by Mary Guinan
Parran estimated that, in 1937, syphilis was responsible for 15 percent of all blindness in the United States and 50 percent of children born blind, 18 percent of all deaths from heart disease, 10 percent of all insanity cases, and 60,000 babies born each year with congenital syphilis. The healthcare costs for the effects of syphilis had brought many of the states to a severe financial crisis, further straining a national economy still in the depths of the Great Depression. Parran’s book was a plea to view syphilis as a public health issue that caused devastating illness rather than as a moral problem. He emphasized the effect on the family and the often-innocent wife whose husband gave her syphilis, of which she was unaware, and who then unknowingly passed it on to her newborn. Parran noted that a wet nurse with a syphilis rash could also pass syphilis on to a suckling infant. It could even be transmitted by a kiss if the chancre or rash were in the mouth. (These last examples of contracting syphilis occurred without “sinning.”) Making the case that the cost of treating and eliminating syphilis would be far less than the existing healthcare costs for all stages of the disease (which were the responsibility of the state), Parran made a compelling case to view syphilis as an economic, not moral, issue. He also presented a plan to fund a syphilis elimination program.
Parran served on a committee that helped draft the Social Security Act (SSA) of 1935. The SSA contained a provision (Title VI) for an annual allocation of funds to the Public Health Service for the purpose of assisting states in establishing and maintaining adequate public health services. Parran was determined to use some of this fund for a syphilis elimination program. This would be the first time (except during wartime) that the federal government considered health as its responsibility. Authority for health matters is not mentioned in the US Constitution and therefore is assigned to the states (in the Tenth Amendment). The SSA did not take authority away from the states but permitted the federal government to provide states with public health funding. As a result, clinics for the diagnosis and treatment of syphilis using Salvarsan were established throughout the country. It was a slow process, as eighteen weekly injections of Salvarsan were deemed necessary for cure, and there were many toxic side effects.
But, fortuitously, in 1944, penicillin began to be mass-produced. This antibiotic was found to be so highly effective for curing all stages of syphilis with minimal side effects that it became the treatment of choice. The penicillin cure rate for syphilis was well over 90 percent, and many patients were cured with just one treatment. It is difficult to exaggerate the dramatic effect of penicillin on the syphilis epidemic. Between 1944 and 1954, the total number of syphilis case rates fell by 75 percent, and new syphilis cases were reduced by more than 90 percent. In 1957, the number of new syphilis cases fell to approximately 6,000, the lowest number recorded since surveillance began in 1941 (10).
Compared to the estimated 500,000 new syphilis cases in 1937, it seemed that Parran’s dream might come true. He had estimated that it would take ten years to eliminate syphilis from the country, and the goal was clearly in sight. But as CDC later learned from the Smallpox Eradication Program, the last cases are the most elusive to find and contain. Because the syphilis program was so successful, it was assumed that it needed fewer resources. So from 1945 to 1955, funds to the Public Health Service for its venereal disease program decreased from $12 to $3 million. Syphilis cases again started climbing, and by 1961, they numbered over 18,000. Dr. William Brown, director of Venereal Disease Control at CDC, fought for more funding for all STDs, but polio was now one of the chief concerns of the public health community (and polio was not linked to sinful behavior), and there was public apathy about syphilis. The director ruefully told a reporter about Brown’s Law: “As the point of eradication is approached, it is more often the program that is eradicated than the disease” (11).
In 1965, an educational consultant at CDC wrote two books on STDs, one for medical professionals and one for the public, in which he tried to educate the public to separate STDs from sin (12). But one of his books incited controversy by claiming that Christopher Columbus’s end-of-life insanity was caused by syphilis. The national Columbus Day Committee was outraged that the man who “discovered” America was being slandered, and demanded that the claim be removed from future editions of the book. But this was not enough for the Knights of Columbus, who appealed to President Lyndon Johnson’s special assistant, Jack Valenti. CDC was eventually required to remove any mention of Christopher Columbus from the 52,000 existing copies of the book (13). The implication was that Columbus could not have been a sinner and therefore could not have had syphilis. Despite his best intentions, the author had reemphasized, rather than diminished, the link between immoral behavior and syphilis.
