The Social Survey, the Metropolitan Life Insurance Company, and the Beginnings of the US Public Health Service's Sickness Surveys.

The earliest sickness survey of the US Public Health Service, which started in 1915, was the Service's first socioeconomic study of an industrial community. It was also the first to define illness as a person's inability to work. The survey incorporated the Metropolitan Life Insurance Company's definition of illness, which, instead of sickness rates, focused on duration of illness as a proxy of time lost from work. This kind of survey took place in the broader context of the reform movements of the Progressive Era and the social surveys conducted in the United States, which led to the creation of the Federal Commission on Industrial Relations, where the Service's sickness survey originated. The Service's focus on the socioeconomic classification of families and definition of illness as the inability to work enabled it to show the strong link between poverty and illness among industrial workers. The leader of the survey, Edgar Sydenstricker, and the Metropolitan Life Insurance Company came up with new ways to measure the health of the population, which also influenced the Service's studies of the effects of the Great Depression on public health and the National Health Survey of 1935-1936. (Am J Public Health. 2021; 111(11):1960-1968. https://doi.org/10.2105/AJPH.2021.306454).

The Work of US Public Health Service Officers in Puerto Rico, 1898-1919.

The history of the US Public Health Service (PHS) is usually presented in terms of diseases or discoveries; this article examines twenty years' activity in one location. When the United States invaded Puerto Rico in 1898, the Marine Hospital Service (now PHS) took responsibility for foreign quarantine, inspection of immigrants, and medical care for merchant seamen. Its officers evaluated the sanitary conditions of port cities, helped reorganize local disease surveillance and control, and investigated endemic diseases (e.g., hookworm-related anemia) and epidemics (e.g., bubonic plague). After World War I and pandemic influenza, and the greater self-government allowed Puerto Rico by Congress in 1917, PHS officers withdrew from routine local sanitary actions. A narrow geographic focus (Puerto Rico), to examine PHS activity over time (1898 to 1919) provides a richer picture of the agency's impact, and reveals how the sum of disease control activities affected the development of an area's health status and institutions. The duties and, importantly, the personal initiatives of PHS officers in Puerto Rico, such as WW King, produced lasting impact on scientific institutions and administrative, professional, and health care practices.

Syphilis and human experimentation from World War II to the present: a historical perspective and reflections on ethics.

Even after the Nuremberg code was published, research on syphilis often continued to fall far short of ethical standards. We review post-World War II research on this disease, focusing on the work carried out in Guatemala and Tuskegee. Over a thousand adults were deliberately inoculated with infectious material for syphilis, chancroid, and gonorrhea between 1946 and 1948 in Guatemala, and thousands of serologies were performed in individuals belonging to indigenous populations or sheltered in orphanages. The Tuskegee syphilis study, conducted by the US Public Health Service, took place between 1932 and 1972 with the aim of following the natural history of the disease when left untreated. The subjects belonged to a rural black population and the study was not halted when effective treatment for syphilis became available in 1945.

The rights and wrongs of intentional exposure research: contextualising the Guatemala STD inoculation study.

In its recent review of the US Public Health Service Sexually Transmitted Disease Inoculation Study, conducted in Guatemala from 1946 to 1948, the Presidential Commission for the Study of Bioethical Issues identified a number of egregious ethical violations, but failed to adequately address issues associated with the intentional exposure research design in particular. As a result, a common public misconception that the study was wrong because researchers purposefully infected their subjects has been left standing. In fact, human subjects have been exposed to disease pathogens for experimental purposes for centuries, and this study design remains an important scientific tool today. It shares key features with other types of widely accepted research on human subjects and can be conducted ethically, provided certain safeguards are implemented. That these safeguards were not implemented in Guatemala is what made that study wrong, rather than the fact of intentional exposure itself. To preserve public trust in the clinical research enterprise, this conclusion ought to be stated explicitly and emphasised.