by Rose George
In 2013, an organization with the unappealing name of Naturally Savvy examined various tampons manufactured by o.b., a German brand, using a “third-party certified” laboratory. The lab was looking for pesticide residue, and it found traces of malaoxon, malathion, dichlofluanid, mecarbam, procymidone, methidathion, fensulfothion, pyrethrum, and piperonyl butoxide.43 The FDA recommends that tampons be “free of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)/2,3,7,8-tetrachlorofuran dioxin (TCDF) and any pesticide and herbicide residues,” but does not require manufacturers to monitor pesticide residue.44 In 2016, a report from Argentina’s National University of La Plata found glyphosate, a chemical used in 750 common pesticides, and judged by the World Health Organization to be a carcinogen, in 85 percent of tampons, cotton wool, and gauze.45 But glyphosate is everywhere: most of us carry traces of it by now. It is in soil and cotton clothing. Dr. Jen Gunter, a Canadian gynecologist who likes to spear pseudoscience, in a post entitled “No, your tampon still isn’t a GMO-impregnated cancer stick,” wrote that she would “worry a lot more about what you eat and what you wear and where you walk barefoot than a tampon you use four days a month.”46 When the Swiss government’s chemical research unit commissioned research into tampon contents, it found nothing of concern.47
There are two facts to trouble this moderation. The first is that highly absorbent vagina. The second: that in an average lifetime, a woman might use many thousands of tampons. As for fragranced sanitary pads and tampons, they are a blank yet scented slate: because tampons and pads are classified as medical devices, there are no regulations requiring manufacturers to disclose ingredients.48 Nor is the FDA currently required to do anything, should toxic shock or a similar health crisis happen again, other than recommend a recall of products. For an industry named for femininity, this seems like a very gentlemanly arrangement. What is a menstruating, tampon-wearing woman supposed to believe?
I side with Carolyn Maloney, a congresswoman in New York State who in 1997 first put forward the Tampon Safety and Research Act.49 Her trigger was a student who asked her what was in tampons. “I was shocked to learn that the science just wasn’t out there. I remember there was more research at the time about coffee filters than tampons.” In 1999, she changed the bill’s name to the Robin Danielson Feminine Hygiene Product Safety Act, in honor of a forty-four-year-old woman who died from toxic shock syndrome. In 2017, Maloney introduced her legislation for the tenth time. The GovTrack website currently gives the bill a 1 percent chance of success.50 Back in the late 1990s, toxic shock was more resonant and Maloney easily got more co-sponsors. Hardly anyone is dying from toxic shock now. And things have slightly improved, she tells me. “The feminine hygiene industry has done some self-correction. We’ve seen changing ingredients and changes in the bleaching process. Some companies have voluntarily labeled at least some ingredients on boxes.” Consumers are being more demanding (and the presence of organic-only competitors might be a factor in persuading manufacturers out of their secrecy habit). But, as Maloney wrote in an opinion piece, there is “almost no data on the health effects of the cumulative use of tampons over a woman’s lifetime.” Imagine, she continued, if we examined the health effects of smoking only a single cigarette. “My bill makes no prejudgments about the safety of products that are enumerated in the bill. It just says show us the research.”51
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These are first-world problems. But not for long. By 2022, according to some market research firms, the sanitary protection industry will be worth $42.7 billion.52 Where is all that growth coming from? From “significant unmet potential in developing markets.”53 From the world of cloths and rags and sand and chocolate cartons.
But the question of how all these pads and tampons will be sensibly disposed of is as quiet as the subject of menstrual blood. Indians already use one billion noncompostable sanitary pads each month;54 where do they go? Incinerators are rare and can have unpleasant environmental impacts if used at scale. Also, burning menstrual cloth is thought to bring on infertility. Burying pads is time consuming and modern plastic-filled sanitary pads can take up to eight hundred years to decompose. In a study in Bihar, nearly 60 percent of women simply chucked their used pads and cloths into fields and roadsides.55 India’s waste disposal infrastructure is already overloaded, and with much garbage disposal done by low-caste waste pickers, the many more millions of pads a month that the sanitary pad revolution will supply is both a huge burden and a biohazard for the humans who deal with them. Even when sewers do work, they can be easily clogged by sanitary napkins, which are designed to absorb liquid and expand, exactly what you don’t want in a narrow sewer.
