Names Matter: Thomas Parran and the American Sexually Transmitted Diseases Association

Susan Reverby is a historian with long-term interests in the infamous Tuskegee Study. In 2010, while researching the archives of John Cutler, one of the Tuskegee study physicians, Reverby discovered extensive records documenting intentional STI human experimentation studies that were conducted by the US Public Health Service in Guatemala in 1946 to 1948. Their objective was to develop and evaluate regimens for immediate pre and post exposure STI prophylaxis. These studies were funded through a scientific peer-reviewed, study-section-approved federal grant from the predecessor of the NIH; were led on-site by Dr. Cutler collaborating with other USPHS physicians and Guatemalan colleagues; and involved technical support from persons in the mainland United States. Reverby's discovery led to an investigation and report by the US Presidential Commission for the Study of Bioethical Issues1 which found that 5540 Guatemalans were subjects in clinical research experiments, including over 582 intentionally exposed to gonorrhea, 688 to syphilis, and 133 to chancroid; all without adequate consent. The experimental subjects included 14 commercial sex workers, 1017 soldiers, 976 prisoners, 716 psychiatric hospital patients, and 51 from the leprosarium. From 2010 to 2012, one of the authors (J.M.Z.) was a technical consultant for the Commission, where his role was to advise on the epidemiology and interpretation of the studies and their results, and preparing the final report. Besides the details of the experiments, the files, which are now available on-line in the National Archives,2 contain detailed correspondence between the principals and the USPHS offices in New York and Washington. As the projects progressed, the correspondence documents increased concern on maintaining secrecy and opacity. Letters between Cutler and the leadership at the USPHS Venereal Disease Division, especially John Mahoney (Director of the VDRL) in 1947 to 1948, expressed increasing unease of the studies being discovered by persons outside the small group of investigators, and also concerns that subjects were not consented, and in many cases, could not provide consent (e.g. the psychiatric hospital patients). One of the most troubling aspects of these studies is the contemporaneous context. At the end of World War II, the German, and later, Japanese medical atrocities were discovered, including medical experimentation without consent. The Nuremberg Doctors Trial, from which evolved the Nuremberg Code which still guides human clinical research ethics, began in December 1946. Ironically, in 1947, the New York Times science correspondent Waldemar Kaempffert published a small article on April 27, commenting on recent experimental findings on postexposure treatment syphilis experiments conducted in rabbits by Dr. Harry Eagle at Johns Hopkins, and added “but no tests on human beings have yet been made. To settle the human issue, quickly it would be necessary to shoot living syphilis germs into human bodies just as Doctor Eagle shot them into rabbits. Since this is ethically impossible, it may take years to gather the information needed”.3 Dr. Thomas Parran was the Surgeon General of the United States from 1936 to 1948, and was renowned for developing the STI control program and for publicizing the importance of STI control. In recognition, since 1972 the ASTDA annually awarded the Thomas Parran Award for lifetime career achievement and leadership in STIs. As the Guatemala story unfolded, the ASTDA was confronted with the difficult question—How much did Dr. Parran know of these studies? And if so, should the career award in STIs remain eponymous? Multiple letters in the Cutler correspondence clearly indicated that, although he never visited the study site, as Surgeon General he was aware of the ongoing Guatemala studies. Most troubling however, was one incriminating although indirect reference to Dr. Parran in a letter in a 1947 letter from one of the NIH scientists, G. Robert Coatney to Dr. Cutler: I saw Dr. Parran on Friday and he wanted to know if I had a chance to visit your project… he was familiar with all of the arrangements and wanted to be brought up to date on what progress had been made. As you well know, he is very much interested in the project and a merry twinkle came into his eye when he said “you know, we couldn't do such an experiment in this country.” Faced with this new information, ASTDA was in a difficult position. On the one hand, Parran was legendary in the field, and his stature during his day was unassailable. As Surgeon General, he was a strong advocate for greater public awareness of syphilis as a public health problem. He was featured on the cover of Time Magazine in 1936 in recognition of his syphilis control efforts, and he later testified before Congress to support legislation for expanded funding for STI research and prevention. In one notable instance, Parran famously pulled off his headphones and canceled a radio interview when CBS officials told him he could not mention the words “syphilis” or “gonorrhea” on the air, decrying hypocrisy in radio broadcasting standards. As a man who had dedicated his professional career to the control and prevention of syphilis and other STIs, it is no wonder that ASTDA had chosen to name its most prestigious award after this important leader. Yet on the other hand, Parran's fingerprints were all over Guatemala, and even if he wasn't personally conducting these horribly abusing “experiments,” he clearly knew what Cutler and his team were doing, and he clearly enabled it. Cutler's correspondence, and in particular Coatney's letter to Cutler, revealed that Parran was fully aware of the details of the studies, and he surely recognized the serious ethical implications of the studies being performed. Guatemala exemplified a disregard for basic human decency, all in the name of scientific progress. Did the ends really justify these ethically impossible means? ASTDA was in a quandary. Members of ASTDA's 10-member Executive Committee (EC), the leadership group of the organization, began to question whether the Thomas Parran Award should be renamed, in light of these emerging findings. As ASTDA vice-president, and then as president, one of the authors (BPS) helped facilitate ASTDA's organizational response to the crisis. As a leadership group, the EC was split on this issue. Some EC members argued that despite Parran's alleged involvement in what we now clearly recognize were unethical studies, times were quite different back then, and modern understandings of informed consent were not fully appreciated. Parran, it was argued, was a person of his times. He should not be held to a higher standard than was in place the time, and ASTDA should not remove his name from the award using a retrospective ethical evaluation. But other EC members argued forcefully that the Parran name must be removed. They suggested that there is an absolute moral standard that guides our work as human beings seeking to care for other human beings, and under no ethical regime would Parran's actions be considered acceptable or appropriate. Parran knew the Guatemala studies were unethical, yet he turned a blind eye and allowed the studies to continue despite knowing the horrible truth about how the research subjects were being treated. What would it say about ASTDA and its members if the organization did not change the name of the award, and were to continue honoring a man whose actions contributed to the direct harm of countless people? Moreover, many felt that addressing the ethical issues of the Guatemala study by changing the name of the Parran Award would be especially important for the STD field given the major ethical lapse committed by US Public Health Service researchers in withholding penicillin treatment from subjects with latent syphilis in the infamous Tuskegee study. Against this backdrop, the EC decided to hold an open conversation about whether to change the name of the Thomas Parran Award. The debate was informed by 5 articles published in the April 2013 issue of Sexually Transmitted Diseases4 describing what had been learned about the Guatemala research studies, the ethical implications of these activities, and the extent to which Parran may have been involved in authorizing the project to move forward. ASTDA members and the general public were invited to add their own comments directly to the ASTDA website, and to participate in a non-binding straw poll on the name change question. ASTDA members also participated in a members-only electronic vote to help guide the EC in its decision-making. In the end, nearly two-thirds of participants in both the website straw poll and the ASTDA membership vote favored changing the name of the award. On March 28, 2013, taking full measure of all the available evidence and in consideration of the views of ASTDA members and the general public, the ASTDA Executive Committee voted to remove Thomas Parran's name from the association's most prestigious award. As wrenching as the process was for ASTDA at the time, it was truly the right decision, undertaken after thoughtful reflection and wide consultation. Today, the award is known as the ASTDA Distinguished Career Award, and it continues to recognize those individuals who have attained the highest level of achievement through a long and extraordinary career in the field of sexually transmitted diseases.

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