Toxic Shock. Sharra L. Vostral

makes a case for understanding tampon-related TSS as the result of biocatalytic activity between technology and bacterium. Moreover, though women were the primary consumers, the bacterium became the unintended user. This unusual disease process challenged standard approaches to public health and required women to evaluate technological risk. It likely portends increasing incidence of injury related to medical devices used and worn within the human body.

      Tampon-related TSS is unique in that it is contingent on both bacterium and technology interacting with one another. TSS is unusual in that it is an illness that strikes otherwise healthy individuals and is predominantly associated with a human-made technology. Many people had a difficult time accepting this relationship, believing that tampons were inert. And those who recognized that something was afoot could not necessarily prove scientifically the mechanisms by which TSS manifested. Because hundreds of thousands of women who menstruated used tampons, and many carried the requisite bacterial strain of Staphylococcus aureus, scientific findings about TSS were urgent. Health practitioners, corporate scientists, federal policy makers, and feminist political advocates shaped and defined the terms of the emergent illness. They both articulated and challenged notions of risk, the results of which changed the conceptualization of tampons from benign to dangerous, affecting all tampon users. Moreover, this tampon technology shares a legacy of silence and coded language linked with menstruation, at best tolerated and at worst shamed. Thus, presumptions about menstruation came to bear on tampon technologies, the conditions of illness, and how women should be warned about potential risk.

      This book is a multifaceted history of tampon-related TSS as understood through distinct lenses: (1) technology and bacterium; (2) medicine and epidemiology; (3) communication and journalism; (4) law and litigation; and (5) policy and politics. TSS remains at the center of each chapter, but the conceptualizations, approaches, methods, and assumptions that different professionals and organizations brought to bear on this emerging health crisis demonstrate reactions to the revelation that tampons were not inert and, moreover, had the potential to cause irrevocable damage. Epidemiologists, corporate scientists, lawyers, and women’s health advocates each asserted different positions about how the emerging illness was related to supposedly inert tampons and how TSS affected menstruating women. The chapters are arranged thematically and overlap chronologically to address the ways that TSS was identified, crafted, constructed, and politically contained. My goal is not to complicate matters but to explain the history of a complicated illness by exploring it through different viewpoints, because a linear history restricts the narrative.

      TSS was identified with the bacterium Staphylococcus aureus in 1978, and the illness was later linked with tampons in 1980. Toxic shock syndrome was an urgent epidemiological event because of the feared potential to harm hundreds of thousands of young women. Though the epidemic never emerged, it is better characterized as a health crisis that instilled fear due to unknown elements and the inability of health providers to offer immediate explanation, relief, and a cure. Medical science failed to produce a quick and accurate resolution to the illness, compounding fears because tampons were simultaneously ubiquitous and also indecorous. According to Arthur Reingold, an epidemiologist at the Centers for Disease Control (CDC), 70 percent of women used tampons in 1980, and a potential national recall of all tampon brands would have affected hundreds of thousands of women.1 News reports and press releases in the media unveiled women’s intimate bodily menstrual management practices, presumably inappropriate to air yet necessary to speak of when warning women about the dangers, including death, associated with tampons.

      This is a story about technology and bacterium, and also about the interrelatedness of these two active components in precipitating illness. Indeed, TSS is frightening because the majority of menstruating women in the United States use tampons, and women cannot willfully control their periods or the makeup of their vaginal microflora. Though menstrual periods are one of the variables to the illness, eliminating them (though currently they can be pharmaceutically managed with synthetic hormones) is both impractical and not entirely desirable. When tampons are avoided, the options are to use sanitary pads, which is a nonstarter for many due to their discomfort. Menstrual cups are gaining in popularity, but they are an expensive up-front investment and do not work for all women. For many, tampons are nonnegotiable and the only method to manage periods well enough to hide them. This is important because there are no privileges to be gained for heavy periods or stains on clothing. As Gloria Steinem glibly points out in her 1978 essay “If Men Could Menstruate,” they “would brag about how long and how much,” with slang such as “He’s a three-pad man!” to boast about bodily performance and rationalize power justifications.2 With no such social benefits extended to women, tampons offer a pragmatic means to absorb menstrual fluid, keep bloodstains off of clothing (for the most part), and leave the body unencumbered, unlike sanitary pads. Thus, the fear of contracting TSS during a period due to tampon use is an entirely legitimate concern, despite the fact that it occurs in “1 to 17 per 100,000 menstruating women and girls per year” and can be treated with antibiotics if diagnosed early enough.3 In light of these statistics, the hype and concern seem overblown, while in other ways the risk is poorly clarified and contributes to ongoing misunderstandings that plague the worried well.

      In part, the Rely tampon, culpable for most of the TSS cases until 1980, is no longer produced and sold, eliminating that particular risk factor while lulling many into a false sense of security. Though other tampon brands triggered TSS and may have even contained similar material components, Rely tampons, which were developed and manufactured by Procter & Gamble (P&G), shouldered the brunt of the responsibility for the outbreak, with epidemiologic data strongly correlating TSS with them. As such, I have put the bacterium of S. aureus and the Rely tampon at the center of this book, and I trace technological innovations, epidemiology, product liability, and health policy through them both as the story’s main protagonists. This history explains the intertwined techno-bacteriological illness of tampon-related TSS and traces the unfolding health crisis, the definition of the illness, the shaping of knowledge distribution, and the gendering of health policy.

      More broadly, this book raises questions about the way certain bodies are subjected to risk while others are not, and about why we are willing to tolerate harm for some people. We operate under a collective illusion and even desire that technologies related to bodies are safe. When something goes wrong, it is preferable to blame user error, presuming things have been vetted technically, scientifically, and medically, because then the problem can be rationalized as an aberration rather than systemic. This, unfortunately, is not the case. Corporations have a large financial stake in making sure the status quo of products is maintained, and women, too, have been compliant by ignoring known risks in favor of technoscientific menstrual management. So deeply ingrained is this narrative of technological progress that journalists often ask me to predict the next menstrual management technology on the horizon. I tell them that what we need is not another technological fix, but a more compassionate attitude toward menstruation. My response is unsatisfactory to them because it challenges the uplift narrative and the hopes of a capitalistic solution for socially conscientious menstrual management. It is also unsatisfactory because it asks women to be better consumers, resist the mantra that “new is better,” and reject further synthetic and nonnatural fibers to be worn within the body. A deep understanding of tampons and their relationship to women’s bodies is vitally important: it can have life-or-death consequences. A reason I wrote this book is to share this knowledge, so each of us does not have to conduct independent research about TSS in order to make decisions about our own bodies. There is much pressure to believe that the technoscientific is the future, but “new” is not always better, and, in this case, the unintended consequence of “new” can be death.

      A Definition of Toxic Shock Syndrome

      In order to understand the historical origins of tampon-related TSS, it is useful to begin with the clinical case definition of TSS put forth in February 1980 and established by the CDC. According to the CDC, a clinical case of TSS included a fever of 102 degrees or more, rash, desquamation (flaking, peeling skin), and hypotension (drop in blood pressure, dizziness). It also included the broad category of “multisystem involvement,” which encompasses three or more of the following: gastrointestinal distress (vomiting, diarrhea), muscular pain (creatine phosphokinase levels twice that of normal), mucous membrane issues (enlarged blood vessels within the eye, throat, or vagina), renal dysfunction (blood