Sexually Transmitted Diseases:
Hook, Edward W. III MD
From the University of Alabama at Birmingham, Birmingham, AL and Jefferson County Department of Health, Birmingham, AL.
Correspondence: Edward W. Hook, III, MD, The University of Alabama at Birmingham, 215 Tinsley Harrison Tower, 1900 University Boulevard, Birmingham, AL 35294-0006. E-mail: email@example.com.
Received for publication January 16, 2013, and accepted January 24, 2013.
No person has influenced US efforts to control sexually transmitted infections (STIs) more than Thomas Parran. First as Commissioner of Health for the State of New York and, subsequently, as the sixth Surgeon General of the United States, Parran provided the foundations for current approaches to control and management of persons with and at risk for STIs. Parran is perhaps best known for his classic book Shadow on the Land, in which he comprehensively outlined the principles of sexually transmitted disease (STD) control for syphilis—promoting timely diagnosis and treatment, screening for unsuspected infection, partner notification, and public education and engagement.1 These same elements have since been modified to accommodate the varied biologic characteristics of different pathogens and, in this way, to guide control efforts for virtually every other STI including HIV. He was likewise ahead of his time in promoting what we now call “sexual health,” targeting lack of public understanding and stigma as major barriers to control of syphilis and other STDs.1 As a policy maker, Surgeon General Parran championed the National Venereal Disease Control Act of 1938, which made public funds available for the first time to support rapid treatment centers designed to provide the most currently available therapy for widespread STDs such as gonorrhea and syphilis.2 Parran also created the National Institutes of Health’s extramural grants programs, which continue to fund so much biomedical research including that directed at control and prevention of STDs.2 All of these remarkable and lasting contributions led me to admire Parran as a personal hero. Consequently, I was dismayed and disappointed to learn that during his tenure as Surgeon General of the United States, Parran also added his approval to recommendations of a Public Health Service Expert Advisory Panel for the Guatemala syphilis and STD studies conducted using federal funds between 1946 and 1948.3
The purpose of this essay is not to defend the abuses of human subjects in Guatemala between 1946 and 1948 which exposed more than 1300 men, women, and children to infectious syphilis, gonorrhea, and chancroid.3 Nor is it our desire to defend any of the leading American scientists who planned, approved, and conducted these studies. The report of the Presidential Commission for the Study of Bioethical Issues makes it clear that throughout the scientific chain of command, there was a clear understanding that the research was not acceptable and breached the propriety and ethics of the day.
At the same time, nor do we pretend to understand processes that guided the thinking of the group who approved and presumably planned the Guatemala studies. There is evidence that, had knowledge of the studies been more public, the work could not have been conducted because of ethical questions that would have arisen. Context, however, although not an excuse, is a consideration, which may have allowed these scientists to rationalize their missteps using the argument that the studies would serve a “greater good.” The studies were carried out at a time when there were more than half a million new cases of syphilis diagnosed in the United States each year and when more than 60,000 children were born with congenital syphilis annually.1 Widespread cultural racism was the norm.4 At the time formal mechanisms for human subjects’ protections were virtually nonexistent, deception was a regular element of scientific studies, and current scientific measures for protection of human subjects were not in use. We suggest that it is because these studies could be performed is precisely why we must remember Parran and these studies—to avoid similar missteps in the future.
It is also important to acknowledge that although the Guatemala studies were the most egregious example, these studies were not a solitary event but are but one of a series of studies along a slippery slope in which persons with limited or no autonomy were knowingly exposed to STIs with the intent of creating experimental infections, which could then be used to better study newly developed, highly promising antimicrobials such as the sulfa drugs and, just a few years later, penicillin. Before Guatemala, Federal prisoners in Terre Haute Indiana were intentionally inoculated with Neisseria gonorrhoeae,2 and as late as the 1950s, prisoners in Ossining, New York, were injected with Treponema pallidum with the goal of creating experimental infections that could be used for further elucidation of pressing scientific questions.5
We suggest that it would be a great disservice to future scientists to allow our memory of Parran, both as a contributor to our field and as one of many persons engaged in these flawed scientific efforts, to not be remembered. Decisions to edit Parran’s name from prominence will likely deprive future scholars from an important source for reflection to help to guide them as future investigators. Displaying his name in the context of the Thomas Parran Award provides an opportunity to reflect on both his contributions and his flawed support of the studies along what may have been a slippery slope, fueled by the prominence of STDs as among the nation’s highest public health priorities and a threat to national security, by excitement over potentially powerful new tools for STI management, and by flawed logic. Knowledge of history is a precious thing and perhaps our best defense against future errors and transgressions. Complexity and contradiction are part of the human condition. Like virtually every great American leader whose life has been examined in detail, Parran and his colleagues put prisoners and others on the margins of society with limited autonomy in harm’s way, perhaps in the name of gaining knowledge for a greater good. We need to learn from these missteps. It is for this reason that we believe that Thomas Parran should be remembered both for his contributions to modern STI control and for his errors in judgment, which include support of the abuses of human subjects in the name of scientific progress. Similar errors are likely to be repeated, unless we have the benefit of the perspective provided by history.
1. Parran T. Shadow on the Land. Syphilis. New York: Reynal & Hitchcock, 1937.
3. Presidential Commission for the Study of Bioethical Issues. “Ethically Impossible” STD Research in Guatemala from 1946 to 1948. New York: Presidential Commission for the Study of Bioethical Issues, 2011 (www.bioethics.gov
4. Brandt AM. Racism and research in Tuskegee’s truths. Reverby SM, ed. Rethinking the Tuskegee Syphilis Study. Chapel Hill; The University of North Carolina Press, 2000: 15–33.
5. Magnuson HJ, Thomas EW, Olansky S, et al.. Inoculation syphilis in human volunteers. Medicine 1956; 35: 33–82.