Efforts to eliminate syphilis have continued, including the most recent campaigns by the surgeon general in 1999 and 2006 (14). In 2000, new syphilis cases reached their lowest level in history (about 2,000 cases), but unfortunately new cases have surged since that time, to more than 16,000 in 2013. The reasons for this resurgence of syphilis cases are complex, but they are not caused by penicillin resistance. Penicillin is still the treatment of choice for syphilis and has maintained its effectiveness for over sixty years. The most recently recognized barrier to syphilis elimination in the United States is its overlap with the AIDS epidemic (10). Each disease may enhance the transmission of the other.
There is one last disgrace regarding syphilis in the United States and Dr. Parran. Two shockingly unethical STD studies were conducted while Dr. Parran was surgeon general (15). In one—the Tuskegee study of black men with syphilis, started in 1932—the men were not treated with penicillin when it became available in the 1940s. They were only treated in 1972, when a whistleblower revealed the truth to the public. In the second study, conducted from 1946 to 1948 in Guatemala, American researchers deliberately exposed more than a thousand Guatemalans to syphilis, gonorrhea, and chancroid. This study was kept secret until 2010.
In 1997, President Bill Clinton apologized to the participants in the Tuskegee study and their families. In 2010, then–US Secretary of State Hillary Clinton and Health and Human Services Secretary Kathleen Sibelius issued a formal apology to Guatemalans.
The harm done to the participants of these studies and their families is immeasurable. Although Dr. Parran was a visionary and a pioneer for the control of STDs, these controversial studies will rightly overshadow his work and public health image forever. They will also taint public health’s image—and thus public health’s impact. The Tuskegee studies, for example, undoubtedly led to many black Americans’ deep distrust of the public health system’s messages about AIDS—a distrust that lingers to this day.
Another taboo concerns the prevention of STDs and the use of condoms. Regardless of the amount of explicit sexuality on the Internet, on television, and in movies, it is still rare to see television advertisements for condoms or for the content of television programs to mention condom use as a means of preventing STDs. Surgeon General C. Everett Koop broke the taboo on government officials using the “c-word” when he released his AIDS Report to the press, in October 1986, in which he discussed the use of condoms for preventing AIDS. An abbreviated version of this release was eventually distributed to every American household in 1988.
I gave a talk on AIDS to a medical audience sometime later and encouraged the audience to advise sexually active men and women (heterosexual and homosexual) to always carry condoms and make sure that they knew how to use them to prevent infection. A few days later, I received a call from an “investigator” for syndicated columnist Jack Anderson, a Pulitzer Prize–winning author and radio show host who was dedicated to exposing government fraud and waste. The investigator told me that Anderson was going to write a column about how CDC was wasting the government’s money teaching homosexuals how to have sex with condoms, and he understood that I had given a talk on this subject recently. No amount of discussion dissuaded him, so I referred him to the director of the HIV/AIDS Program a
t CDC. Anderson eventually called for an investigation on how CDC spent AIDS prevention funds.
In response to the surgeon general’s report, Time magazine dedicated a whole issue to sex education of children, and I was interviewed for it. I called the representatives of condom companies to let them know about the sex-education issue and suggested that it might be a good issue in which to place a condom ad. With two CDC colleagues, I had traveled to Alabama to tour the largest condom manufacturing plant in the country. We were impressed with the manufacturing process and the quality-control standards for the products. I thought that the time was right for the marketing of condoms. (I was relieved to learn that all condom manufacturers at the time were privately held companies. As an advocate of condom use, I was often asked if I had stock in condom companies—which would have been a conflict of interest.) On November 24, 1986, Time’s STD issue was published without a single condom ad. The magazine refused to accept them. The same issue did have a back-cover, full-page advertisement for cigarettes, a substance that has been proven to kill, but it had no room for an advertisement for a product that might save lives.
