, age group, gender, and cause from the Centers for Disease Control and Prevention ( CDC 2014 ). We focus our attention on these measures for older (45–74) individuals, using other age groups as placebo tests since the mortality and health-seeking behavior of younger individuals is generally driven by acute conditions such as childbirth or trauma in which the needs for care are urgent and the benefits immediate. Because mistrust is more likely to discourage preventive and non-emergency medical care, we report results for both all-cause mortality and chronic disease mortality outcomes.

To generate testable predictions beyond those implied by the timing of the disclosure in 1972, we use race and sex as additional treatment indicators. This approach is based, in part, on the supposition that individuals for whom the news of the Tuskegee Study’s abuses was more salient should exhibit a more robust behavioral response. Economic models of trust formation and social identification (e.g., Tabellini 2008 ) and a vast psychology literature (e.g., Gutsell and Inzlicht 2010 ; Singer et al. 2006 ) indicate that individuals tend to be more affected by news if they can identify with the subject. We posit that individuals might perceive themselves at higher risk of medical mistreatment if they share socio-demographic characteristics with the study’s victims. In this view, the Tuskegee abuses became a signal for how black men might expect the medical system to treat them. A simple Bayesian, multi-period model of belief formation regarding physician trustworthiness implies that, under certain conditions, agents having previous experience with the medical system, e.g., child-bearing women, are less dissuaded from seeking medical treatment by bad news, again implying stronger responses among men than women. 2 The model and all supplementary materials are available in an Online Appendix .

As a final exposure to treatment, we interact these demographic characteristics with a location-based measure of proximity: geographic distance to Macon County, Alabama, which contains Tuskegee. In doing so, we test whether black men living in closer proximity to the study’s victims were more heavily influenced by the TSUS revelation. Such a pattern would be observed if, for example, individuals in closer geographic proximity believe the event is more instructive for how they may anticipate being treated by their local medical system. For an alternative proximity measure, we substitute the share of black migrant inflows from the state of Alabama to an individual’s local geography. The Great Migration was characterized by strong chain migration and by substantial amounts of return migration such that individuals living in locations with higher rates of black migration from Alabama would have experienced a lasting information network, in addition to any additional salience arising from these connections.

We test these hypotheses using an interacted difference-in-difference-in-differences framework that captures post-1972 changes in the racial and gender gaps in healthcare utilization and health outcomes for those in varying proximity to the event. Whenever feasible, we condition on a rich set of control variables found to be correlated with individual health seeking behavior, including education ( Aizer and Stroud 2010 ), income ( Deaton 2002 ), marital status ( Holt-Lunstad, Birmingham, and Jones 2008 ), and urbanization. Race-gender-location, race-gender-time and location-time fixed effects non-parametrically control for time-invariant factors that influence outcomes for a specific demographic group in a given locale and for changes in public health and other government policies that might have differentially affected members of each group in each year. The finest level of geography observable in the utilization regressions is a respondent’s state, and we use observations at the county or state economic area level for mortality outcomes. We focus on the short- and medium-term impact of the disclosure on health behaviors and outcomes; given the data limitations, persistent causal impacts are more difficult to identify.

Our estimates imply that a one-standard deviation increase in geographic proximity to Macon County, Alabama, reduced utilization of routine care (outpatient physician contacts) among older black males by 0.90 interactions per year, a 22% reduction in utilization relative to the pre-disclosure mean value for black men. These utilization effects are driven by the behavior of black men with lower levels of education and income. We also find weaker evidence of a reduction in the probability that black men were admitted to the hospital, though their length of stay was significantly longer, consistent with more advanced disease upon presentation. Mortality outcomes indicate that a one standard deviation increase in geographic proximity to Tuskegee was associated with a spike in the post-1972 age-adjusted mortality penalty for black men of 4 log points. Our estimates imply that the Tuskegee Study disclosure contributed to widening health disparities between 1970 and 1980, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women.

An alternative explanation for our findings is that access to healthcare was deteriorating for blacks relative to whites in this period, particularly in the South, and black men were precluded from obtaining routine medical care regardless of their underlying demand. But controlling for public health expenditures and for the availability of hospital services has little effect on our estimates, and this alternative explanation is inconsistent with other research concluding that access to health services and health outcomes for black Americans improved substantially in the years immediately after the Civil Rights Act ( Goodman-Bacon 2015 ; Almond, Chay, and Greenstone 2006 ; Cascio and Washington 2014 ). Our results indicate that the Tuskegee revelation stalled the overall pattern of convergence for older black men, producing a drag on healthcare utilization for this specific demographic group and contributing to an abrupt divergence in their mortality patterns.

We pursue a number of strategies to provide further evidence that the correlations we find are indeed causal. First, the results we find are specific to black men; coefficient estimates for the post-1972 treatment effect of being "black and female" or "white and male" in closer proximity to Macon County, Alabama, are generally not economically or statistically significant, do not exhibit an observable break in 1972, and are often opposite-signed to the main treatment effects. In additional tests, we show that our findings are robust to estimation on a within-South sample and that the baseline coefficients for mortality (utilization) based on geographic proximity to Macon County, Alabama, are larger (smaller) than 96% of placebo tests substituting proximity to all other geographies in the data. Thus the effects we measure are specific to black men and to geographic proximity to central Alabama, not to a post-1972 condition affecting the South overall.

Finally, to evaluate whether the behavioral responses we observe are driven by medical mistrust, we use survey data from the 1998 wave of the GSS on whether individuals trust a doctor’s judgment and whether they suspect that the medical establishment will deny them necessary treatment or services. When we interact race and gender indicators with a measure of the distance of an individual from Macon County, Alabama, we find the same geographic gradient apparent in our baseline utilization and mortality results. This geographic gradient in mistrust is not present for general mistrust as revealed in the respondents’ answers to other survey questions.

This paper builds on and contributes to several literatures in economics. First, our findings elucidate factors influencing healthcare demand and medical outcomes among minorities in the United States and deepen our understanding of how this watershed event affected the relationship between black Americans and the U.S. healthcare system. Second, and more broadly, our study is motivated by the theoretical contributions of Guiso, Sapienza, and Zingales (2008) regarding the transmission and updating of beliefs and empirical work by Nunn and Wantchekon (2011) regarding the role of previous exploitation in shaping interpersonal mistrust in Africa. Our findings also connect to rich empirical evidence on the importance of trust for economic development ( Knack and Keefer 1997 ; Fafchamps 2006 ; Greif 1989 ). Finally, these findings shed light on questions in development economics regarding low demand for products that have been shown to improve health ( Dupas 2011 ; Chapter 3 of Banerjee and Duflo 2011 ). The findings presented herein suggest that historical exploitation and its enduring impact on beliefs may explain some of the uptake paradox.

II. Context

The following section places the study in historical and medical context by providing background on the pathology of syphilis and the TSUS experiment, prior literature on the legacy of Tuskegee, and health patterns across demographic groups in the years surrounding the disclosure.

II.A. Background on the Tuskegee Study

The Tuskegee Study was designed to trace the course of untreated syphilis in black men. The organism that causes the disease is related to that causing Lyme disease, and both bacteria manifest themselves in stages. The first stage of sexually acquired syphilis is often an ulcer, followed by a full body rash that includes the palms and soles. However, it is the tertiary (or late-stage) syphilis that inflicts the most damage. The third stage is characterized by gummas (syphilitic tumors teeming with the bacteria) which coalesce and eat away at bone (frequently the nasal bridge) as well as other organs and show a predilection for the arch of the aorta often leading to hemorrhage. Neurosyphilis (an attack on the nervous systems) presents in late-stage syphilis with paresis, gait disturbance, blindness, and dementia ( Mandell, Bennett, and Dolin 2009 ). 3

According to Jones (1992) , much of the natural history of syphilis outlined above was known at the time the study commenced:

"The germ that causes syphilis…and the complications that can result from untreated syphilis were all known to medical science in 1932 – the year the Tuskegee Study began. Since the effects of the disease are so serious, reporters in 1972 wondered why the men agreed to cooperate. The press quickly established that the subjects were mostly poor and illiterate, and the PHS had offered them incentives to participate."

These incentives included physical exams, hot meals, and burial stipends that would be paid to their survivors. Most of the men also believed they were receiving some form of treatment. Approximately 600 black men (approximately two-thirds of whom had syphilis) were recruited to the study using these techniques and followed passively for forty years while the disease took its toll.

In 1972, news of the Tuskegee Study was leaked to the press and quickly spread, including reporting from the New York Times and the Los Angeles Times , via the Associated Press wire, on broadcast television, via congressional hearings, and, of course, by word of mouth. The study was halted that same year, but few of the original test subjects were alive and dozens of their wives and children had been infected ( Heintzelman 2003 ). Medical historian Allan Brandt (1978) summarizes the study as follows: "In retrospect the Tuskegee Study revealed more about the pathology of racism than the pathology of syphilis; more about the nature of scientific inquiry than the nature of the disease process. … The degree of deception and the damages have been severely underestimated." Those damages may include a legacy of medical mistrust among black Americans. The Final Report of the Tuskegee Syphilis Study Legacy Committee (1996) noted that "the Study continues to cast a long shadow over the relationship between African-Americans and the biomedical professions," and was "a significant factor in the low participation of African-Americans in clinical trials, organ donation efforts, and routine preventive care." 4

Despite the Committee’s conclusions, the empirical evidence of a link between the Tuskegee Study and medical mistrust has been mixed and suffers from several limitations. First, and perhaps most crippling, all quantitative and qualitative studies of the relationship between medical mistrust and awareness of Tuskegee’s abuses are dated 20 or more years after 1972. By this time, the link between medical mistrust and knowledge of Tuskegee may have faded for a number of reasons, including a socialization of mistrust without an accompanying socialization of the relevant history. 5 Second, a correlation between medical mistrust and knowledge of the Tuskegee Study provides no information on the direction of causation; distrustful individuals may do more to collect information on past abuses. Third, the extant literature focuses on participation in clinical trials rather than medical mistrust per se . Although these outcomes are likely to be correlated, it is the mistrust of care providers that directly impacts health conditions. Finally, samples used in these studies are frequently restricted to particular geographies.