Yet despite extensive and expensive outreach and education programs run by Procter & Gamble, Kimberly-Clark, and others, the feminine hygiene market is slow to flourish. P&G has partnered with NGOs and UN agencies to bring school-based and community-based feminine hygiene and puberty education programs to between seventeen million and twenty million young women annually.56 As Muruga quickly learned, commercial products are too expensive for poor women. A single sanitary pad is a luxury item, let alone a box of tampons. I read accounts of girls who have sex with older men in order to earn money for essential items like sanitary napkins. It’s called “sex for pads,” and though it is hidden, it is common. A field officer for one NGO called Freedom for Girls in Nairobi reported that 50 percent of girls she encountered in the slum of Mathare had turned to prostitution to afford sanitary pads.57 When researchers surveyed 3,418 menstruating girls and women in rural western Kenya, one in ten of the fifteen-year-olds reported selling sex for sanitary pads.58 In Ghana, the Girls’ Education Unit of the Ghana Education Service reported that 414 teenage girls in twenty-six districts in the eastern region “were impregnated in the last two years while exchanging sex for sanitary pads.”59 Out of this 414, 229 got pregnant in the first year; 185 in the second. One young Kenyan girl responding to interviewers said, “Some people exchange sex for money. The money is used to buy pads.” Another said, “You pay him your vagina.”60
Only 120 girls were interviewed in that study, and large-scale academic research is still absent, but there are enough anecdotes and small studies to cause alarm. Other women thankfully resort to knockoffs, not sex. Sanitary pads can be faked like anything else. Lebanese customs officials recently seized a half-ton shipment of sanitary pads that were found to be severely radioactive. The pads were made in China by a company claiming they contained anions, groups of negatively charged ionized atoms that apparently had health benefits if you put them in your pants and bled into them. (Another name for anions, the company said, was “air vitamins.”)61 A writer on one Chinese blog, pleased with himself, wrote that the products were “guaranteed to redefine the concept of having a ‘hot girlfriend.’”62 In China, forty-three suspects were arrested in 2013 in a “counterfeit sanitary-napkin ring,” a phrase I was unprepared to read, that spread across six Chinese provinces. The operation had been undertaken when women reported feeling unwell after using sanitary pads, and forty-three manufacturing “dens” and twenty production lines were closed down. The net worth of that counterfeit sanitary-napkin ring was 150 million yuan ($22.7 million). Under one of the reports, a woman left a comment. “We women are already in pain during our period and you people (the suspects) produce fake sanitary towels. You are not human. I suggest they be sentenced to death.”63
An investigation into India’s sanitary pad market found dirt and ants in nineteen products widely on sale. Indian sanitary napkin standards haven’t been updated since 1980, apart from an amendment in 1981 that replaced the words showing up with staining or leaking through. Sanitary napkins must absorb “30ml of colored water or oxalated sheep or goat blood or test fluid when flowed on to the center of the napkin (at the rate of 15ml per minute) and it shall not show up at the bottom or sides of the sanitary napkin. The pH value shall be from 6 to 8.5.” I go through the document carefully, but this doesn’t take long: a product that is to come into contact wi
th a highly sensitive part of a woman’s body several thousand times gets five pages, double spaced. There are no requirements for what the cotton or material should contain, though the government does worry sufficiently that the filler of the pad “does not cause lump formation with the effect of sudden pressure.”64 I’m not much more soothed by a rare insight into Procter & Gamble R&D, which reveals the behind-the-knee (BTK) test. Designed to assess possible chemical and mechanical irritation, “materials (pad, panty liner, topsheet, uncompressed tampon, fabric, facial tissues, etc.) are placed horizontally behind the knees and held in place using an elastic athletic band of the appropriate size.” After six hours, both band and test material are removed, and “the area is illuminated and visually scored for erythema or dryness by an expert grader.”65 Although I’m not convinced that my popliteal fossa looks and feels anything like my genital area, BTK has been accepted by the American Society for Testing and Materials as a global standard test.66
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Psychologists and NGOs like “drivers” because they bring change. A driver might be someone like Muruga, self-made and eccentric, or period activists like AFRIpads or Irise, all good NGOs doing good work in developing countries. But a driver doesn’t have to look like an NGO or charity. Sometimes it can look like Levi’s or Timberland or Coke, despite Muruga’s scorn of “mosquito” parasitical big business.
In 2010, a women’s health initiative began in Dhaka, Bangladesh. It was named HERproject (in which HER stands for Health Enables Returns) and was a program run by Business for Social Responsibility, a membership organization of 250 companies worldwide that includes Microsoft, Sony, Pepsi, and Coca-Cola.67 Dhaka was an appropriate place for a business-backed project because many BSR members have their products made in Bangladesh’s five thousand garment factories. There are three million Bangladeshis working in the garment industry, and 80 percent are women. They are difficult to reach: the garment industry is suspicious of the press because the press reports things like the Rana Plaza factory building collapse in 2013, which killed 1,129 workers.68 Under the wings of HERproject, I was given access to a factory that I wasn’t allowed to name, on a street I couldn’t identify, run by companies I wasn’t permitted to mention who produced clothing for Western brands that had to remain anonymous.
Most garment workers in Bangladesh arrive in the cities with little education. They come aged sixteen or younger, but with a certificate from the village leader saying they are eighteen. They leave their villages too soon to benefit from NGO education programs, and there are barely any NGOs working on hygiene or education in urban areas. So Nazneen Huq, HERproject’s Bangladesh director, set up schemes to improve awareness about nutrition, sexual health, and HIV/AIDS. But she knew she also needed to talk about periods. Factory managers admitted that their female workers were not turning up for work for several days every month. When a factory operates on tightly controlled production lines, a missing pieceworker is noticed. A missing day is definitely noticed, by man, machine, and spreadsheet. Huq, who has worked with garment factory workers for years, had two simple implements: frankness and economic loss.
