Chapter 1
The Unmentionable Crisis Beneath Our Feet
When was the last time you thought about where your waste goes after you flush? For most of us in developed countries, the answer is likely "never." Yet this daily function-the most universal human activity beyond breathing-reveals profound truths about civilization, inequality, and our future. Rose George's "The Big Necessity" has been called "the best book about shit ever written" by Time magazine and counts Bill Gates among its devoted fans. This groundbreaking exploration of global sanitation has influenced public health initiatives worldwide and sparked uncomfortable but essential conversations about humanity's most taboo subject. As George reveals in her unflinching investigation, the way we handle-or fail to handle-human waste may be the most important public health challenge of our time.
Chapter 2
A Tale of Two Toilets: Global Sanitation Inequality
I need the bathroom. In the Ivory Coast, a Liberian waiter laughs at my expectation of a toilet, telling me to "do it on the floor." Meanwhile, at the British Library, I use one of many clean facilities without a second thought. This stark contrast illustrates why sanitation is a privilege, not a right-2.6 billion people have no access to any toilet whatsoever.
Despite technological advances, even wealthy nations struggle with waste management. Ninety percent of global sewage ends up untreated in waterways. When discussing sewage, most people recoil, yet great thinkers have found it worthy of study. Gandhi declared sanitation more important than independence. Le Corbusier called toilets beautiful objects. Freud thought studying excretion essential to understanding human psychology.
Human waste itself contains valuable nutrients that can fertilize plants and produce cooking gas. Historically, it was even used medicinally. The strongest taboos and euphemisms surround this daily function, yet those who address sanitation problems most effectively are those who speak frankly about it.
At a World Toilet Organization Expo in Bangkok, dedicated professionals work to solve the world's biggest unsolved public health crisis, their efforts largely unheralded outside their field. Their work represents a profound truth: how we handle our most basic bodily function reveals everything about our civilization, our priorities, and our relationship with our own humanity.
Chapter 3
London's Great Stink: How Sewers Saved a City
London's transformation from a disease-ridden metropolis to a modern city hinged on one critical infrastructure development: sewers. As the population exploded from 959,000 in 1801 to 2.3 million by 1851, the traditional cesspool system collapsed under pressure. Emptying fees-one shilling, twice a laborer's daily wage-were prohibitively expensive, and the introduction of flush toilets increased water volume beyond what the system could handle.
People illegally dumped waste into rivers, ponds, and sewers-structures that weren't designed for human waste but rather for rainwater drainage. By 1840, builder Thomas Cubitt testified that "The Thames is now made a great cesspool." This environmental catastrophe fostered disease, particularly cholera, which arrived from India in 1831. The first epidemic killed 6,536 Londoners; the 1848-49 outbreak killed 14,000 in London and 50,000 nationwide.
Ironically, early sanitary reforms worsened the situation. Edwin Chadwick, a prominent "sanitarian," advocated expanding sewers to carry sewage to the Thames, believing this would improve public health while sacrificing the river. Combined with the prevailing "miasma" theory of disease (which incorrectly attributed illness to bad smells rather than bacteria), this solution made cholera more deadly by contaminating drinking water drawn from the river.
The 1858 "Great Stink" finally forced change when Parliament could no longer ignore the Thames's foul odor. After just ten days of debate, they passed the Metropolis Local Management Act. Joseph Bazalgette, a small energetic engineer, designed an ambitious solution: enormous main sewers running parallel to the river at different levels, fed by smaller sewers, carrying waste to discharge points downriver. His twenty-year project used 318 million bricks, cost 4 million (6 billion today), and included the Victoria Embankment. Despite saving countless lives, Bazalgette has received little recognition beyond a small plaque and two suburban street names.
Today's "flushers" (sewer workers) admire Bazalgette for building 25% extra capacity, but his system now struggles with 13 million people instead of the 3 million it was designed for. Modern challenges include FOG (Fat, Oil, and Grease)-solidified cooking fat that blocks sewers and costs 6 million yearly to remove. Half of London's 100,000 annual blockages are caused by it, creating what workers call "fatbergs" that can grow to the size of buses.
The UK's aging sewer infrastructure causes 6,000 homeowners annually to experience sewage backups. Despite the 1875 Public Health Act requiring "effectual drainage," water utilities struggle with infrastructure costs while facing public outrage over rate increases. A 2004 parliamentary committee deemed sewage in living rooms "one of the most unpleasant events that can happen to any household"-an understatement that reveals our continued discomfort with discussing the most basic infrastructure that keeps our cities habitable.