With these qualifications in mind, the earliest quantitative study on this topic is from 1994 (22 years following the disclosure). Researchers surveyed residents of Jefferson County, Alabama ( Green et al. 1997 ). Although 55% of the sample held knowledge of the Tuskegee Study, and the rate was no higher for black men and women than for whites, knowledge of the study by black men increased with age, reaching 74% for those aged 46–64 (who would have been 24–42 at the time of the study). The sample’s age distribution differed substantially by race, and the survey write-up does not include a conditional relationship between race, age, sex, and knowledge of Tuskegee, nor does it give a conditional relationship between willingness to participate in health research and Tuskegee knowledge. But unconditional cross tabulations indicate that 27% of black men were less interested in participation as a result of the study, compared to 20% of black women and 10% of whites. Among all African Americans (male and female), this disinterest was highest for individuals with a high school degree, but no college, and among those aged 31–65. These survey responses also indicate significant racial gaps in respondents’ perceptions of the fairness of medical care and research. 6

In addition to the Green et al. study, Brandon, Isaac, and LaVeist (2005) surveyed 401 black and white adults living in Baltimore, Washington D.C., and New York City in 2003 and found that blacks were far less likely to report knowledge of Tuskegee than whites (74% vs. 25%), a statistic uncovered by White (2005) in his critique of their paper. This result, along with the survey’s high refusal rate, led White to cast doubt on the study’s methods. Brandon et al. also reported that blacks with knowledge of the study were 50% more likely to believe the PHS researchers injected the men with syphilis (75.3% vs. 52.8%) and to believe Tuskegee could "occur today" (76.6% vs. 47.2%). In this study, medical mistrust was positively related to black race, male sex and lower education, but not significantly related to knowledge of the Tuskegee Study. Shavers, Lynch, and Burmeister (2002) found the opposite: a greater unwillingness to participate in medical research among blacks who knew about the study. The Tuskegee Legacy Project of 2003, which interviewed black, white, and Hispanic men and women, found that blacks were more likely to have a higher "guinea pig fear factor" score than whites and were more likely to have knowledge of the Tuskegee Study than whites or Hispanics (56.2% vs. 38.5% and 24.3%, respectively) ( McCallum et al. 2006 ).

As best we can ascertain, Freedman (1998) is the earliest qualitative research on the relationship between medical research mistrust and the Tuskegee Study. Freedman asserts that the Tuskegee legacy is not enough to fully explain racial differences in participation in medical research, yet cites interviewees who explicitly and vividly expressed their unwillingness to participate in medical studies in connection with the Tuskegee Syphilis experiment. Additional qualitative evidence links mistrust associated with the Tuskegee Study with take-off of the HIV/AIDS epidemic in minority communities. On May 12, 1992, the New York Times published poll results wherein blacks were more likely to believe in conspiracy theories related to HIV/AIDS, including that the virus was a genocide tool designed to limit the number of blacks in America. (These results have been replicated many times over.) According to Quinn (1997) , resulting letters to the editor "clearly placed the origin of such attitudes within the historical context of the Tuskegee Syphilis Study". 7 At the height of the HIV/AIDS crisis in the U.S., health publications implored medical professionals to directly confront these conspiracy theories with facts, and correct the common misconception that the Tuskegee abuses included infecting study subjects with syphilis. "Public health professionals must recognize that Blacks’ belief in AIDS as a form of genocide is a legitimate attitudinal barrier rooted in the history of the Tuskegee Syphilis Study" ( Thomas and Quinn 1991 ).

In addition to specific Tuskegee legacy studies, the public health literature provides ample documentation that being black and male is an important predictor of health disparities, including those in life expectancy, survival rates within disease category, and health-promoting behavior. Black men are less likely to know their cholesterol levels, engage in blood pressure monitoring, or otherwise benefit from early detection of chronic conditions than their white male peers ( Sandman, Simantov, and An 2000 ; Viera, Thorpe, and Garrett 2006 ). Although reasons for these disparities are multifactorial, the legacy of medical exploitation (represented in part by the Tuskegee Study) has led to research on whether medical mistrust is particularly heightened among black men ( Carlson and Chamberlain 2004 ). Indeed, black men exhibit higher levels of medical mistrust which are correlated with reduced probabilities of routine, preventive, and early-stage disease care. 8 Medical mistrust among black men is also correlated with poor compliance with treatment plans, conditional on diagnosis, for a range of diseases including HIV/AIDS, cancer, and hypertension. 9

II.B. Patterns of Healthcare Utilization and Mortality

Prior to the Tuskegee experiment revelation, the 1960s marked an era of rapid convergence in healthcare access and utilization for black Americans relative to whites. Hospitals gradually integrated over the 1950s and early 1960s, a process that culminated not with the Civil Rights Act of 1964, but with President Lyndon Johnson’s insistence that any hospital receiving Medicare funding fully desegregate by July 1966. This process was quicker in the North than in the South; separate hospital wings were present in 75% of hospitals in the South as late as April of 1966. Still, full compliance appears to have been achieved by July of the same year. These decades also witnessed expansions in public health insurance coverage and services, some of which favored black Americans, including the establishment of Medical Assistance for the Aged (a precursor to Medicare), establishment of and expansions in Medicare and Medicaid ( Goodman-Bacon 2015 ), local health center construction ( Bailey and Goodman-Bacon 2015 ), and the expansion and funding of public hospitals.

By 1970, black Americans had gained substantial ground in terms of healthcare utilization, even if the quality of the services they acquired lagged behind their white peers. 10 Using data from the NHIS, among individuals ages 45 to 74, the percentage of black women who did not have recent contact with a medical professional declined between 1964 and 1971 by about 6 percentage points. The improvements for black men were similarly impressive; the same metric declined by 8 percentage points. These gains were three to four times as large as those experienced by white males and females over the same time period. 11 The convergence of black and white healthcare utilization rates in the years prior to the Tuskegee disclosure was closely mirrored by convergence in mortality rates. Using CDC-provided annual county-level mortality statistics by age, race, and gender, as described above, we plot the racial difference in age-specific mortality rates (ASMR) (black minus white) for both men (solid line) and women (dashed line) in Figure I . Panels A and B demonstrate that, for infants and children 1 to 4 years of age, there was a marked reduction in racial health disparities that continued, uninterrupted, after the 1972 disclosure. But the pattern for adult mortality is starkly different. Panels C and D plot the same data for adults aged 55–64 and 65–74. At these ages, convergence at the beginning of the period is followed by a striking divergence in the mortality rates for black men relative to white men beginning in the early 1970s, a pattern which is not reflected in the differences between black and white women. The mortality patterns for other ages (contained in Appendix Figure A.2 ) mimic those for infants and children. 12 Unlike younger ages, where parental behavior (for early childhood) and unintentional injuries (for young adults) play key roles in determining mortality, premature and preventable mortality in older adults is more frequently driven by health behaviors and physician involvement, including timely diagnosis and management of illness. To facilitate comparisons across age groups, the mortality rates represented by Figure I are those from all causes of death; specific cause-of-death is available in the underlying data and utilized later in the paper. These stark mortality patterns for black men relative to both black women and white men motivate the paper’s focus on health behaviors and outcomes of black men in particular.

Notes : The data are from the CDC compressed mortality files and represent the black-white difference in age-specific mortality rates. Each mortality rate is calculated by dividing the number of deaths in the relevant population by the at-risk population (in thousands). The solid (blue) line represents the difference for males, and the dotted (red) line represents the difference for females. The vertical line represents the year “The Tuskegee Study of Untreated Syphilis in the Negro Male” was disclosed. For additional figures, including plots of all other age-specific mortality rates and South only, see the Appendix .

The paper’s empirical approach focuses on changes in health-seeking behavior and health outcomes as a result of the Tuskegee disclosure. We measure health-seeking behavior using data on healthcare utilization from the NHIS. The survey is a repeated cross-sectional sample of Americans which began in 1963. The survey is taken by household visit, and we use the individual-level respondent data in our analysis. We rely on a harmonized data source, the Integrated Health Interview Series (IHIS), provided by the University of Minnesota, which is based on the NHIS public-use data ( Minnesota Population Center 2012 ). Consistent, harmonized responses regarding the utilization of medical services are available from 1969. 13 The public-use samples are stripped of geographic identifiers necessitating the use of restricted access for these data from the National Center for Health Statistics (NCHS). 14 One important caveat with using these data is that PHS, the same entity that carried out the Tuskegee Study, sponsored the survey, although the interviews were conducted by the U.S. Census Bureau. If mistrustful individuals refused to answer the survey, our estimates may represent attenuated behavioral responses. In a simple difference-in-difference-in-differences (DDD) specification where we regress the NHIS sample weight for each individual on year fixed effects, an indicator for black, an indicator for male, an indicator for black-male, and an indicator for post-1972 interacted with each of the demographic indicators, we find that the survey weights for black men in the sample after 1972 rose by a statistically insignificant 0.3%.

Each individual in the survey self-reported the interval since their last doctor’s visit or physical, the number of physician visits and other physician interactions (including phone calls) in the last 12 months, as well as the frequency and duration of hospital admissions. The data also contain detailed demographic information, including age, family structure, income, education, and veteran status. 15 As discussed previously, we focus on men aged 45 to 74 to capture the effects on men (and women) in the age range most likely to benefit from preventive and early-stage disease care. We distinguish between non-veteran and veteran men given differences in their previous physician interactions. Our baseline utilization results are for non-veteran males, and we present results by veteran status later in the paper.