I rest my case.
REFERENCES
CHAPTER TWO
1. Foege WF. House on fire: The fight to eradicate smallpox. Berkeley: University of California Press; 2011.
CHAPTER FOUR
1. Sabin AB. Misery of recurrent herpes: What to do? New England Journal of Medicine. 1975;293:986–88.
2. Guinan ME, MacCalman J, Kern ER, et al. Topical ether in herpes simplex labialis. JAMA. 1980;243(10):1059–61.
3. Guinan ME. Session 27: Herpes simplex and EB viruses. Interscience Conference on Antimicrobial Agents and Chemotherapy. Oct. 1–4, 1978. Atlanta, GA.
4. CDC. Pneumocystis carinii pneumonia, San Francisco. MMWR. 1981;30: 250–52.
5. Mather AD. Mystery of AIDS begins to unravel. Infection Reporter. 1984; 1(6):1–2.
6. Mather AD. Media medicine or what’s a nice doc like you doing on TV? Infection Reporter. 1989;6(9):65–67.
CHAPTER FIVE
1. How the CIA’s fake vaccination campaign endangers us all. Scientific American. 2013;308(5).
2. Letter to Obama: www.virology.ws/2013/08/deans-write-to-Obama-about-CIA-vaccine-scheme-in-Pakistan.
CHAPTER SIX
1. CDC. Pneumocystis pneumonia—Los Angeles. MMWR. 1981;30:250–52.
2. Shilts R. And the band played on: Politics, people, and the AIDS epidemic. New York: St. Martin’s Griffin; 1987.
3. Jaffe HW, Choi K, Thomas PA, et al. National case-control study of Kaposi’s sarcoma and Pneumocystis carinii pneumonia in homosexual men: Part 1, epidemiologic results. Annals of Internal Medicine. 1983;99:145–51.
CHAPTER SEVEN
1. Guinan ME, Hardy A. Epidemiology of AIDS in women in the United States, 1981–86. JAMA. 1987; 257:2039–42.
2. Gould RD. Reassuring news about AIDS: A doctor tells why you may not be at risk. Cosmopolitan Magazine. 1988 Jan.
3. Coady E. 300 protest definition of AIDS. ACT UP group claims CDC is killing women. Atlanta Journal Constitution. 1990 Dec. 4. p. D3.
CHAPTER NINE
1. Ryan H. How to whitewash a plague. New York Times. 2013 Aug. 3.
CHAPTER TEN
1. Department of Health and Human Services (HHS) v. Westchester County Medical Center. DAB CR191. 1992 Apr. 20.
2. Civil Rights reviewing authority’s decision on review of administrative law judge decision Westchester County Medical Center. DAB 1357. 1992 Sept. 25.
3. DAB CR191, Findings of fact and conclusions of law, finding 128.
4. Ibid., finding 129.
5. McCray E, and the Cooperative Needlestick Surveillance Group. Occupational risk of the acquired immunodeficiency syndrome among health care workers. New England Journal of Medicine. 1986;314:1127–32.
6. Henderson DK, Saah AJ, Zak BJ, et al. Risk of nosocomial infection with human T-cell lymphotropic virus type III / lymphadenopathy-associated virus in a large cohort of intensively exposed health care workers. Annals of Internal Medicine. 1986;104:644–47.
7. Henderson DK. Human immunodeficiency virus in health care settings. In: Mandell GL, Bennett JE, Dolin R. Principles and practices of infectious diseases. 7th ed. Philadelphia: Churchill, Livingstone, Elsevier; 2010. p. 3755.
8. CDC. Pneumocystis pneumonia—Los Angeles. MMWR. 1981;30:250–52.
9. Marcus R, and the Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. New England Journal of Medicine. 1988;319:1118–23.