Chapter 4
America's Crumbling Underbelly: New York's Sewer Crisis
Unlike London's unified approach under Bazalgette, New York's sewer development was piecemeal, with each borough president handling construction at their own pace. While drinking water infrastructure was built "for the ages," the sewer system was constructed with minimal investment. Though regularly maintained with concrete spraying, America's wastewater infrastructure received a D-minus grade from the American Society of Civil Engineers in 2005, with the EPA estimating that by 2020, half of the nation's sewer pipes would be in poor or very poor condition.
New York faces a critical design flaw: its combined sewer system (CSS) mixes sewage with storm water, causing regular discharges of raw sewage into waterways during rainfall. Even modest rain of one-tenth inch can overwhelm the system, resulting in weekly combined sewer overflows (CSOs) averaging 500 million gallons. Nationwide, 1.46 trillion gallons of wastewater are discharged annually. Despite catastrophic flooding in 2007 that paralyzed the subway system, New Yorkers quickly forgot the infrastructure crisis, unlike Londoners who responded to their "Lesser Stink" with protests and eventual government action.
The sewer workers themselves are a proud, skilled group who face challenges from massive cockroaches ("waterbugs"), aggressive rats, and the constant battle against an aging system. Despite their crucial role in protecting public health, they lack the prestigious nicknames given to other city workers, jokingly calling themselves "New York's stinkiest." They've assisted in criminal investigations and maintain a system that, while deeply flawed, would be difficult to replace with anything better.
Security concerns have increased since 9/11, with sewers now recognized as potential terrorist targets, similar to how sensitive London sewers have sensors linked to police stations. This vulnerability highlights how critical-yet invisible-our sanitation infrastructure remains to daily life. As one worker noted, "The best we can hope for is indifference." This indifference may prove our undoing as climate change brings more intense storms to cities with already overwhelmed systems.
Chapter 5
Japan's Toilet Revolution: Technology Meets Tradition
Japan stands alone in its approach to toilets, treating them as design objects worthy of innovation and improvement. The Japanese high-function toilet, commonly known as the Washlet, has become a standard household fixture-more Japanese homes have a Washlet than a computer. These remarkable devices can check blood pressure, play music, wash and dry intimate areas, heat seats, deodorize air, and automatically raise and lower lids.
This toilet revolution represents a remarkable cultural transformation. In less than a century, Japan shifted from a nation where 97% used squat toilets to one where heated seats and bidet functions are expected. TOTO, Japan's largest toilet manufacturer with two-thirds of the bathroom market and $4.2 billion in annual sales, began this transformation in 1917 when Kazuchika Okura decided to manufacture ceramic toilet bowls-a bold move in a country that primarily used wooden squatting toilets.
Progress was initially slow, but post-WWII reconstruction and American occupation forces' demand for flush toilets accelerated adoption. By 1977, sitting toilets had overtaken squatting ones in Japan, though not without cultural adjustment. The cold ceramic seats during Japan's winters presented a problem that eventually led to TOTO's innovation opportunity. In 1964, they adapted the American Wash Air Seat with spray and drying functions, but the initial version failed due to high cost and unfamiliarity.
TOTO's engineering prowess is evident in products like the Neorest, their premium $1,700 toilet with "a brain" that learns user habits and adjusts heating and water use accordingly. With sensors to detect when to raise or lower the lid and when users are finished, it represents the pinnacle of toilet technology. This technological advancement stems from meticulous research, including determining the precise 43-degree angle for the Washlet nozzle to prevent "backwash," achieved by surveying 300 employees who marked their anatomy's position on specially rigged toilet seats.
TOTO's market dominance over rival Inax came down to brilliant marketing. While Inax launched a similar product first, TOTO captured 70% of the market through strategic placement of Washlets in hotels and public spaces, allowing consumers to try them. Their masterstroke was a 1982 television campaign featuring actress Jun Togawa declaring that "even though it's a bottom, it wants to be washed, too." This memorable campaign resonated with Japanese cultural sensibilities around cleanliness. TOTO's genius was addressing the wabi sabi (simplicity and purity) values of Japanese consumers, offering a way to maintain distance from bodily functions in increasingly cramped urban living spaces.