Because morbidity data is difficult to interpret in this context (disease diagnosis would generally require a physician’s visit), we rely on separate mortality data to assess whether the changes in beliefs and behaviors which we document below translate into an effect on health. In doing so, we follow a sizable literature that uses mortality to assess the effectiveness of health interventions. 16 County-level mortality statistics by age, race, and gender are available from the CDC for each year between 1968 and 1988. We merge population data for the same period from the CDC to calculate mortality rates by age group, race, and gender ( CDC 2014 ). Because some U.S. counties have small black populations, the per-year mortality counts in some places are quite low, and sometimes zero. Mortality rates based on a sparse number of events exhibit a large amount of random variation ( Curtin and Klein 1995 ), thus we follow advice from NCHS and aggregate over space and time, combining annual county-level mortality counts to the state economic area (SEA) level and measuring biennial mortality rates. 17 We do not observe veteran status in the mortality files.

Our baseline results are for both age-adjusted all-cause and age-adjusted chronic-cause mortality. Chronic causes include cardiovascular disease (including hypertension and stroke), cancer, smoking-related respiratory disease, ill-defined conditions and ongoing symptoms, gastrointestinal disorders, and diabetes. Chronic mortality therefore includes the leading causes of death for this cohort and represents diagnoses for which therapies and interventions by health professionals could plausibly prevent or delay mortality. 18 We use age-adjusted mortality rates to account for differences in age structures across groups. 19 Since the impact of the Tuskegee revelation might affect mortality with a lag and last longer than the impact of utilization, we include mortality rates from 1968 to 1987 in our main analysis. 20

IV. Estimating Equation and Identification

Our main specification is an interacted DDD comparing differences across race (first difference) and gender (second difference) before versus after the study disclosure (third difference), interacted with a continuous, location-based measure of salience, either geographic proximity to Macon County, Alabama, or the share of black migrants originating from Alabama.

Why might the disclosure of the Tuskegee Study fuel mistrust in medicine particularly among black men? First, as discussed in the introduction, models of social identification and studies of empathy demonstrate that individuals are more responsive to injustices perpetrated against their own group and more empathetic to individuals in closer "proximity" to themselves. Distance between agents, as described by Tabellini (2008) , "could refer to geography, but also to social or economic dimensions such as religion, ethnicity and class." Second, in recent work on the formation of trust, psychologists have noted that men tend to form collective trust (with "categories" of people rather than individuals), while women form individual-specific relational trust ( Maddux and Brewer 2005 ). Third, even in the absence of differences in trust formation, ceteris paribus black women would have had more experience with the healthcare system through previous childbirth experiences, and this experience may have inoculated them against the Tuskegee Study revelation. Fourth, men have more elastic demand for health services ( Vaidya, Partha, and Karmakar 2012 ; Thanakijborisut 2015 ) and thus are more easily dissuaded from visiting a physician. Finally, and perhaps obviously, the victims of the Tuskegee Study were black men. The disclosure detailed how the medical establishment purposefully selected and abused black men and may have therefore revealed to black men information about how they might expect to be treated.

Empirically, we build on Tabellini’s description of "distance" by employing both race and gender as treatment indicators, as well as one of two location-based treatment measures. 21 Our primary measure is linear geographic proximity to Macon County, Alabama ( Figure II ; Panel A), supported by the linear relationship between post-1972 mortality changes and distance, as discussed below. 22 This continuous proximity metric creates concentric circles of equal proximity around the impact point of Tuskegee, Alabama. Although we remain agnostic regarding the precise mechanism through which geographic proximity affects behavior, we note that geography may capture an identification or empathy response as discussed above. Alternatively, this proximity metric may also reflect information contained in the signal if, for example, individuals at greater geographic distances do not believe that the Tuskegee experiment disclosure provided relevant information regarding the trustworthiness of their local medical practitioners. 23

Notes : Figure 2 plots proximity measures. Panel (A) represents distance from Macon County from the centroid of each SEA calculated using ArcGIS proximity tools. Panel (B) represents the fraction of black migrants from Alabama by SEA calculated using the 1940 census. Darker tones reflect closer proximity to Tuskegee or a higher fraction of Alabama migrants using 20 natural breaks. The white open circle in Panel (A) demarcates approximately 1000 kilometer radius from Macon County. The white closed circle in Panel (A) and black closed circle in Panel (B) represent Macon County.

As an alternative measure of salience, we use the fraction of black migrants to a particular state or SEA from the state of Alabama ( Figure II , Panel B). (We drop Alabama observations from the sample in this analysis.) The Tuskegee disclosure followed several decades of large-scale migration, particularly among African-American males, and we hypothesize that individuals in locations with larger numbers of incoming migrants from Alabama will also find the study’s revelation more salient. We take advantage of the complete count version of the 1940 U.S. Census, which contains a question about 5-year migration patterns with detailed geography measures, to calculate this statistic. 24 Migration rates are highest in young adulthood; thus, the migration patterns from 1935–1940 will be reflective of the origins of individuals aged 45–74 in 1972. The 1940 Alabama migration rates are additionally relevant as migration patterns are roughly stable over time, making the 1940 patterns a good proxy for patterns in the years subsequent.

IV.A. Motivating Difference-in-Differences Estimates

Recall from Figure I that black male mortality was converging relative to white men from 1968 through the early 1970s before diverging thereafter. We use a simple difference-in-differences (DD) framework to explore these changes. Specifically, we compare the post-1972 age-adjusted mortality rates from chronic disease of older black men relative to their white male or black female peers across SEAs grouped into K bins of 150 kilometers of distance from Macon County, Alabama. 25

To estimate the post-1972 mortality penalty for older black men compared to white men in each bin, we estimate a set of β k coefficients from the equation below. Group-specific, chronic cause mortality is reflected by Y rat k where a reflects the SEA of residence at time of death, t is year of observation, and r denotes the race of the group:

I r black and I t post are binary indicators for black and post-1972 observations, respectively, while ϕ a,black is an SEA-by-race fixed effect common across all years. Regressions are weighted by the relevant population in each SEA (e.g. 45–74 year old men for the all-male sample).

In this equation, β k captures the post-1972 effect of being a black male relative to white men, controlling for time-invariant differences in black and white male mortality in each SEA and for a general post-1972 mortality effect ( γ k ). If mortality rates for black men had continued to converge in the post-1972 period, we would measure a value of β less than zero in each bin. Alternatively, stalled convergence would generate a value of β greater than or equal to zero. As anticipated, given the results in Figure I , the full-sample β (across all values of k ) is positive and significant, indicating post-1972 divergence in mortality for older black men relative to their white peers of approximately 5.3 log points. This estimate is plotted as a thick line, and both the estimate and 95% confidence interval are reported in the heading for Figure III , Panel A.

Notes : These figures plot β coefficients from equation (1) estimated on various demographic group samples (all-male, all-black, all-white and all-female) as indicated by the figure headings and further subdivided into distance bins from Tuskegee. The outcome variable for each regression is the log of age-adjusted chronic mortality. Panels (A) and (B) plot β coefficients on black*male*post in the all-male and all-black sample, respectively. Panels (C) and (D) plot β coefficients on white*male*post and black*female*post in the all-white and all-female sample, respectively. Panels (E) and (F) plot the same coefficients as in Panels (A) and (B), however, the time period of the analysis is restricted to the pre-1974 period with all observations after 1969 constituting the “post” period. SEAs were grouped into K bins of 150 kilometers of distance from Macon County, Alabama each bin yielding a β k . Bins in the middle of the country with less than 2,500 black men in 1970 were combined, and confidence intervals that were greater than 0.6 in absolute value were omitted so that the scale could be the same for all figures. Regressions for a given bin were weighted by the relevant SEA population (e.g. 45–74 year old males for the all-male sample), and the size of the bubble reflects the total weight of the respective treated population within each distance bin. Each β k coefficient is indicated by a bubble and the dashed vertical lines connected to the bubble denote its 95% confidence interval. The thick (blue) line depicts the average β coefficient across the entire subsample. This average estimate and its 95% confidence interval are provided in the figure subheading. The line of best fit between the β coefficients and distance from Tuskegee is drawn as a dashed (red) line. Data are from the CDC compressed mortality files and cover the period 1968 to 1987 unless otherwise indicated. Rates are constructed biennially, and post is an indicator equal to 1 in the years following 1972/1973 for Panels (A) through (D). Placebo post is an indicator equal to 1 in the years 1970/1971 and covers the period 1968 to 1973. See main text and Appendix for further details on the data source and variable construction.

Yet this average treatment effect of being a black male after 1972 masks significant heterogeneity. We find a strong geographic gradient in the value of β along a measure of distance from Macon County, Alabama, with locations closer to Macon County showing stronger evidence of divergence. In Figure III , Panel A, we plot the value of these coefficients by bin, as well as a (thin, dashed) line of best fit. Black men in close proximity to Tuskegee saw an increase in relative chronic mortality of about 10 log points, and the effect declines with distance.

To compare the post-1972 experience of black men to that of black women, we estimate a separate set of β k coefficients on a sample of black mortality rates, male and female, replacing indicators for black with indicators for male in equation (1) . 26 As indicated in the header for Panel B of Figure III , black male age-adjusted chronic mortality increased relative to black female mortality by a statistically significant 9.1 log points after 1972. Here, the geographic gradient is even more apparent; the value is 17 log points in locations closest to Tuskegee and again declines with distance.

