The prisoners in Indiana would not get sick, so the doctors went looking for a country that would help.

1946
14.6349° N, 90.5069° W

Penicillin changed what was worth asking. Before it, syphilis was treated with arsenic compounds and mercury over months or years, and the treatment frightened people nearly as much as the disease did. By the middle of the Second World War, the new drug was being made in quantity, and it cured both syphilis and gonorrhea in a matter of days. The United States Army, which had lost enormous numbers of duty days to venereal disease in every war it had ever fought, finally had a cure on hand.

What it did not have was a way to stop an infection before it started. That was the open question inside the Public Health Service after the war. If a man was exposed, and something was given to him soon afterward, could he be kept from ever getting sick? Ointments, washes, and post exposure treatments were already in wide use in the military, and nobody could say how well any of them worked. The field data came from soldiers reporting on themselves. A man told the medics what he chose to tell them, and the record was built out of that.

To measure prevention, you have to know the exposure. To know the exposure, you have to arrange it.

In 1943, the Public Health Service began a study at the federal penitentiary in Terre Haute, Indiana. Inmates were asked to volunteer. The terms were explained to them, including the plan to give them gonorrhea and then treat it, and several hundred men agreed. They received a small payment and a certificate of participation for their files. The method was a suspension of gonococcus applied directly to the urethra.

The infections would not take. Some men got sick, most did not, and the results were scattered. A prevention trial needs a disease the researcher can produce on demand, in a known number of people, at a known hour. By 1944 the Terre Haute work had been shut down.

The officers who ran it came away with a conclusion about technique rather than about ethics. Artificial inoculation was unreliable. What the science wanted was normal exposure, the real thing, arranged so the researcher knew exactly who had been exposed and precisely when. There was no place inside the United States where that could be set up.

One of the physicians on the Terre Haute study was John Charles Cutler, a young officer in the Service's venereal disease division. In 1946 he went south.

Guatemala was chosen for practical reasons. Prostitution there was legal and regulated, with registered women examined by government physicians. The country also permitted sex workers to visit inmates inside its prisons, a practice the state tolerated and the prison administered. That combination gave a researcher what Indiana could not: sexual exposure that could be scheduled, documented, and repeated, inside an institution where the subjects were not going anywhere.

The money came through a federal grant. The work was run in cooperation with the Pan American Sanitary Bureau, with the agreement of Guatemalan government ministries, and with the participation of a Guatemalan public health physician who had trained at the Service's venereal disease laboratory in the United States. The institutions involved were the national penitentiary in Guatemala City, an army barracks, and the national psychiatric hospital. Officials at each one signed off.

The penitentiary came first. Women with documented active infections were paid to visit inmates. The men were examined afterward, and blood was drawn, and the results were recorded against names and dates. It was cleaner data than anything the Army had ever collected.

It was also disappointing. The rate of infection through ordinary contact ran low, and low numbers meant the prevention question stayed unanswered. So the design escalated. If a man did not catch the disease from the woman, he was inoculated directly. The skin of the penis or the forearm was abraded with a needle or scraped, and a suspension made from infected tissue was laid into the wound and left under a dressing. Material was introduced into the urethra by catheter. In some cases the suspension was injected. The sequence was worked out by trial: more concentration, longer contact, fresher material, until the infection took.

The barracks were next. Soldiers were brought into the same protocol, and the same escalation followed when ordinary exposure failed to produce the numbers.

Then the psychiatric hospital. The patients there were the least able to refuse of anyone in the country, and the arrangement reflected that. The hospital received supplies it badly needed in exchange for access to its wards. Patients were inoculated with syphilis and gonorrhea and drawn for blood, and some were given no treatment at all so that the untreated course of the disease could be observed. Cigarettes were handed out.

A woman recorded in the files as Berta was a patient there. She was already gravely ill when she was injected with syphilis. In the months that followed her condition worsened, and the record does not show that she received adequate treatment. Late in her illness she was inoculated again, and gonorrheal pus taken from a male subject was placed into her eyes, her urethra, and her rectum. Her eyes filled with pus. She bled. She died within days of that final procedure, and the entry recording her death sits in the same file as the entry recording what was put into her eyes.

Children were used too, though not in the same way. Patients at a national orphanage were drawn for blood as part of the serological work, to test how the diagnostic assays performed across different populations. The records show blood taken from children who had no idea what it was for.

Across roughly two years, about thirteen hundred people were deliberately exposed to syphilis, gonorrhea, or chancroid. Several thousand more were enrolled in the associated blood testing. The stated intention was always that anyone infected would be treated with penicillin, and the drug was available. The records do not show that all of them were.

Everything was written down. Cutler kept meticulous notes, sent regular reports back to his superiors in the United States, and had the whole of it typed and filed. The correspondence went up the chain. The Surgeon General of the United States was briefed on the work, and the observation entered into the record from that discussion was that an experiment of this kind could not be conducted at home.

The program ended in 1948. The funding ran out, the Guatemalan political situation was shifting, and the results had not produced the prevention answer the Service wanted. Cutler came home. Nothing from the Guatemala work was published in the medical literature at the time. No paper, no summary, no report to a journal. The men who knew about it moved on to other assignments, and the files went into boxes.

Cutler stayed with the Public Health Service. In the following decade he worked on the syphilis study at Tuskegee, Alabama, the one that ran on Black men in Macon County and withheld treatment from them for forty years. He later left government for academia and became a professor of public health at the University of Pittsburgh. He spent the rest of his career there. He gave interviews late in life defending the Tuskegee study as sound science. He died in 2003, and his professional papers remained in the university's archive.

In 2010, a historian at Wellesley College, Susan Reverby, was working through those papers while researching Tuskegee. She found the Guatemala records: the protocols, the correspondence, the tallies, Berta.

In October 2010, the President of the United States telephoned the President of Guatemala to apologize, and the Secretary of State and the Secretary of Health and Human Services issued a joint apology. A presidential commission was ordered to investigate, and its 2011 report, titled Ethically Impossible, laid out what had been done and concluded the researchers had understood at the time that it was wrong.

Guatemalan survivors and the families of the dead sued the United States. In 2012 a federal district court in Washington dismissed the case, holding that the government could not be sued for conduct that took place in another country. No one was ever prosecuted. No compensation was paid to the subjects or their descendants by the United States government.

The files had never been classified. They were never sealed, never shredded, never lost. They sat in an open university archive in Pittsburgh, in boxes catalogued under his name, and for years anyone could have asked to see them.