Leadership on Syphilis Studies – for Better and for Worse
An excerpt from Health and Humanity: A History of the Johns Hopkins Bloomberg School of Public Health, 1935–1985
By Karen Kruse Thomas | September 1, 2020
The excerpt below is the second of two from the published book Health and Humanity: A History of the Johns Hopkins Bloomberg School of Public Health, 1935–1985. We are publishing these excerpts on our School website as part of our commitment to Inclusion, Diversity, Anti-Racism, and Equity. In order to shape a more equitable and just future, we feel it is important to acknowledge our own past. These excerpts will be followed by additional articles on the current affairs of racism and public health and stories of our School’s research and efforts aimed at creating a better future.
When the School of Hygiene and Public Health (now the Bloomberg School of Public Health) was founded in Baltimore, Maryland in 1916, geography was destiny.
The School’s southern context shaped its efforts to conquer tropical plagues in the global South as well as urban maladies in Baltimore. Maryland was poor and overwhelmingly rural, bearing more resemblance to its southern neighbors than to other more prosperous mid-Atlantic states. Compared to the rest of the United States, the South’s population was poorer, younger, and more rural; had higher fertility and lower standards of living; posted shorter life expectancy and higher rates of illiteracy, morbidity, and mortality; and was more isolated, with a much smaller supply of doctors and hospital beds. In short, the South was still part of the developing world.
Baltimore’s health problems were a unique product of its industrial economy and large international port, a growing population squeezed into an aging housing stock, and the injustices and inefficiencies of racial segregation. The fifth-highest cause of Black mortality in Baltimore was syphilis, which also destroyed lives in myriad ways before it ended them. Neurosyphilis was the leading diagnosis for admissions to state mental hospitals, since patients exhibited cognitive decline, paranoia, hallucinations, and other features consistent with general paresis, an acronym coined to catalog the changes in personality, affect, reflexes, eyes, senses, intellect, and speech. Syphilis also caused a range of other complications ranging from weakening of the heart muscle to severe skin problems. Nowhere was the impact of local attitudes and conditions more evident than in Baltimore’s sexually transmitted disease control program, the impetus for record growth and far-reaching changes in the School’s research and teaching missions.
The School’s leadership was on close terms with President Franklin D. Roosevelt’s new surgeon general, Thomas Parran, who helmed the US Public Health Service (PHS) from 1936 to 1948. Dean Lowell J. Reed and Parran both served as president of the American Public Health Association (APHA). Thomas B. Turner, who came to the School in 1936 to head a new venereal disease control training program, and Parran both hailed from Calvert County in rural southern Maryland, and Turner was married to Parran’s cousin, Anne Parran Somervell. Parran considered the South “the number one health problem of the Nation,” and made it the PHS’s public health laboratory.
In 1936, Parran helped J. Earle Moore, associate professor of medicine at the Johns Hopkins School of Medicine and head of the Johns Hopkins Hospital syphilis clinic, to secure an annual $10,000 training grant from the Social Security Act to establish the nation’s first graduate training program in syphilis control. The program’s graduates would lead the VD campaign and take it out into the countryside. Moore, arguably the most prominent syphilis expert of his generation, had worked closely with Parran when he headed the PHS Division of Venereal Disease.
In 1938, the schools of Medicine and Public Health at Hopkins and City Health Commissioner Huntington Williams convinced the city government to generously support a syphilis control program in Baltimore, including a syphilis clinic in the neighborhood surrounding JHSPH, the Eastern Health District (EHD). Parran hoped the Baltimore program might become a model for other cities, and Turner declared, “The set-up to which we have access here will be one of the most favorable places in the world to study syphilis.” In 1939, the joint Medicine–Hygiene program to train physicians in VD control methods was formalized as the first specialized track in the MPH degree.
The JHSPH program in VD control was originally conceived as a Johns Hopkins Hospital residency, and Moore and Parran had attempted to circumvent the hospital’s discriminatory staff policy by requesting funding to establish a syphilis clinic at Provident Hospital, Baltimore’s only general hospital for Black patients. Their plan was for Black physicians to receive their academic training at Hopkins but their clinical experience in an all-Black patient setting. When no sponsors stepped forward, Parran arranged for the District of Columbia Health Department and Howard University (a historically Black institution that was one of only three medical schools in the country that did not discriminate against Black applicants) to conduct a recurring three-month postgraduate course in syphilis control, with scholarships for Black physicians funded by state VD control grants. Three days before the attack on Pearl Harbor in December 1941, the PHS informed Dean Reed that JHSPH’s two-month VD control course should admit Black military medical officers, and Reed eagerly requested “application blanks for this group as quickly as possible.” The course was, however, only offered a few times and admitted one Black officer, a nurse in the Women’s Army Corps.