These temporal and geographic mortality patterns for black men are not mirrored in other sub-groups. In Panel C of Figure III , we estimate equation (1) on an all-female sample. In this case, β k coefficients reflect the post-1972 convergence or divergence experiences of black women in each geographic bin. Consistent with Figure I , we find that black women continue to converge on their white peers after 1972, and the average estimated value of β is −9.2 log points. Moreover, the geographic gradient in these results is upward-sloping, indicating that black women in closer proximity to Macon County were converging more quickly than their peers further afield. A similar exercise in Panel D examines the experience of white men relative to white women. Overall, the gap in age-adjusted chronic mortality for white men relative to white women fell by 5.4 log points, perhaps as white men became beneficiaries of medical technologies and advice that spread over this time period. (See Appendix Section IV .) We see little evidence that proximity to Macon County was detrimental for the health of white men in the post period. Although the dotted line of best fit is downward sloping, this result is driven by convergence occurring at distances beyond 2000 kilometers from Alabama; estimated values of β k within the South show no geographic gradient.

To assess whether the observed geographic patterns in health outcomes for black men compared to black women and white men emerged in the post-1972 period, we look for the same patterns in the years prior to the Tuskegee disclosure, instituting a false definition of I post in this set of observations. We plot estimates of β for the same set of distance buckets in Panels E and F of Figure III , defining I post to be one for all observations after the mid-point of the pre period. These falsification tests indicate no geographic gradient in the estimates of β , and the slope of the line of best fit is flat for both the all-male and all-black specifications.

IV.B. Baseline Estimating Equations

The geographic gradients documented in Figure III motivate a DDD estimator which interacts differences over time, race, and gender with a continuous measure of proximity to Macon County, Alabama. We denote this proximity measure P j where j ∈ s, a represents measurement at the state or SEA level, respectively. To facilitate interpretation of regression coefficients, geographic distance is transformed to proximity to Macon County, Alabama, in thousands of kilometers. 27 The relevant estimating equation for healthcare utilization for individual i of race r and gender g measured in state s at time t ( Y igrst ) is:

For mortality outcomes, the vector of covariates ( X ) must be treated differently, and the estimating equation for the mortality rate of groups characterized by race r and gender g in SEA a at time t is:

In both equations, a full set of race-gender-time ( θ ), race-gender-geography ( ϕ ), and geography-time ( τ ) fixed effects are included. Race-gender-time fixed effects control flexibly for secular changes that could have differentially affected the health care utilization and mortality of each of the four groups. Race-gender-geography fixed effects absorb time-invariant location-specific factors that could differentially influence the health outcomes of each of the four groups. Local, time-varying shocks to health outcomes that affect all groups are absorbed by geography-time fixed effects.

In utilization regressions at the individual level, the vector X includes income, education, age, whether or not the individual owns a telephone, marital status, as well as an indicator for rural-urban status. For mortality rates, measured at the SEA level, the model includes SEA-year fixed effects that control for the changing supply of healthcare across locations over time, provided those changes affected all demographic groups equally. We add supply measures (the prevalence of doctors, hospitals, and hospital beds; the presence of community health centers; the log of total government healthcare expenditures–Medicare, Medicaid, and veterans healthcare; and the log of Social Security expenditures), each interacted with black and male indicators, to allow for differences in the effects of these supply measures on each group over time. Practically, they matter little for the estimates. (See Appendix Table A.3 for results without X variables.)

We limit our analysis to a window around the disclosure of 1969–1977 for utilization measures and 1968–1987 for mortality. We do not attempt to model the carry-on effects of TSUS to future cohorts of black men given that the identifying assumption behind the DDD approach becomes more tenuous as one moves out in time.

IV.C. Identification

The estimates of β 1 coming from equations (2) and (3) reflect the effect of the Tuskegee Study disclosure provided there are no other systematic shocks to black men that affected healthcare utilization and mortality correlated with proximity to Macon County, but not due to the timing of the study’s disclosure. By conditioning on the fixed effects and covariates described above, these estimates flexibly control for the health penalty associated with being a black male in all years and for time-varying threats to identification such as national trends in incarceration and unemployment that affected all black men. 28 Similarly, although access to care and insurance coverage for black men differed from other groups in this period, any time-invariant geographic differences in these factors are absorbed by the race-gender-location fixed effects. Location-year effects net out any time-varying health advantages or disadvantages associated with geography that affected all Americans, such as the rollout of Medicare and Medicaid and their various expansions, although we note that there is no major expansion or contraction of public insurance in or around 1972 that would serve to confound interpretation of our results. Because we also condition on supply-side healthcare measures in the mortality regressions, interacted with group indicators, our specification accommodates changes in healthcare supply that affected black men in particular. If our attempts to control for these changes are inadequate, most policy changes coinciding with the timing of the disclosure served to increase access for disadvantaged populations, particularly in the South, and would therefore bias our estimates towards zero. 29

Together, these controls limit the scope for unobserved factors to those affecting only black men, but not black women or white men, in closer proximity to Macon County, Alabama, and only after 1972.

V.A. Event Study Estimates

We first present the results of event study versions of equations (2) and (3) in which we generate a coefficient for the interaction of proximity with black and male indicators for every year, each relative to 1972, as well as a coefficient for proximity interacted with a black indicator in each year and a coefficient for proximity interacted with a male indicator in each year, again relative to 1972. Specifically, we estimate:

and a similar equation for mortality. I t = n is an indicator for each year (other than 1972), such that each β coefficient represents the interaction of proximity and group indicators in year n .

Figure IV , Panel A plots estimates of β 1 , the difference across genders in the racial gap in healthcare utilization as a function of distance from Macon County, Alabama, relative to the difference in 1972, along with 95% confidence intervals. Panel B plots estimates of β 2 , the gender gap in health care utilization for whites as a function of distance from Macon County, Alabama, relative to 1972. Panel C plots estimates of β 3 , the difference in health care utilization for black women versus white women as a function of distance from Macon County, Alabama, relative to 1972. The set of pre-1972 β 1 coefficients are statistically indistinguishable from zero, with the exception for the first year (1969), but there is a sharp, statistically significant and sustained change beginning in 1972. Such an abrupt discontinuity after 1972 is not seen in the dynamic plot of β 2 or β 3 coefficients, providing evidence that we are not capturing a generic, location-based shock that affected other groups.

Notes : Event study coefficients from versions of equation (4) . Panel (A) plots the β 1 coefficients on the interaction of proximity, an indicator for black, an indicator for male, and a year indicator. Panel (B) plots β 2 coefficients, the interaction of proximity, an indicator for male, and a year indicator. Panel (C) plots β 3 coefficients, the interaction of proximity, an indicator for black, and a year indicator. The dependent variable for Panels (A) through (C) is the number of outpatient visits within the last 12 months. The sample includes non-veteran black and white men and women ages 45–74 and covers the period 1969–1977. Data are from the harmonized version of the National Health Interview Survey (NHIS) available from IPUMS and merged with restricted identifiers for use in the RDC. Panels (D) – (F) plot the β 1 , β 2 , and β 3 coefficients for the outcome of (log) age-adjusted chronic mortality constructed biennially. Mortality data are from the compressed mortality files from the CDC and cover the period 1968 to 1987. The unit of observation is the state economic area (SEA), and the sample includes black and white men and women ages 45–74 who died in the United States. Each estimate is relative to either 1972 (vertical dashed line in Panels (A) – (C)) or 1972/1973 (vertical dashed line in Panels (D) – (F)). See Table I notes, text and Appendix for further details.

** p<0.05.

Panels D through F of Figure IV contain the event studies for mortality. (Recall that the mortality data have been grouped to measure biennial averages and thus results are relative to 1972/1973.) Just as in Panel A, the plotted β 1 coefficients in Panel D are not statistically significant in the pre-disclosure years. After the disclosure of the Tuskegee Study, however, the differences in age-adjusted chronic mortality rates for black men relative to white men, compared to black women relative to white women, (or black men relative to black women, compared to white men relative to white women) increase with proximity to Macon County, Alabama, as indicated by the positive and statistically significant β 1 coefficients for years after 1973. Panels E and F, which plot the β 2 and β 3 coefficients for mortality, do not demonstrate an abrupt change in 1972. 30

V.B. Main Estimates

The event studies contained in Figure IV are consistent with the notion that the Tuskegee disclosure had an impact on both health-seeking behaviors and mortality. To provide a summary measure of the impact of the Tuskegee Study revelation, and to subject our results to a battery of placebo and other robustness checks, we move to reporting the results of equations (2) and (3) .

Table I reports the β 1 , β 2 , and β 3 coefficients in equation (2) for outcomes related to both health seeking behavior and mortality. We report four utilization outcomes of interest: how many outpatient physician interactions an NHIS respondent reported in the last 12 months ("Number Outpatient Visits"), whether an individual reported any outpatient visit with a physician in the last 12 months ("Any Outpatient Visit"), whether an individual reported having been admitted to a hospital in the past 12 months ("Any Hospital Admission"), and the number of nights spent in the hospital in the past 12 months ("Number Nights in Hospital"). We report four mortality outcomes of interest in Table I columns (5) to (8): the log and level of age-adjusted all-cause mortality and the log and level of age-adjusted chronic mortality for adults 45–74 years of age.