10. Hevesi D. Hospital told to hire man with HIV. New York Times. 1992 Apr. 23.
11. HHS website. Press release January 11, 1993 [cited Aug. 27, 2014]. Available from: http://archive.hhs.gov.
12. DAB CR191, analysis FN 16.
13. Ibid., FN 17.
14. Henneberger M. Pharmacist with HIV awarded job. New York Times. 1993 Jan. 12.
CHAPTER ELEVEN
1. Fleming DW, Cochi SL, MacDonald KL, Brondum J, Hayes PS, Plikaytis BD, Audurier A, Broome CV, Reingold AL. Pasteurized milk as a vehicle of infection in an outbreak of listeriosis. New England Journal of Medicine. 1985;312(7):404–7.
2. CDC. Outbreak of Listeria monocytogenes infections associated with pasteurized milk from a local dairy. MMWR. 2008;57(40):1097−1100.
CHAPTER TWELVE
1. HIV stigma and discrimination in the U.S.: An evidence-based report, Nov. 2010, HIV Reports [cited Jan. 2015]. Available from: www.lambdalegal.org.
2. Etheridge E. Sentinel for health: A history of the Centers for Disease Control. Berkeley and Los Angeles: University of California Press; 1992. p. 89.
3. Kelly HA, as cited in: Brandt AM. No magic bullet. New York: Oxford University Press; 1985. p. 46.
4. Brandt, No magic bullet.
5. Parran T. Shadow on the land: Syphilis. Baltimore: Waverly Press; 1937. Chapters 3, 5, 6. [Special education edition published by the American Social Hygiene Association, New York, in cooperation with Reynal & Hitchcock.]
6. Brandt, No magic bullet, p. 186.
7. Parran, Shadow on the land, p. 225.
8. Morrow PA. Publicity as a factor in venereal prophylaxis. JAMA. 1906;47(10):1246.
9. Parran, Shadow on the land, p. 226.
10. Douglas JM. Penicillin treatment of syphilis. JAMA. 2009;301(7):769–71.
11. Etheridge, Sentinel for health, p. 121.
12. Schwartz WM. Student’s manual on venereal diseases: Facts about syphilis and gonorrhea. Washington, DC: American Association for Health, Physical Education, and Recreation; 1965.
13. Etheridge, Sentinel for health, p. 121–22.
14. CDC. The national plan to eliminate syphilis from the United States. Atlanta: US Department of Health and Human Services; 2006.
15. Altman L. Of medical giants, accolades and feet of clay. New York Times. 2013 Apr. 1.
INDEX
The term gallery refers to photographs located after page 62.
ACT UP (AIDS Coalition to Unleash Power), 63–70
tactics of, 63
targeting of CDC and Guinan by, 65, 67–70, gallery
acyclovir, 42–43
Afghanistan, 45
African Americans, 63, 77, 78, 111–12
AIDS/HIV: ACT UP and, 63–70
AIDS case definition, 64–65, 68, 69–70
AIDS diagnosis, 58–59, 65, 76
And the Band Played On, account of, 56–57
antiviral treatment for, 74
CDC early work on, 42, 53–56, 57–58, 102
employment discrimination around, 79–92
gay community and, 63, 78, 105
HIV blood test, 58, 60, 61, 64, 72, 83–84
homophobia around, 75–78
myths around, 65–66, 101–3, 105
public fears about, 52, 71–73, 92
Reagan and, 107
syphilis overlap with, 111
transmission modes of
, 58–59, 86, 87
virus identified and named, 58
AIDS in New York: The First Five Years, 75
American Chicle, 14–15, 17n
Americans with Disabilities Act, 80
Anderson, Jack, 112
And the Band Played On (Shilts), 56–57
Astrue, Michael, 82–83, 89
Berkelman, Ruth, 68
bin Laden, Osama, 51–52
Brachman, Philip, 19
Brahmins, 21
Brandt, Allan M., 104–5
breast-feeding, and HIV transmission, 86
Broome, Claire, 95, 96, 98
Brown, William, 110
Carter, Jimmy, 45
case-patient definition, 7
CBS: Evening News, 38
local Utah affiliate for, 38
60 Minutes, 41
