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TUSKEGEE AND THE HEALTH OF BLACK MEN*
MARCELLA ALSAN AND MARIANNE WANAMAKER
ability 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.
JEL Codes: I14, O15.
∗ 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,
and the National Institute on Minority Health and Health Disparities (Alsan
1R03MD011449). Mario Javier Carrillo, Anlu Xing and Afia Khan provided excellent research assistance.
C The Author(s) 2017. Published by Oxford University Press on behalf of the President and
Fellows of Harvard College. All rights reserved. For Permissions, please email:
journals.permissions@oup.com
The Quarterly Journal of Economics (2018), 407–455. doi:10.1093/qje/qjx029.
Advance Access publication on August 2, 2017.
407
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For 40 years, the Tuskegee Study of Untreated Syphilis in the Negro Male
passively monitored hundreds of adult black men with syphilis despite the avail-
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QUARTERLY JOURNAL OF ECONOMICS
I. INTRODUCTION
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, Xu, and Kochanek 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 cancers (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
1. For a comprehensive review of racial inequalities in U.S. medical care, see
Institute of Medicine (2003).
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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)
TUSKEGEE AND THE HEALTH OF BLACK MEN
409
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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 United States, 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), healthseeking 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 healthseeking 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 nonemergency
medical care, we report results for both all-cause mortality and
chronic disease mortality outcomes.
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QUARTERLY JOURNAL OF ECONOMICS
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).
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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., Singer et al. 2006; Gutsell and Inzlicht 2010) 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
sociodemographic 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,
multiperiod model of belief formation regarding physician trustworthiness implies that, under certain conditions, agents having
previous experience with the medical system, for example, childbearing 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.
TUSKEGEE AND THE HEALTH OF BLACK MEN
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We test these hypotheses using an interacted differencein-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-gendertime, and location-time fixed effects nonparametrically 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 shortand 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 reduced utilization of
routine care (outpatient physician contacts) among older black
males by 0.90 interactions a year, a 22% reduction in utilization
relative to the predisclosure 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
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QUARTERLY JOURNAL OF ECONOMICS
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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 (Almond, Chay,
and Greenstone 2006; Goodman-Bacon forthcoming; 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 post1972 treatment effect of being “black and female” or “white and
male” in closer proximity to Macon County 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 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 article 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
TUSKEGEE AND THE HEALTH OF BLACK MEN
413
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 the one 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 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
3. Syphilis can also be transmitted from mother to child and cause severe
congenital problems, including stillbirth.
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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 (Greif 1989; Knack and Keefer 1997; Fafchamps 2006).
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.
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QUARTERLY JOURNAL OF ECONOMICS
According to Jones (1992), much of the natural history of
syphilis outlined above was known at the time the study commenced:
These incentives included physical exams, hot meals, and burial
stipends that would be paid to their survivors. Most of the men 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 40 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 f …
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