Baseline Estimates Utilization and Mortality

Notes : OLS estimates of equations (2) and (3) . Panel (A) presents outcomes on utilization. Utilization data are from the harmonized version of the National Health Interview Survey (NHIS) available from IPUMS and merged with restricted identifiers for use in the Restricted Data Center (RDC) and cover the period 1969–1977. Post is an indicator variable equal to 1 in the years following 1972. The unit of observation is the individual, and the sample includes non-veteran black and white men and women ages 45–74. In column (1) the outcome is the number of outpatient physician interactions in the past 12 months. In column (2) the outcome is an indicator variable for any outpatient physician visit in the last 12 months. In columns (3) and (4) the outcome variables are any hospital admission and the number of nights in a hospital, respectively. Panel (B) presents outcomes on mortality. Mortality data are from the compressed mortality files from the CDC and cover the period 1968–1987. The unit of observation is a demographic group within a state economic area (SEA) and the sample includes black and white men and women ages 45–74 who died in the United States. Rates are constructed biennially, and post is an indicator equal to 1 in the years following 1972/1973. In columns (5) and (6) the outcomes are the log and level of age-adjusted mortality from all causes, respectively. In columns (7) and (8) the outcomes are the log and level of age-adjusted chronic mortality, respectively. In addition to the listed fixed effects, utilization regressions control for age, education, marital status, urbanization, whether the respondent has a telephone and income. Mortality regressions include controls for the log of total health (e.g. Medicaid and Medicare) expenditures, the log of Social Security expenditures, the density of hospitals, hospital beds and physicians and the presence of community health centers. Regressions using NHIS data are weighted using provided survey weights. Standard errors are clustered at the state level or SEA level.

Estimated coefficients in column (1) of Table I indicate that black men experienced sharp declines in the probability of visiting a doctor in the years following 1972 as a function of their proximity to the Tuskegee Study’s location. These estimates indicate that a standard deviation increase in proximity to the study’s home county was associated with reduced outpatient interactions of 0.9 visits per year — approximately 22% of the pre-disclosure black male sample mean. From column (2), a one standard deviation increase in proximity to Macon County, Alabama, was associated with a 2.5 percentage point decline in the probability of having an outpatient doctor’s visit, approximately 4% of the sample mean.

For hospitalization outcomes, estimates for β 1 in column (3) of Table I indicate a reduction in the probability of hospital admission for black men after 1972 of 1 percentage point per standard deviation of geographic distance. These results, although not statistically significant, indicate a post-Tuskegee Study disclosure reduction in acute medical care of 7% of the pre-disclosure mean. Although hospital admission rates went down, column (4) of Table I indicates black men appear to have had more advanced illness on presentation as reflected in longer hospital stays: black men experienced an increase in duration of stay of 0.5 nights per standard deviation. These estimates are large, representing 22% of the pre-1972 sample mean.

In Appendix Table A.2 , we estimate this baseline equation on another healthcare utilization outcome less likely to have been affected by the Tuskegee disclosure: dental visits over the last 12 months. This outcome is available for a slightly truncated period of time (1969–1975), and shows black men in closer proximity to Macon County, Alabama, are slightly more likely to visit the dentist after 1972, although the estimated coefficient is not statistically significant. This result provides suggestive evidence that racial gaps in other forms of care stabilized after 1972 and that relative avoidance was specific to institutions most reminiscent of the Tuskegee Study.

In columns (5) and (7) of Table I , we estimate that a one-standard deviation increase in proximity to Tuskegee was associated with a post-1972 increase in both all-cause and chronic-cause age-adjusted mortality for black men of 3.7 and 4.5 log points, respectively. When we estimate the model in levels, we find a one standard deviation increase is associated with 1.1 more deaths from any cause per 1000 population (column (6)) and 0.8 more deaths from chronic causes per 1000 population (column (8)). Based on our estimates, the elasticity of all-cause age-adjusted mortality with respect to physician visits ranges from 0.14 to 0.18; in other words, a 1% decrease in physician visits would increase mortality by approximately 0.14 – 0.18%. 31 We view these estimates as an upper bound since men might have not only stopped interacting with physicians, they might have also delayed going to the hospital or heeding public health messaging around smoking, for instance (see Appendix Table A.2 column (2)). However, this value is consistent with similar estimates from Medicare and community health center expansion. 32 Notably, we do not observe an effect of the Tuskegee disclosure on mortality rates from acute causes of death associated with violence, accidents, or other external causes (see Appendix Table A.6 ). In unreported results, the largest impacts appear to come from deaths due to cardiac conditions, diabetes, and respiratory diseases.

In almost all cases, estimates of β 2 and β 3 are insignificantly different from zero, implying no systematic post-1972 change in the gender gap in mortality for whites or the racial gap in mortality for women as a function of proximity to Macon County, Alabama. The estimated value of β 2 is positive and significant for the log mortality outcomes, but the significance of the coefficient belies two important observations. First, there is no change in the trajectory of the β 2 coefficient in 1972 (see Figure IV , Panel E). Rather, there is a low, positive rate of growth in the geographic mortality gradient for white men compared to white women with a slope an order of magnitude smaller than β 1 . Second, unlike the β 1 effect, the β 2 effect is not centered on Macon County, Alabama, as demonstrated in Appendix Figure A.5 .

V.C. Heterogeneous Effects

In Table II , we explore heterogeneous effects by splitting the sample in various ways and reporting estimates of β 1 , β 2 , and β 3 for these subsamples. First, we explore the roles of income and education by dividing the sample at the median of black male household income (columns (1) and (2)) and at the median of black male education (columns (3) and (4)). Because the entire sample is divided at the black male median, above- and below-median samples are not equally sized. In both cases, we conjecture that black men lower on the socioeconomic ladder would respond more strongly to the Tuskegee Study disclosure if the channel for utilization effects is empathy or salience. Indeed, although the estimates of β 1 are negative and significant for both income groups, the point estimates for the effect of the Tuskegee disclosure on the health seeking behavior of poorer, less educated black men are significantly distinguishable from higher income, better educated black men at the 1% level. Black men in the lowest 50 th percentile of the income distribution reduce their utilization by approximately 3 times more than black men in the top half of the income distribution. At the same time, black men with below-median education reduced their utilization by 1.9 visits per standard deviation of proximity to Macon County, Alabama, while the upper 50 th percentile of the education distribution exhibits a point estimate of approximately zero.

Heterogeneous Effects, Utilization

Notes : OLS estimates of equation (2) assessing heterogeneous effects by income level, education level, black doctor prevalence, and marital status. Specifically, in the first two columns we divide the sample by median black male income. In the following two columns we divide the sample by median black male education. In the next two columns, we calculate black physicians as a percentage of all physicians using occupational data from the 1970 Census and bifurcate states as above or below median on this dimension. In the last two columns, we divide the sample by whether the survey respondent was married. Utilization data are from the harmonized version of the National Health Interview Survey (NHIS) available from IPUMS and merged with restricted identifiers for use in the Restricted Data Center (RDC) and cover the period 1969–1977. Post is an indicator variable equal to 1 in the years following 1972. The unit of observation is the individual, and the sample includes non-veteran black and white men and women ages 45–74. The outcome variable across all panels and columns is the number of physician interactions in the last 12 months. In addition to the listed fixed effects, individual-level controls in every specification for utilization include indicator variables for educational status, income, age, marital status, telephone ownership, and rural/urban status. Regressions are weighted using provided survey weights. Standard errors are clustered at the state level.

Next, we examine the moderating effect of black physicians on our baseline results in columns (5) and (6) of Table III . We hypothesize that the availability of a black physician would have reduced the rate at which black men downgraded their expectation of encountering a "good" doctor. For these results, we utilized data on the number of black and white physicians in each U.S. state from the 1970 U.S. Census of Population ( U.S. Census Bureau 1970 ). Importantly, these counts are measured before, and are therefore not endogenous to, the 1972 disclosure. When we split the sample by places above and below the median number of black doctors (as a percentage of all doctors), we find suggestive, but weak, evidence for a moderating effect of black doctors. The coefficient for locations above the median is smaller than that for locations below this median, although these differences are not statistically significant. 33

Alternative Measures of Proximity, Robustness Checks

Notes : OLS estimates of equations (2) and (3) . Panel (A) presents outcomes for outpatient visits. Utilization data are from the harmonized version of the National Health Interview Survey (NHIS) available from IPUMS and merged with restricted identifiers for use in the Restricted Data Center (RDC) and cover the period 1969–1977. Post is an indicator variable equal to 1 in the years following 1972. In columns (1) through (4) the outcome is the number of outpatient physician interactions in the past 12 months. Columns (1) and (2) use an alternative measure of proximity – the fraction of black migrants from Alabama – instead of geographic proximity to Tuskegee. Alabama is excluded from these regressions. Column (2) is identical to column (1), but restricts the sample to the South. Columns (3) and (4) both use geographic proximity to Tuskegee as an instrument (as in Table I ). Column 3 restricts the sample to the South, and column (4) uses the placebo outcome of children’s utilization. Panel (B) presents outcomes for mortality. Mortality data are from the compressed mortality files from the CDC and cover the period 1968 to 1987. The unit of observation is a demographic group within a state economic area (SEA) and the sample includes black and white men and women ages 45–74 who died in the United States. Rates are constructed biennially, and post is an indicator equal to 1 in the years following 1972/1973. In columns (5) and (6) the outcome is log age-adjusted chronic mortality, and fraction of black migrants from Alabama is used as the measure of proximity. Column (6) repeats the specification in (5), restricting the sample to the South. Column (7) restricts the sample to the South and uses geographic distance to Tuskegee. In column (8), the outcome variable is the level of age-adjusted child mortality. Regressions using NHIS data are weighted using provided survey weights. Standard errors are clustered at the state level or SEA level.

Last, we divide the sample by marital status. In the absence of individual birth histories in the NHIS, we use marital status as a proxy for whether or not a woman had given birth. By 1960, 97% of all births were in hospitals ( Feldhusen 2000 ), and unmarried women had fewer children compared to married women. 34 Thus, if marriage is a proxy for more childbirth-related experience with the healthcare sector, β 2 for unmarried black women should be more similar to β 1 , the coefficient for black men. These results are tested in columns (7) and (8) of Table II . In estimates for β 1 , we find that unmarried men have a more negative response to the news of the Tuskegee Study than their married counterparts, though the difference is relatively small and not statistically significant. But unmarried black women, represented by estimated coefficients on P s · I t post · I r black in column (8) of Table II , respond differently from married black women in column (7), both in sign and magnitude. Mirroring the behavior of black men, unmarried black women reduce health provider interactions in proportion to their proximity to Macon County, Alabama, whereas married black women continue to exhibit convergence in the South. For both married and unmarried women, the size of the coefficient is about a third of that for black men, albeit with opposing signs for married women.

