From a reader:
I read your column today, and it has one small error. During the 1930s there was actually a treatment for syphilis: salvarsan. This treatment did work, but it was expensive, hard to administer and had serious side effects. Therefore it wasn’t at all clear whether treating asymptomatic patients was better than doing nothing. The actual history of the Tuskegee experiments is as follows:
1) In the late 1920s doctors decided to test whether treating rural black with salvarsan was medically beneficial and cost effective. In order to do this, they planned to recruit men with syphilis and follow them for six months to get a baseline health status. After that they would treat the men and see if their health improved.
2) Great Depression hits and funding gets cut. The doctors scaled back their project to just following the men to see how untreated syphilis progressed.
Of course, I agree with the general point of your column. But you should correct that error.
Me: I should have been more clear and I regret giving the impression that there were no other options. But I think even this reader (and Wikipedia) exaggerate the effectiveness and desirability of salvarsan, at least from what I’ve read on the subject. Here’s part of Richard Schweder’s discussion of pre-penicillin treatments for syphillis:
The first theme of the counter-narrative suggests that a reasonable person in those circumstances might conclude that participation in the study did not involve a substantial increase in risk to the health of the men involved, and might produce some useful knowledge.
Here is how Benedek and Erlen (2) describe the medical belief and knowledge system of that pre-penicillin era. They suggest that in 1930 there was an urgent sense of the need for more rapidly acting and safer drugs for treating syphilis. They quote the surgeon-general (in 1938) who reports: ‘[S]yphilology of 1925 was a chaos of different regimes of treatment, of different dosages, of private preferences for different variations of the arsenical compounds. There were many piecemeal case studies but no accurate data upon which the scientist could judge the relative efficacy of these methods.’ (p7) They point out that between 1932 and 1946 the conclusion was reached by several investigators that ‘treatment improves the eventual course of syphilis in only a minority of cases’ (p13). They write: ‘However, all of the anti-syphilitic drugs of the 1930s were rather weak, and no dramatically more potent drugs were anticipated. Therefore, particularly detailed knowledge of the range of variability of the therapeutically unaltered course of the disease would be desirable to determine as early as possible whether a new treatment significantly altered its course.’ (p22-23).
Benedek and Erlen present evidence showing the weakness of the 1930s drugs (people receiving little or no treatment did almost as well as those going through a long, expensive, painful and risky treatment). They point out that a major medical and scientific issue at the time was the need for a baseline against which to evaluate the effectiveness of any therapy (all of which were known to be hazardous and therapeutically weak). They suggest that at that time ‘knowledge of the chronic course of syphilis was inadequate to reliably distinguish therapeutic effect after the initial phases of the disease from the variability of its chronic course’ (p2). In other words, the disease was self-limiting or self-correcting in most cases – yet no one knew for which smaller sub-population of patients that was not true or how they could be identified. In addition, it was hard to tell whether arsenical poisoning or any other therapy administered during the early stages of infection, really had a sufficiently beneficial long-term effect.