In 1946, Moore appointed Ralph J. Young as the first Black house officer at the Johns Hopkins Hospital syphilis clinic. After finishing his residency, Young joined the BCHD staff and ran the Eastern Health District clinics for Black patients under the supervision of C. Howe Eller, MPH ’33, the EHD health officer. Since the BCHD often combined its screening programs for tuberculosis and venereal disease, Young worked closely with Miriam Brailey, ScD ’30 in the BCHD Bureau of Tuberculosis and E. Gurney Clark, MPH ’36 in the BCHD Bureau of Venereal Disease. With funding from JHSPH and the state and city health departments, Young established the East Baltimore Health Organization to encourage Black residents to get screened for TB and syphilis, which supported both the BCHD’s public health campaigns and the School’s research and education needs. In 1952, he would break the color bar on the Maryland State Board of Health as well as the Hopkins medical faculty; in the early 1960s, Young joined the JHSPH faculty in the Department of Chronic Diseases.
Until 1943, everything Turner and Moore had accomplished in the syphilis control program had been done without penicillin, but the largest VD grants to the school were for studies of penicillin therapy to treat early syphilis. Moore and other medical faculty worked closely with Biostatistics faculty Lowell Reed and Margaret Merrell, ScD ’30, who provided crucial advice on experimental design and physiological reaction rates for most of the therapeutic drug studies at Hopkins. Their expertise in the application of statistical analysis for medical research made them JHSPH’s most frequently sought collaborators. Merrell, the principal statistician for the penicillin trials and statistical consultant to the PHS and the US Army Surgeon General, emerged as one of the premier experts on statistical analysis for randomized controlled trials of therapeutic compounds. She and Reed helped to develop standard clinical protocols and follow-up procedures that would ensure comparability among the results of centralized, cooperative studies of large numbers of patients.
Along with the achievements of the clinical trials of penicillin therapy for early syphilis and the military’s VD prevention program, the antisyphilis campaign had another, deeply troubling legacy. Public health campaigns to fight disease by offering treatment, modifying environmental conditions, or conducting other types of interventions require significant resources and human effort, even as they pose potential risks to their intended beneficiaries. Wade Hampton Frost, chair of Epidemiology, had written in 1923 that, to justify such campaigns, health officers (and, by extension, health policymakers) must have “more than a knowledge of [how] the specific organisms of disease [react] under the controlled conditions of the laboratory. It equally requires a knowledge of the community, of the psychology of the people, their social organization, the conditions and events of their everyday life. It requires that the knowledge of fundamental causes of disease be fitted together with the knowledge of people into a practical epidemiology, directly applicable to prevention.” Frost—named for a Confederate general—had also mentored Ruth Rice Puffer and Brailey, who, like him, drew some of the earliest scholarly attention to racial disparities in health. He did not live long enough to teach Reginald G. James, MPH ’46, the School's first Black graduate.
The School of Hygiene and Public Health, with its liberal reputation for welcoming international and political diversity, was the first Johns Hopkins University division to desegregate when it admitted James in 1945. Its faculty and alumni published pioneering studies of racial disparities in malaria, tuberculosis, syphilis, and other diseases. Yet despite Moore and Parran’s sincere efforts to open opportunities for Black physicians at Johns Hopkins and in the PHS, they also advised the PHS on the Tuskegee Study of Untreated Syphilis in the Negro Male, known as the Tuskegee Syphilis Study. The PHS, which funded and carried out the study in Macon County, Alabama, from 1932 to 1972, recruited 439 Black men with late-stage syphilis as subjects and 185 as controls. Johns Hopkins University was not involved in funding, planning, or administering the syphilis research in Tuskegee at any point. Moore, while serving on the faculty of both the medical school and JHSPH, served as an independent consultant, and Parran, although he did not originate the study, allowed it to continue and expand during his tenure as surgeon general. Throughout the study, PHS physicians intentionally deceived the mostly illiterate men to continue to observe the natural history of the disease, telling them that they were receiving “special free treatment” for their “bad blood,” in the form of diagnostic spinal taps, aspirin, and vitamins, but no effective therapy for syphilis.
The initial purpose of the study was to compare the health of two otherwise similar groups of individuals, one with untreated syphilis and another without syphilis. This was a prospective cohort study of the natural history of a disease, which was a common tool for medical research in an era with few effective treatments. JHSPH researchers would continue to use and improve similar methods as the first step toward developing effective screening and treatment programs for newly discovered diseases such as AIDS. When the Tuskegee Study began in 1932, it had no clearly defined protocol and was not planned as a long-term study. Because the PHS did not then have an effective research review system, bureaucratic inertia allowed the study to continue until 1972, and it became the longest nontherapeutic medical study in U.S. history.
During the Tuskegee Study’s second decade (1942–1952), as noted above, the research protocols developed for the penicillin trials by Moore, Turner, Reed, and Merrell helped ensure the scientific validity and reproducibility of all subsequent JHSPH research and shaped the broader parameters of the randomized controlled trial. The PHS quickly applied the new methods to its trials of streptomycin for TB, but PHS researchers on the Tuskegee Study ignored such protocols. For example, 12 men in the control group who later tested positive for syphilis were switched into the syphilis group, which also compromised the original goal of only studying late-stage syphilis. For nearly 30 years after penicillin became widely available, the PHS failed to use it to cure the Tuskegee Study’s participants.