VI. Threats to Identification and Robustness Checks

We perform several tests to bolster a causal interpretation for our results. First, we test the robustness of our estimates by incorporating migration networks as an alternative measure of proximity and demonstrating similarly signed and statistically significant estimates. Second, we use placebo locations to show that the main results are specific to gradients of proximity to Macon County, Alabama. Third, we use placebo populations to demonstrate that the main results for both utilization measures and mortality rates are not observed when we estimate the baseline equations on younger population samples. We also show that our results are robust to a South-only sample; to dropping all control variables; to limiting to non-South observations; and to parametric estimating equations that allow for trends in unemployment and incarceration in the mortality specifications. We discuss the findings of the main robustness checks below, and the remainder are described in the Appendix .

VI.A. Alternative Measures of Proximity

The reduction in healthcare utilization and uptick in mortality for black men as a function of geographic proximity to Macon County, Alabama, is also apparent using an alternative measure of proximity. Table III , Panel A reports these checks for the utilization results regarding the number of physician interactions and Panel B provides analogous results for log age-adjusted chronic mortality. In both cases, we replace the baseline proximity measure, geographic proximity to Macon County, Alabama, with the percentage of 1935–1940 black migrants to a particular state or SEA who originated in Alabama. (All Alabama SEAs and the state of Alabama are excluded from this analysis.) We observe statistically significant differences in the post-1972 utilization of primary healthcare and in the post-1972 mortality rates for black men as a function of this variable as well. Specifically, we estimate that a 10% increase in the share of black migrants from Alabama reduces utilization by 1 interaction per year and increases mortality by approximately 2%.

VI.B. Permutation Tests

To test whether the geographic gradients documented in our baseline interacted DDD results are specific to distance from Macon County, Alabama, we run placebo regressions, replacing the baseline proximity measure (proximity to Macon County, Alabama) with proximity to the geographic centroid of every other state or SEA and re-estimating the model. These regressions serve as placebo tests, evaluating whether we find the same (or stronger) utilization effects as a function of the gradient to other locations in the U.S. Figure V presents the distribution, in histogram form, of the estimated values of β 1 in each of these tests when the outcome is the intensive margin of primary care utilization (Panel A) and log age-adjusted chronic mortality (Panel B). The vertical line indicates the estimated coefficient from Table I when the proximity measure is the baseline proximity to Macon County, Alabama. In both cases, the value of the Macon County estimate is greater (in absolute value) than 96% of placebo estimates; other outcomes exhibit similar patterns.

Notes : Frequency of the “false” β 1 coefficient estimated using distance from every other state (exclusive of Alabama) or SEA (exclusive of the one containing Macon County) in the sample and estimating equation (2) in Panel (A) or equation (3) in Panel (B). The vertical line denotes β 1 from baseline estimates using the true treatment distance (to Macon County, Alabama) as reported in Table I .

For the mortality results, we can also display heat maps of the coefficient estimates of β 1 as well as β 2 and β 3․ . These results, contained in Appendix Figure A.5 , Panel B, demonstrate that the handful of locations where the estimates for β 1 are greater than those using proximity to Macon County, Alabama, are also close geographically and thus highly correlated with the treatment. The coefficients for β 2 and β 3․ using these alternative proximity measures exhibit a far smaller range of estimate values. For β 2 , these values are largest in the North Central states, while β 3․ values are actually smallest in the U.S. South.

VI.C. Robustness Checks

To evaluate whether the paper’s measured impacts simply reflect a general southern effect, columns (2), (3), (6), and (7) of Table III restrict the analysis sample to southern residents only. This reduces the scope for identification threats to things correlated with geographic proximity to Macon County, Alabama, in particular, and not to the South in general. The estimated value of β 1 is relatively unchanged in these specifications compared to our baseline estimates, particularly when using geographic proximity as the treatment variable. In Appendix Table A.3 , we include additional robustness checks for the utilization and mortality outcomes, including dropping the South entirely and adding interactions between region fixed effects and post, black, and male indicators. Results are similar to those presented in Tables I and III .

We next limit the sample to children under 14 years of age for both mortality and utilization results. The post-1972 difference in outpatient care for black and white male children exhibits no geographic gradient, nor does the difference in utilization for black male and black female children as evidenced by coefficients statistically indistinguishable from zero in column (4) of Table III . For mortality outcomes, there is no differential change in the mortality rate of black male children after 1972 as a function of proximity to Macon County, Alabama, although male children and black children, in general, experienced lower death rates along this geographic gradient. This result is based on a mortality outcome in levels (instead of logs) due to the large number of zeroes, but caution should still be used in interpreting these results given the small death counts compared to older age groups. The non-result for black male children is consistent with both a lower salience of the study’s abuses for younger children and with results showing that black married women were seemingly unaffected by the study’s disclosure. Although the perceptions of their fathers could feasibly have affected the demand for children’s healthcare utilization, the non-result here may indicate that decision-making for children at this time was mostly driven by maternal preferences. Given these results, the scope of identification threats is narrowed substantially to those factors correlated with the primary care utilization and mortality rates of older black men centered on Macon County, Alabama, after 1972 which did not affect child mortality or children’s healthcare utilization.

VII. Channels

Our measure of how much trust one has in their doctor comes from the GSS, a repeated cross section extending from 1972 to the present. The earliest year questions were asked about doctors was 1998, when several questions were included. In particular, participants were asked about whether “doctor’s judgment trusted" and whether "doctors deny me the treatment needed". As a placebo outcome, we also examine respondents’ views on whether people, in general, can be trusted. 35 Although we do not have data for both before and after the disclosure, we can test whether individuals living closer to Macon County, Alabama, exhibit greater post-disclosure mistrust. For this analysis, we ask whether there is a racial (gender) gap in medical trust that varies across genders (races) as a function of proximity to Macon County, Alabama. The estimating equation for survey responses for individual i residing in state s of race r and gender g is given by:

where P s is proximity to Macon County, τ represents a current state of residence fixed effect, and θ denotes race-by-gender fixed effects. State fixed effects ensure that β coefficients capture the geographic gradient in mistrust for each demographic group net of state-specific attitudes common across all groups. The sample includes individuals at least 10 years of age at the time of the disclosure. 36 X contains age, education, and marital status fixed effects. Standard errors are clustered at the level of treatment (state of residence). The results, contained in Table IV , demonstrate that black men exhibit a strong, statistically significant geographic gradient in mistrust of doctors and similar (though not statistically significant) concern regarding treatment denial. A one standard deviation increase in proximity to Macon County, Alabama, is associated with a 14 percentage point increase in medical mistrust and a similar increase in treatment denial suspicion among black men as compared to white men, net of such racial gaps for women. Note that β 2 (the geographic gradient in mistrust for white men as compared to white women) and β 3 (the gradient for black women compared to white women) are often oppositely signed and not significant. It is not the case that black men closer to Tuskegee are simply less trusting; β 1 in column (3) where the outcome is general mistrust is opposite signed and not statistically significant.

Effect of Tuskegee on Beliefs About Medical Care

Notes : OLS estimates of equation (4) . The data are from the General Social Survey for the year 1998. The sample contains black and white males and females at least 10 years old in 1972. The outcome variable for column (1) is whether the respondent disagrees with the statement that doctors can be trusted. The outcome variable in column (2) is whether the respondent believes they will be denied needed treatment by the medical profession. The outcome variable in column (3) is general mistrust (whether people, in general, can be trusted). In addition to the controls listed above, every specification includes indicator variables for age categories, marital status, state of current residence fixed effects, and indicators for being black, male, and the interaction. Standard errors are clustered at the state of residence level.

Finally, we have posited the impact of Tuskegee would be more poignant for individuals who had limited experience with the healthcare sector prior to the disclosure. To isolate the role of experience as a mitigating factor on belief formation, we examine the post-1972 differences in healthcare utilization between men who have served in the military versus those who have not, again as a function of proximity to Macon County, Alabama. To do so, we drop women from the utilization sample, add back veteran men, and replace I g male in equation (2) with an indicator variable for whether an individual was a non-veteran, i.e., never drafted or entered into the military.

Estimated coefficients from this modified specification, contained in Table V , indicate a marked geographic gradient in the veteran/non-veteran gap in primary care utilization in the years following the Tuskegee disclosure. This finding is restricted to black men (as evidenced by the null or oppositely signed β 2 coefficient). Although black men’s utilization declined overall (see β 3 in columns (1) and (2)), this effect was far more pronounced for non-veterans. For example, veteran black males reduced the number of outpatient visits per year by 0.59 per thousand kilometer proximity to Macon County, Alabama, while nonveteran black males reduced their utilization by about one additional visit per year. 37 There are several possible explanations for this observation, including that veteran black men may have expected doctors to treat them as "veteran patients" rather than as "black male patients" and were therefore less worried about facing discrimination. Nevertheless, the results for veterans are consistent with predictions from the multi-period model wherein past experience with the medical profession dampens the response to the news of Tuskegee.