Despite opening its U.S. office in 1989, TOTO has faced resistance in America. When they tried marketing "Clean is Happy" with billboards featuring bare bottoms, they encountered cultural barriers. The company has pivoted to celebrity endorsements, with Madonna, Jennifer Lopez, and Will Smith among Neorest owners. But as one competitor observed after years in the American market: "Americans just don't want to use it. They're not scared. They're just not interested." This cultural resistance reveals how deeply ingrained our bathroom habits are-and how difficult it can be to change them, even when presented with clearly superior technology.
Chapter 6
The Biogas Revolution: China's Excrement Economy
China's relationship with human excrement is fundamentally different from most Western nations-the Chinese are fecalphiliacs rather than fecalophobes. For 4,000 years, Chinese farmers have used human "night soil" as fertilizer, a practice that's kept their fields productive while other ancient civilizations' soils failed. This cultural comfort with excrement extends beyond agriculture into literature, mythology, and politics.
During the Communist era, excrement gained political significance, with night-soil collectors celebrated as national heroes and provinces competing in fertilizer collection campaigns. Today, China leads the world in biogas production from human waste. In biogas digesters-oxygen-free chambers that function like stomachs-microorganisms break down organic material into methane-rich gas that can fuel cooking, lighting, and electricity generation. The remaining slurry makes safer fertilizer than raw excrement. According to official figures, 15.4 million rural Chinese households connect their toilets to biogas digesters.
The scientific center of China's biogas program is BIOMA in Chengdu, established in 1981 with UN support. Despite aging facilities, its 87 staff members conduct research on improving gas yields, studying fermentation microbiology, and reducing disease risks. The technology is remarkably simple for farmers-"All he has to do is use the toilet, and then the gas." In Mian Zhu village, which serves as a showcase for the Ecological Homeland program, 60% of households (10,000 total) have digesters. The government provides substantial subsidies-1,200 yuan ($175) toward the typical 3,000 yuan cost.
The Shaanxi Mothers' Environmental Protection Volunteer Association has installed nearly 1,300 digesters across 26 villages. Each digester saves approximately three trees (1.2 tons of firewood) annually. Beyond environmental benefits, the technology reduces odors, decreases fly populations by 64%, and frees women from the labor-intensive task of gathering wood.
In Da Li village, which specializes in apple production, biogas has transformed daily life. Villagers previously used primitive "mao kun" (straw holes) for human waste, leading to worm infections and contamination issues. The digesters have increased village income by 300,000 yuan ($43,000) annually through savings on fertilizer, fuel, and medical expenses for stomach ailments. Women now have free time for weaving and other income-generating activities.
Despite its benefits, biogas isn't perfect. Digesters can fail due to mechanical issues or human error. There's debate about whether the digestion process fully eliminates pathogens. And as China rapidly urbanizes, the household digester model faces challenges in cities where livestock is absent.
Still, biogas shows promise beyond rural applications. The French city of Lille has converted buses to run on biomethane derived from municipal sewage, demonstrating that human waste can power public transportation with fewer emissions than fossil fuels. For rural Chinese like the elderly Mrs. Zhou, biogas has brought dignity, time, health, and pride-all from methane and excrement, inspiring her to compose poetry in honor of the technology that transformed her life.
Chapter 7
The Toilet Revolution: From Beijing to Bangalore
In rain-soaked Beijing, an ambitious toilet revolution is underway. As the 2008 Olympics approached, Chinese authorities launched an epic plan to construct or renovate 5,000 public bathrooms, ensuring no one would be more than five minutes' walking distance from decent facilities. This top-down "civilizing" effort follows historical precedent. Eighty years after Chiang Kai-shek's New Life Movement prescribed 96 specific rules for Chinese behavior (including no public urination), modern authorities are again attempting social engineering, targeting spitting, bad manners, and public defecation.
Meanwhile, in India, Dr. Bindeshwar Pathak founded Sulabh International in 1970, now India's largest sanitation charity with 50,000 staff. They've built millions of Sulabh Shauchalaya latrines and half a million public toilets used by ten million Indians daily. The phrase "going to the Sulabh" has become common parlance.
Pathak, a Brahmin who scandalized his family by working with untouchables, lived with scavengers in the 1960s and was horrified by their conditions. Recognizing Gandhi's approach of encouraging brotherly love across castes had failed, Pathak developed a technological solution: the twin-pit pour-flush "Easy Latrine" requiring minimal water and no sewers. Despite initial resistance, his model eventually succeeded by making sanitation a self-sustaining business rather than relying on grants.