The syphilis research conducted by JHSPH in Baltimore bears many striking contrasts to the PHS study in Macon County, Alabama. In Baltimore, Moore and Turner focused on finding and treating patients with early syphilis, including those without apparent symptoms, and conducted follow-up casefinding and partner notification. They also developed effective educational interventions targeted to different population groups, and Turner’s success in testing and applying these prevention methods in Baltimore led to his appointment as director of the US Army’s VD control programs in military personnel as well as civilians. In the PHS Tuskegee Study, not only were the men denied treatment, but their wives, children, and sex partners also were not traced and few were treated. Researchers assumed the men were noncontagious since they were in the late stage of the disease, but their medical records contradict this. At least 16 deaths, and possibly many more, of Tuskegee Study participants were attributable to syphilis; 40 of the men’s wives contracted the disease, and 19 of their children were born with congenital syphilis.
Moore, the only JHSPH faculty member involved in any capacity with the Tuskegee Study, also chaired the 12-member PHS Syphilis Study Section. Moore and the other study section members from JHSPH, Reed, Turner, and Harry Eagle, served independently of their roles as Johns Hopkins University faculty and were not representing the University. In 1946, the PHS study section approved a grant proposal for an ill-fated project directed by John C. Cutler, MPH ’50, then at PHS, who later enrolled at JHSPH. Cutler’s never-published research, conducted between 1946 and 1948, involved intentionally exposing 1,308 Guatemalan prison inmates, mental patients, sex workers, and soldiers to syphilis and gonorrhea. The participants were given blood tests afterward to determine whether they were infected, and Cutler’s team administered penicillin to some, but not all, subjects with positive results to test the new drug’s effectiveness as both a cure and a prophylactic against developing the disease after exposure. For this project and other serologic diagnostic studies of syphilis transmission and penicillin therapy, Cutler obtained the cooperation of the PHS, the Guatemalan government, and the Pan American Sanitary Bureau.
During his subsequent career as a PHS officer, Cutler spent time working on the Tuskegee Study and dedicated himself to stamping out syphilis in the United States and abroad. Using findings from the Tuskegee Study, he emphasized to public health professionals that untreated syphilis among Blacks caused its incidence to spiral and reduced Black life expectancy by 17 percent, which justified continued federal funding for syphilis control efforts. Cutler would go on to serve as assistant US surgeon general, deputy director of the Pan American Health Organization, and chair of the Department of Public Health Administration at the University of Pittsburgh Graduate School of Public Health, where Parran was the founding dean. (Parran’s name was removed from the School’s main building in 2018 in response to ethical concerns over his role in the Tuskegee and Guatemala syphilis studies). Another JHSPH alumnus, Leroy Burney, MPH ’32 was among the many PHS venereal disease control officers whose training included a stint on the Tuskegee Study. As US surgeon general from 1956 to 1961, Burney, like his predecessors, allowed the study to continue.
Ironically, the laudable desire to spare as many people as possible from disease in the future could become a justification for subjecting a small number of people in the present to pain and suffering, just as a general stoically decides to sacrifice the shock troops in a battle to win the wider war. But, as medical historian Susan L. Reverby reminds us, “it was allowable to use the ‘other’ as the foot soldiers.” The tragedies of Tuskegee, Guatemala, and other breaches of bioethics hinged on power disparities at both the individual and community levels. These differentials do not always line up neatly as Good versus Evil but may more closely resemble Dr. Jekyll and Mr. Hyde—the same individual may be both resisting and accommodating ethically questionable science. For example, Reverby observed that “physicians in under-resourced communities often say yes to research because they have few other options and they triage the ‘for right now’ against the future. They remind us that the American doctors [of all races] involved [in the Tuskegee and Guatemala syphilis studies] believed they were doing good science for the common good. They thought it was their responsibility to protect the nation through this kind of research.”
The history of the Johns Hopkins School of Hygiene and Public Health is a compelling antidote to what Reverby calls “the monster doctors-are-infecting-the-vulnerable story[,] a powerful tale where our horror deepens as we expect to see the hapless victims and the evil scientist.” Johns Hopkins was acknowledged as the foremost center of syphilis research, and the University and hospital contributed a disproportionate share of the knowledge necessary to treat the very common, often disabling, and potentially fatal disease. Yet Johns Hopkins was also a very powerful institution in a segregated city where both law and custom devalued Black lives and rights.
Karen Kruse Thomas, PhD, is the Bloomberg School historian.
Health and Humanity: A History of the Johns Hopkins Bloomberg School of Public Health, 1935–1985 by Karen Kruse Thomas is available in its entirety for purchase or download here.