All Male Sample, Veterans vs. Non-Veterans

Notes : OLS estimates of equation (2) testing differences between “experienced” (veteran) and “less experienced” (non-veteran) males in response to the disclosure of the Tuskegee study. Utilization data are from the harmonized version of the National Health Interview Survey (NHIS) available from IPUMS and merged with restricted identifiers for use in the Restricted Data Center (RDC) and cover the period 1969–1977. Post is an indicator variable equal to 1 in the years following 1972. The unit of observation is the individual, and the sample includes non-veteran and veteran black and white men ages 45–74. The outcome varies across columns and is given by the column heading. In addition to the listed fixed effects and controls in the table, individual-level controls in every specification for utilization include indicator variables for educational status, income, age, marital status, telephone ownership, and rural/urban status. Standard errors are clustered at the state level.

VIII. Effect on Life Expectancy

The paper’s baseline results for the mortality of older adults, aged 45–74, can be converted into predicted reductions in life expectancy. To do so, we use levels of all-cause mortality as the outcome in equation (3) . Predictions based on the full complement of terms, including the interaction of P a · I t post · I r black · I g male multiplied by β 1 ^ , reflect mortality with the Tuskegee Study revelation. Predictions based on equation (3) , but without this product, reflect counterfactual mortality in the absence of the revelation. The average value of these predictions are weighted so that they reflect the mortality patterns of black men given their population distribution circa 1970. These predicted mortality rates allow us to construct abridged, current life tables, in the presence and absence of the Tuskegee revelation, as described in the London Health Observatory Technical Supplement (2010) .

For black men in our sample, the observed life expectancy, conditional on reaching age 45, is 23.7 years. Counterfactual life expectancy in the absence of the calculated treatment effect is 25.2, an increase of 1.5 years. This estimated decrease in the life expectancy of black men attributable to the Tuskegee revelation represents approximately 35% of the racial gap in male life expectancy in 1980 and 25% of the gender gap in black life expectancy at the same juncture ( National Center for Health Statistics 1985 ). As a benchmark for these results, Black et al. (2015) find that migration to the North in the first waves of the Great Migration (1916–1932) resulted in decreased life expectancy at age 65 of at least 1.5 years. Because their most robust analysis is based on Medicare data, these authors do not provide a similar estimate for life expectancy at age 45. Another useful benchmark is the hypothetical removal of smoking, which has been projected to increase life expectancy of an 18-year old by 1.7 years ( Stewart, Cutler, and Rosen 2009 ) .

IX. Conclusion

The Tuskegee Study was one of the most egregious examples of medical exploitation in U.S. history. Our estimates indicate that the years immediately following the study’s disclosure brought significantly lower utilization of both outpatient and inpatient medical services by older black men in closer geographic proximity to the study’s subjects. The effects are particularly heightened among less-educated and lower income men, a socioeconomic profile shared by the men targeted by PHS investigators. Moreover, the reductions in healthcare utilization we document paralleled a significant increase in the probability that older black men died before the age of 75. The data indicate no corresponding effects for younger black males or for white males or black women. Our results are robust to accounting for a wide range of policies, economic forces, and individual characteristics thought to shape health behaviors. These findings underscore the importance of trust for economic relationships involving imperfect information, including in the provision of medical care.

Although our study has focused on how Tuskegee generated mistrust and shaped demand for healthcare services by blacks, the Tuskegee example also revealed racial inequities inherent in the provision of healthcare. A modern literature indicates these inequities persist. For example, Hoffman et al. (2016) document false beliefs among medical students and residents regarding race-based biological differences in pain tolerance that resulted in racial differences in treatment. As long as biased beliefs, policies, and practices are still prevalent in the U.S. healthcare system, mistrust is a rational response that may continue to contribute to health disparities.

Supplementary Material

* We thank the editor, Lawrence Katz, and four anonymous reviewers for constructive comments that improved the paper. For detailed feedback at an early stage of our work, we thank Nathan Nunn, Arun Chandrasekhar, Martha Bailey, Pascaline Dupas and William Collins. We are also grateful to John Parman, Achyuta Adhvaryu, Rebecca Diamond, Claudia Goldin, Melanie Morten, Mark Duggan, Mark Cullen, Melissa Dell, Nancy Qian, Ran Abramitzky, Rema Hanna, Grant Miller and seminar participants at NBER DAE, NBER Cohort Studies, University of Tennessee, Vanderbilt Health Policy, Carnegie Mellon and University of Pittsburgh Joint Seminar, University of Copenhagen, University of Pennsylvania Health Policy, ASSA 2016, PACDEV 2016, Berkeley Population Center, University of Chicago Harris School of Public Policy, Stanford Health Policy, University of California-Davis, University of Maryland Population Center, Stanford Social Science and History Workshop, University of South Carolina, Florida State University, University of Richmond, Highland Hospital of Oakland, Dartmouth College, Harvard Medical School, University of Michigan, University of California Berkeley, Simon Fraser University and CIREQ Montreal for constructive comments. We thank the CDC for providing access and the administrators at the Atlanta and Stanford Census Research Data Centers for their help in navigating the restricted data. We thank Michael Sinkinson, Martha Bailey, Andrew Goodman-Bacon and Walker Hanlon for sharing data and methods. Mario Javier Carrillo, Anlu Xing and Afia Khan provided excellent research assistance.

1 For a comprehensive review of racial inequalities in U.S. medical care, see Institute of Medicine (2003) .

2 In our model of medical mistrust, we consider Bayesian updating as the benchmark, although behavioral models could deliver similar results (e.g. Becker and Rubinstein 2011 ).

3 Syphilis can also be transmitted mother to child and cause severe congenital problems, including stillbirth.

4 This lack of minority representation in clinical trials may have important spillover effects, including on the speed and direction of innovation for ailments that heavily afflict their communities. See Hamilton et al. (2016) for a structural estimation of these losses.

5 Vann Newkirk II (2016) highlights the cultural role of Tuskegee, even in the absence of specific details, saying: "Like me, several other black men that I interviewed throughout the rural South were either inculcated from birth or from experience living in 1972 with the idea that the American health-care system is not for them. Young boys and old men felt it alike, and even if the Tuskegee Study was not known by name, it was a definite part of a vivid shared cultural memory. References to injection of ‘bad blood’, government research, or conspiracies about HIV were clearly influenced by details of Tuskegee, even if the details weren’t always quite right."

6 For example, 75% of black men believed that "African Americans are more likely to be treated poorly in health research studies" compared to 58% of black women and 37% of whites. Sample sizes here are quite small, however, so caution is warranted.

7 Additional beliefs were that "HIV was deliberately created in a laboratory in order to infect black people, that AZT is a plot to poison them, that condom distribution campaigns are a scheme to reduce the number of black babies, and that needle distribution programs are a plot to encourage drug abuse," ( Quinn 1997 ). Similar Tuskegee-attributed mistrust related to the origins of the HIV virus emerged in a 1996 ABC News 20/20 forum and in a 1997 Atlanta-based forum audience.

8 The life expectancy gap between black and white men can be substantially reduced by controlling for stage at diagnosis. See American Cancer Society (2008) and Silber et al. (2014) . For evidence on these racial gaps, see Boulware et al. (2003) ; Wiltshire, Person, and Allison (2011) ; and Hood et al. (2012) .

9 In a 2016 study of low adherence to antiretroviral treatment among HIV-positive black men, researchers documented that 63% of the study’s subjects held a "conspiracy belief", for example that the federal government was responsible for HIV’s introduction into the black population. These beliefs, in turn, were associated with a reduced likelihood of adhering to a physician-prescribed treatment regimen ( Bogart et al. 2016 ). See also Halbert et al. (2009) , Kayaniyil et al. (2009) ; and Laveist, Nickerson, and Bowie (2000) .

10 Blacks were more likely than whites to utilize public and community-based healthcare resources, including charity clinics, public health departments, community health centers, and city and county hospitals and less likely to make use of private and non-profit hospitals. Some of this difference was the result of rapid suburbanization of the white population ( Byrd and Clayton 2002 , p. 391).

11 The level of utilization for black (and white) men is lower than for women in every period. Note that we do not have a continuous series of outpatient utilization data in the pre-1969 period.

12 The Appendix also contains figures for Southerners alone ( Appendix Figure A.1 ). In Appendix Figure A.2 , younger black men exhibit an increase in relative mortality beginning in the 1980s. This is likely due to the evolving HIV/AIDS crisis in this community. Appendix Section V.A . contains more detail.

13 The question we use regarding outpatient interactions is unchanged between 1969 to 1981. In 1978 the race categorization changed, with mutiple categories included, making 1977 a natural stopping point. But we have also extended our analysis to 1981 (the year the question on doctor visits changes and harmonization is no longer possible) and obtain similar (though not disclosed) results. Inpatient (hospital) utilization data is available prior to 1969 and the broad patterns are discussed in Section II.B. Our results are robust to the inclusion of these earlier data. IHIS is now known as IPUMS Health Surveys: NHIS.

14 We accessed the IHIS harmonized data, with location-based treatment variables (geographic proximity and migration shares) attached, inside Census Research Data Centers (RDCs) at Atlanta and Stanford. In later years, the NHIS data have been linked to mortality files, but these linked data are not available for our study period.

15 The NHIS data do not contain consistent measures of individual health insurance coverage over our time period; however, in all mortality regressions we control for local, time-varying Medicare and Medicaid expenditures, interacted with race and gender. Because phone calls to medical providers were counted as physician interactions, all NHIS regressions control for whether the household has a telephone.

16 Recent examples include Almond, Chay, and Greenstone (2006) ; Alsan and Goldin (2015) ; Bhalotra and Venkataramani (2011) ; Bailey and Goodman-Bacon (2015) ; and Goodman-Bacon (2015) .

17 State economic areas are groups of counties reflecting relatively homogenous areas within states. Results using county-level and annual mortality rates are in Appendix Table A.5 .

18 Some examples include blood pressure and glucose control for the management and prevention of cardiovascular and diabetic complications such as heart attack, stroke, and kidney failure, as well as counseling on prevention, early detection, and treatment of cancers. See Appendix Section IV for a discussion of medical and public health innovations over this time period.

