About the cover illustration

Abstract

The name “Walter Reed” has been prominent in the news of late; as this issue of the Journal was being put together, the decision to close the U.S. Army’s flagship medical center was announced. The Walter Reed General Hospital was opened in 1909; by the 1950s, it had grown to a complex of over 100 buildings and had been renamed the Walter Reed Army Medical Center. Over the years it has provided services to presidents and foreign dignitaries, as well as soldiers and their families. Though the name may now most quickly evoke images of bricks and mortar and Georgian architecture, the person behind that name is worthy of our attention - indeed, my generation remembers him as one of the heroes of Paul de Kruif’s Microbe Hunters (New York; 1926; Harcourt, Brace, Jovanovich). Major Walter Reed, a native Virginian, directed the studies around the turn of the (19th to 20th) century that showed yellow fever to be an arthropod-borne disease. As a result, mosquito control measures became a major feature of work in tropical settings, and the human costs of such projects as the Panama Canal were much reduced. Less widely known is the contribution Reed made to the development of research ethics. He studied with Osler and Welch, both of whom had close ties to Rudolf Virchow – the famous pathologist who was instrumental in the drafting of the Berlin Code in response to research abuses in Prussia in the late 1800s. In his yellow fever studies, Reed was faced with a difficult question: How can you conduct research that has a real risk of serious harm to the subjects, yet offers them no prospect of offsetting benefit? From a different perspective: How does one decide whether the societal benefit of research is great enough to allow serious risk without real benefit? Perhaps conditioned by his mentors’ interest in research integrity, Reed proposed a demanding criterion: If you think your research is important enough to expose subjects to substantive risk without benefit, you should yourself be one of the research subjects. In the yellow fever studies, Reed did just that. It’s a recommendation that was remembered almost a half-century later in reviewing another body of research abuses; Provision 5 of the Nuremberg Code is “No experiment should be conducted where there is an a priori reason to believe that death or disabling injury will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects.” Reed also made use of written consent forms for research, and he may have been the first to do so. Although structured as contracts, the forms clearly disclosed that there was a risk of death for the subjects who contracted yellow fever, set forth that participation was voluntary, described what benefit there would be for participation (a payment of $100), described what would be given to the surviving family if a subject died ($200) and described that the monetary benefit would be forfeit if the subject withdrew from the study. Unlike most modern researchers, Reed managed to get this message into a single, double-spaced page of typescript! In 1940, the US Postal Service issued a series of 35 stamps commemorating famous Americans: Authors, Poets, Educators, Scientists, Composers, Artists and Inventors. The 5-cent stamp in the “Scientists” series was devoted to Major Walter Reed; it was issued in Washington, D.C. on April 17th, in a printing of just under 24 million copies. It is reproduced on our cover this month.