Deadliest Enemy: Our War Against Killer Germs

by Mark Olshaker

This coronavirus pandemic resembles an influenza-like scenario in the way it transmits person to person via breathing an infected person’s airborne droplets and tiny aerosol particles that are filled with virus, just as we detailed an influenza pandemic would unfold in chapter 19. What do all of these infectious disease outbreaks have in common? They all came as a surprise, and they shouldn’t have. Nor should the next one; and rest assured, there will be a next one, and one after that, and on and on.

It is far better to say we don’t know something but that we’re working on finding out than to offer happy talk that may be contradicted by the next news cycle. If the president sacrifices his credibility, the public will not know where to turn. However, studies have repeatedly shown that if the public is given honest, forthright information, panic almost never ensues and we all learn to pull together.

In the nearly two decades since SARS, the world has become far more critically dependent on China for its manufacturing resources.

Two advanced city-states that experienced the outbreak in the early stages both attempted to respond as quickly and efficiently as possible. Hong Kong closed its schools. Singapore did not. As it turned out, there was hardly any difference in the rate of transmission.

The term “black swan” was introduced by Nassim Nicholas Taleb, author and scholar, to explain certain rare occurrences in financial markets. In his 2007 book, The Black Swan, he extended the concept to explain unusual high- or extreme-impact and difficult-to-predict events in the larger world.

Twenty years after that first mention in MMWR, the CDC announced that nearly half a million people had died from AIDS in the United States alone. Yet

In 2014, an estimated 36.9 million people around the world were living with HIV infection, most in sub-Saharan Africa. There are an estimated 2 million new cases a year and 1.2 million deaths. Today, during an average week, there are 30,000 new HIV infections, and 20,000 will die from AIDS in sub-Saharan Africa.

Primo Levi, the revered Italian chemist, philosopher, and author whose searing memoir, Survival in Auschwitz, is one of the essential Holocaust narratives. Levi said, “When you know how to relieve torment and don’t, then you become the tormentor.”

It is not surprising, then, that when Microsoft founder Bill Gates and his wife, Melinda, decided to dedicate much of their multibillion-dollar fortune to a foundation devoted to world health, they chose Bill Foege as one of their chief advisers. In establishing their foundation, they were pursuing their belief that every child is entitled to a healthy life, to the extent that other human beings can provide it. “It is our responsibility to bring people around the world as close to a level of health as possible,” Gates commented.

So what is the public health agenda? It is not to prevent death; let’s get that one out of the way here and now. That’s still impossible. The overall rate of death to birth so far always has been—and as far into the future as we can see, always will be—constant at 100 percent: one death for every birth. The agenda is not even to prevent the so-called leading causes of death. If you could do that, there would still be a top ten causes of death, and I’m certain some of them wouldn’t be any better than the ones we have now. What we in the public health sphere are always trying to do is replace bad deaths with good deaths; to prevent early and needless death and disease.

Just about all deaths are sad, and many are tragic. But from a public health standpoint, there are more profound and meaningful differences. A ninety-year-old man with limited mental and physical impairment expiring in his sleep is a good death. A six-year-old child, whether living in the United States or in a country in Africa or Asia, dying of a diarrheal disease is a bad death. The first is a peaceful end to a long and eventful life. The second is the loss of many decades of life and potential and an absence of future generations. As epidemiologists, we have two goals. The first is to prevent. When that is not possible, the second is to minimize disease and extended disability. Toward that end, we deploy an arsenal of medical countermeasures.

In 1900, the average life expectancy in the United States was forty-eight years. By 2000, just one hundred years later, it was seventy-seven. For every three days we lived in the twentieth century we gained a day of life expectancy.

With clean water, sewer systems, safer food, pasteurized milk, and vaccines, we made historic advances in eliminating the diseases that killed children, who are particularly vulnerable to the illnesses related to these environmental conditions.

we asked for detailed information about their sexual histories and the use of tampons and pads during their periods. Despite these sensitive questions, every control candidate we contacted agreed to participate. They were the real heroes in our study and helped us save many lives.

The CDC’s public message was that Rely brand tampons were responsible for the outbreak, and with their removal from the marketplace, the threat had now been eliminated. Rely consisted of polyester foam and a chemical called cross-linked carboxymethylcellulose, along with a coating called a surfactant. Surfactants are compounds that lower the surface tension between two liquids or between a liquid and a solid and make it possible for them to more easily blend together. Our TTSSS investigative team never dismissed a problem with Rely for one minute. But as far as we were concerned in the Midwest, where the initial cases had presented, simply an association with a particular brand of tampons was not enough. There had to be follow-up studies to get closer to a more complete answer.

We stopped enrolling new cases on September 19 because the CDC study reports all but guaranteed a bias toward the selective diagnosis and reporting of cases that used Rely tampons going forward.

While we had evidence there was something special about the risk of using Rely tampons, the real driver in the chance of developing TSS was the fluid capacity of the tampon a woman chose to use. And the TTSSS finding virtually predicted what would happen with cases in our states in the months following the removal of Rely from the market. The number of cases of young women with TSS did not change much; actually, it rose slightly. What happened instead was that those who came down with toxic shock syndrome were now mainly users of Tampax Super Plus brand high-absorbency tampons and a few other competing products. Not surprisingly, young women continued to use high-absorbency tampons because no one warned them about the real risk factor. And the prime beneficiary of P&G’s decision to withdraw Rely tampons? Tampax.

We eventually determined that the key factor in the development of TSS and the relationship between fluid capacity was the increased release of oxygen in the vagina with high-absorbency tampons and the presence of S. aureus bacteria. As the menstrual fluid was absorbed into the highly absorbent material, oxygen was displaced into the vagina. The higher the absorbency, the more oxygen was released.

Once produced, these toxins were absorbed through the vaginal mucosa—the membrane lining the vaginal walls—and straight into the bloodstream.

Ironically, shortly after the CDC announcement on September 19, the American College of Obstetricians and Gynecologists speculated publicly that it was a personal hygiene issue and recommended that menstruating women change tampons more frequently. This turned out to be exactly the wrong advice. By telling them to change their high-absorbency tampons more frequently, the college was putting women at higher, rather than lower, risk. The more frequently a woman changed her high-absorbency tampon, the more oxygen she introduced into her vagina. Another lesson I learned from my experience investigating TSS is that if you don’t know what you’re talking about, then don’t talk, or at least say you don’t know.

all the tampon manufacturers, reacting to the TTSSS findings, greatly reduced the fluid capacity of their highest-absorbency styles, and cases of TSS dropped dramatically.