19 Briefly, to construct age-adjusted rates, age-specific mortality rates, calculated as deaths per 1000 relevant at risk population, are weighted by a reference population. We follow the demographic literature and use the standard 1940 population for weighting. See the Appendix for further details.

20 After 1987, the paper’s conclusions are likely to be compromised by the evolving HIV/AIDS epidemic. But in the 1981–1987 period, HIV/AIDS was a nascent health threat, particularly among older black men. In this period, there were roughly 9,000 AIDS-infected men older than 45, of which perhaps 25% were black ( CDC 2001 ). Young people were at higher risk of acquiring HIV, and by 1994 AIDS had become the leading cause of death among black males aged 25–44. This increased mortality among younger black males in the late 1980s is apparent in Appendix Figure A.2 .

21 The Appendix contains a fully-specified model of how prior beliefs, prior experience with the medical profession, shared characteristics with the Tuskegee study subjects, and proximity to the study interact to determine health-seeking behavior

22 Data from the 1979 Survey of Black Americans support the notion that black men from the South identified more with the men from the study. When asked "how close does the respondent feel to black people who are poor", 78% of black men born in the South answered they felt "very close" compared to 65% of men born elsewhere ( Jackson and Gurin, 1999 ). We thank Trevon Logan for pointing out this source. As another example, although the Rodney King beating, which took place in March 1991, was widely publicized in many media markets, opinions on the police force shifted most markedly for black men. Though we lack geographic identifiers in the survey data, comparing 1989 and 1992 polling data, the percentage of people who disagree with the statement: "These days police in most cities treat Blacks as fairly as they treat Whites" jumped 18% among black men, 7% among black women, and declined among whites ( ABC 1992 ; NBC 1989 ).

23 We exclude the SEAs containing Los Angeles and San Francisco from the analytic sample. These two cities hold most of the black population in the West region, and they are more connected to Alabama (via migration) than our distance-based proxy for study salience would suggest (see Appendix Figure A.7 ). Our migration-based results are robust to the inclusion of these two cities. See Appendix Table A.5 , Column (1).

24 Using later census years would preclude us from using the detailed geographic information publicly available for 1940. We normalize by black migrants for two reasons. First, doing so gives a measure of what percentage of new information is coming from Alabama. (If the denominator was the black population, for example, the new information measure would be diluted.) Second, and more importantly, we only observe the migration variables in the five year period of 1935 to 1940. But the migration of this generation of men extended from 1918 up through 1960. The patterns of migration were persistent over time, so even though the 1935–1940 measure is not an accurate measure of the absolute number of migrants, the relative measure (those from Alabama divided by all migrants) is a good proxy for how connected the stock of black residents in 1972 would have been to Alabama, given several decades of migration preceding 1972.

25 Age-adjusted mortality rates for older adults (ages 45–74) are measured at the level of each SEA (denoted a ) for each race ( r ) and gender ( g ) combination: black males, black females, white males, white females. Bins in the middle of the country with few older black men were paired.

26 The estimating equation is Y gat k = α + β k ( I g male · I t post ) + γ k ( I t post ) + ϕ a , male + ε rat for k ∈ [1, K ], where g reflects gender.

27 Specifically, we use max(distance)–(distance s ) so that locations farthest from Tuskegee receive a proximity value of 0. Distance is measured at the state level in the utilization data and at the SEA or county level for the mortality data. In the mortality data, distances are measured from the geographic centroid of each SEA to the centroid of Macon County, Alabama. For the NHIS outcomes, which are available at the state level, we use county-level black adult population statistics and geographic county centroids to create black population-weighted state centroids which are used to construct proximity as above. These centroids represent the average latitude and longitude of black individuals in each state based on the black population of counties ( Haines 2010 ).

28 In the Appendix , we show that our results are robust to controls for local measures of incarceration and unemployment as well. See Appendix Table A.5 columns (3) and (6).

29 We find no evidence that expenditure levels for these social programs exhibited a temporal or geographic pattern mirroring our main empirical results. In Appendix Table A.7 , both hospital beds per capita and Medicare expenditures show a continuous increase over this time period, and more so in locations closer to Tuskegee. But there is no trend break in 1972 that would have induced utilization and mortality changes in that year. (See Appendix Figure A.8 .)

30 Due to data limitations, we cannot acurately generate a longer pre-period for the mortality or utilization results. NCHS mortality data are available for earlier years, but the 1960 U.S. Census of Population, from which population counts would need to be derived for such an exercise, only reports local population counts by age and gender for the nonwhite population. In an attempt to construct a denominator for black mortality rates for years prior to 1968, we limit the sample to locations where at least 60% of the 1960 non-white population was black. (Our results are robust to other choices of this cutoff.) Extended event study results (in Appendix Figure A.3 ) generated under these limitations also demonstrate insignificant and relatively flat pre-period estimates of the black male mortality penalty as a function of proximity to Macon County, Alabama.

31 The elasticity was obtained by dividing a one standard deviation percent change in all-cause mortality by a one-standard deviation change percent change in outpatient physician interactions. The range is due to the inclusion or exclusion of veteran males from the utilization estimates; the higher elasticity is from a sample including veterans (whose utilization response was more muted).

32 Bailey and Goodman-Bacon (2015) show that exposure to a community health center in one’s county of residence between 1965 and 1974 reduced adult all-cause mortality by as much as 2%; implying an elasticity of approximately −0.18. Lichtenberg (2002) reports an elasticity of −0.095.

33 We do not find the same pattern if we use black physicians per black capita, suggesting that black men responded to the "whiteness" of the local medical profession, rather than to the availability of a black physician.

34 In 1965, approximately 75% of black infants were born to married mothers ( Akerlof, Yellen, and Katz 1996 ). In related work, Thomasson and Treber (2004) find that the hospitalization of childbirth in the 1930s and, in particular, the introduction of sulfa drugs may have disproportionately reduced maternal mortality among black women, despite the segregation of hospitals and otherwise racially inequitable access. Because older women in our sample would have given birth between 1925 and 1960 (roughly), a substantial share of them would have benefited from this "positive" healthcare experience.

35 Individuals who replied "no" or "don’t know" to the question of whether people can be trusted were coded as 1 and those who replied "yes" were coded as 0. A similar coding strategy was applied to the outcome variables for medical mistrust (measured on a four point Likert scale) so that the coefficients can be easily interpreted as marginal effects.

36 This implies that age in the sample ranges from 36 to 89, with an average in the mid-fifties. Note that if we restrict to age<10 in 1972, those aged 18 to 35 in our sample, our coefficients on medical mistrust and deny treatment generally have the "wrong sign".

37 Appendix Figure A.9 contains event study coefficients for the within-male comparision.

Contributor Information

Marcella Alsan, Stanford University, NBER and BREAD.

Marianne Wanamaker, University of Tennessee, NBER and IZA.

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• Peter Buxtun: US...

Peter Buxtun: US government employee who exposed racist and unethical Tuskegee syphilis study

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In 1965 Peter Buxtun had just started working as a contact tracer with the Public Health Service (PHS) in San Francisco when he overheard colleagues talking about a syphilis study. Wanting to learn more, he called the PHS office in Atlanta, now part of the Centers for Disease Control and Prevention (CDC). A helpful clerk sent him a large manila envelope crammed with documents. The more Buxtun read, the more convinced he became that the study was racist, unethical, and immoral.

The PHS had launched the Tuskegee Study of Untreated Syphilis in the Negro Male 1 in 1932 in the Tuskegee area of Alabama, where the incidence of syphilis was high. It enrolled 399 infected men and 201 negative control participants, most of whom were illiterate farm workers. The study’s purpose was to observe the natural course of the disease at a time when treatment options were limited.

The PHS told the men that the study was about “bad blood,” not the fact that they were infected with a disease that, by the 1940s, was treatable with penicillin. They were promised medical exams, meals, and burial expenses but …

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Research Implications

After the U.S Public Health Service’s (USPHS) Untreated Syphilis Study at Tuskegee, the government changed its research practices.

In 1974, the National Research Act was signed into law, creating the  National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research . The group identified basic principles of research conduct and suggested ways to ensure those principles were followed.

In addition to the Commission’s recommendations, regulations were passed in 1974 that required researchers to get voluntary informed consent from all persons taking part in studies done or funded by the Department of Health, Education, and Welfare (DHEW). They also required that all DHEW-supported studies using human subjects be reviewed by Institutional Review Boards, which decide whether research protocols meet ethical standards.

The rules and policies for human subjects research have been reviewed and revised many times since they were first approved and efforts to promote the highest ethical standards in research are ongoing.

An Ethics Advisory Board was formed in the late-1970s to review ethical issues of biomedical research. As a result of their work, the 1979 publication commonly known as The Belmont Report summarized the three ethical principles that should guide human research: respect for persons ; beneficence ; justice. From 1980-1983, the  President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research  reported “every two years on the adequacy and uniformity of the Federal rules and policies, and their implementation, for the protection of human subjects in biomedical and behavioral research.” In 1991, federal departments and agencies (16 total) adopted the Federal Policy for the Protection of Human Subjects .

In October 1995, President Bill Clinton created a  National Bioethics Advisory Commission , funded and led by the Department of Health and Human Services. The commission’s task was to review current regulations, policies, and procedures to ensure all possible safeguards are in place to protect research volunteers. It was succeeded by the  President’s Council on Bioethics , which was established in 2001, and then the  Presidential Commission for the Study of Bioethical Issues  established in 2009.

 Related Links

• Facts & Information about Syphilis
• STD Health Equity
• The National Archives – USPHS Untreated Syphilis Study at Tuskegee
• Tuskegee University National Center for Bioethics in Research and Health Care