“They knew that women were going absent, and they knew that it had to do with periods, but they didn’t dare talk about it.” Huq’s tactic was to focus on what managers would talk about, which was business. “I would say, if you have a thousand workers who are women, and each woman is absent one to three days … They answered, embarrassed, yes, yes. If five hundred are absent for one day you lose five hundred productive days. Then they get very shy, but they say, yes. It makes sense.”
All these managers knew about compliance, as Bangladeshis call workplace safety. They just hadn’t thought about health, beyond providing the medical center required by laws. They didn’t realize that poor health costs them money. They didn’t know, for example, that 80 percent of their female workers didn’t use sanitary pads because they couldn’t afford them. One of the first factories targeted by HERproject is in Ashuria, a suburb only a few miles from downtown Dhaka, but a three-hour trip in Dhaka’s appalling traffic. It is a good factory, as factories go: it is properly ventilated and it has decent toilets. Downstairs, there is a crèche. The workers are protected by face masks, obviously produced from material covered in cartoons that will become children’s leggings or pajamas, a sight that is jolting among the machinery and industry.
Panna, a twenty-five-year-old worker, comes away from her post on the Finishing Section to talk. The HERproject model works with “peer educators,” women who are trained, then responsible for disseminating information to twenty other female workers. Panna came to Dhaka four years ago, and as soon as she started work, she managed her period as everyone else did, by using scraps of cloth from the factory floor. They call it joot. “We got it from the cleaners. They would sweep it up and give it to us. It was very itchy.” Every month, she stayed at home for one or two days. “I was in pain a lot, and the joot only lasted half an hour. There was leaking, discharge. But we didn’t know about reproductive health, even though we are women.” (She uses “reproductive” to mean “gynecological.”) In another smaller factory nearby, a woman named Banani leads me to the cutting room. Here, barefoot men run along long tables pulling billowing lengths of cloth behind them, for fellow workers to cut. It’s quite beautiful to watch. Banani, the factory’s welfare officer, leads me to a bin near one of the tables. “There. That is joot.” It used to be her job to gather the joot in secret and hand it over discreetly to whoever asked for it. Every woman I spoke to had regularly had discharge and health problems from using joot. There were insects in the bins; people threw water into them. Seventy percent of women, says Huq, had white or smelly discharge. “They thought white discharge was a part of life.” Up to 10 percent of workers were going absent. Once they were asked, the factory managers—all male—admitted that they knew about joot. One was getting requisitions to clean the sewer pipes all the time, because they were clogged with menstruous rags.
Most women here now use sanitary pads. A central part of HERproject is to persuade factories to buy sanitary pads from a local supplier and sell them at a highly subsidized cost. In this factory’s medical center, a basic but clean room off the factory floor, there are several boxes of pads, sold to workers for 31 taka, about 30 US cents (compared to a market price of 90 taka). The compliance officer here is an intense young man named Hasan. “We had real problems with absenteeism. And obviously this is a production-based factory. But even so, the general manager was embarrassed to talk about menstruation.” Absenteeism is now down to 6 percent, according to the factory’s records, and embarrassment is redundant. Sewer pipes are no longer clogged. In another Dhaka factory, absenteeism dropped by half. A factory manager said that although she initially saw the program as “just another project,” she had to change her mind.69 Now the male workers are asking for a health project.
Managerial blockages still occur, as surely as joot blocks a sewer. The program model requires an hour a week for the training in the first years, and not every manager is willing to take that time away from the production line. Progress may not have the speed of those barefoot men on the cutting tables, but it is going in the right direction. And hopefully unblocking one stigma unblocks others. “The HERproject has also helped my relationship with the women workers,” a factory manager named Mr. Riaz said. “They are not so shy to talk to me anymore. If there are problems, I now hear about them.”70 HERproject has now reached eight hundred thousand women in seven hundred factories and farms. In Bangladesh, its data show that in ten factories, the proportion of women using sanitary pads has risen by 49 percent.71
As I sit in a HERproject refresher course for peer educators, surrounded by young women wearing pink HERproject aprons and head scarves made from the school uniform material the factory produces, someone brings me a brown paper bag. All around me, women are talking with frankness and freshness about a subject that would usually be confined to whisper and shame. It’s great. As the women d
iscuss sexually transmitted infections, the health and hygiene of the reproductive tract, and the unquestionable nutritional value of pumpkins, I open the bag and find a sanitary pad taken from the factory’s subsidized supply. It is produced in Bangladesh, manufactured by Savlon, and its name is Freedom.
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A driver might be a blocked sewer. It might be a large dose of bloody-mindedness. It might be an end of a tether. Whatever the driver, the last few years have seen something tip and topple. A male gynecologist told me a few years ago with conviction that menstruation was not taboo in the UK. I looked at him in disbelief and said, “The day that menstrual blood doesn’t have to be represented by blue mouthwash, because it is thought dirty and distressing, you will be right.”