Pathak pioneered the pay-per-use public toilet model, charging one rupee for toilet use while keeping urinals free. He approached municipalities with an innovative proposal: if they provided land and construction costs, Sulabh would operate the facilities and keep the profits. This business model transformed sanitation from something "no one wanted to know about" to a competitive tender opportunity.
In Mumbai, Sulabh operates 750 toilet blocks in prime locations, cross-subsidizing facilities in poorer areas. Unlike government toilets that are often vandalized, Sulabh facilities remain well-maintained. They provide free weekly passes to pavement dwellers and sometimes incorporate schools and health clinics. Though 60,000 scavengers have been "liberated" through Pathak's efforts, caste hierarchies persist-caretakers collecting money are typically Brahmins, while former scavengers work as cleaners.
In 1994, Pathak founded the world's best-known toilet museum to "make toilets interesting." The collection includes historical commodes, a model of the world's largest public toilet at Shirdi, and educational displays about sanitation history-from ancient Indus Valley flush toilets to modern celebrity toilet seats. Despite Sulabh's achievements, half a million Indians still clean dry latrines manually. "Sanitation is a gigantic problem," says one colleague. "The world needs a thousand Sulabhs."
Chapter 8
Community-Led Total Sanitation: Triggering Change
In 1999, agricultural scientist Kamal Kar revolutionized sanitation approaches when he visited the Bangladeshi village of Mosmoil for WaterAid. Instead of assessing latrine-building programs, Kar asked villagers why they defecated in the open. Using "participatory rural appraisal" techniques, he led villagers through their open defecation areas and had them map where they relieved themselves.
The breakthrough came when villagers calculated they produced "120,000 tons of shit" annually and realized they were consuming about 10 grams of each other's fecal matter daily through contamination. This revelation triggered immediate disgust-people vomited from shock and children began digging latrine pits without any subsidies or technical assistance.
Kar named this approach Community-Led Total Sanitation (CLTS), emphasizing that change must come from within communities rather than through external intervention. The method deliberately triggers disgust, then harnesses shame and pride to maintain momentum. Despite initial reluctance to try CLTS in India's subsidy-dependent environment, Kar eventually brought the approach to Himachal Pradesh, where 80% of people practiced open defecation.
The method's success relies on simple demonstrations like showing flies moving between feces and food, and encouraging local innovation in latrine construction rather than providing expensive standardized solutions. The CLTS process relies on "natural leaders"-persuasive local residents who emerged during triggering sessions. These leaders earn 100 rupees per household they successfully trigger in nearby communities.
India's sanitation efforts have evolved from the subsidy-heavy approach to the Total Sanitation Campaign (TSC), inspired by successful regional programs. The TSC reduced subsidies to just $11 per poor family (a third of previous amounts) while emphasizing education, persuasion, and local "Rural Sanitary Marts" selling affordable equipment.
The program shifted focus from counting toilets built to counting people still practicing open defecation, with the goal of making India "Open Defecation-Free" (ODF). Rural Development Minister Raghuvansh Prasad Singh backed the campaign with $810 million and creative initiatives like the Nirmal Gram Puruskar (Clean Village) prize, awarded by India's president to villages achieving 100% toilet coverage. In 2007, ten thousand villages applied, up from just 35 winners in the first year.
In rural villages, the impact has been profound. Gram Vikas villages display posters reading "I will give my daughter in marriage only to a village with a toilet and a bathroom"-not mere propaganda but reality. Young brides now return home from toiletless in-laws' villages, disturbed by their practice of defecating and bathing on opposite sides of the same pond. This creates "sanitation contagion" as villages persuade neighbors to adopt toilets. Villagers who've adopted toilets find it difficult to visit places practicing open defecation, showing how sanitation becomes a moral issue and communal concern rather than individual choice.
Chapter 9
The Urban Challenge: Slums and Sewage
Cities should make sanitation easier due to density, wealth, and shorter distances for infrastructure. Historically, the "sanitarian city" or "hydraulic city" emerged when urban environments successfully separated humans from waste. Yet slums defy this logic, being so chaotic that experts struggle to define them beyond what they lack: secure housing, quality construction, and adequate water and sanitation.
Mumbai's slums illustrate this contradiction. In Shanti Nagar, some houses are worth more per square foot than posh apartments, with two floors and lockable doors. Its location near roads, schools, and markets makes it desirable for servants and tradesmen. Yet 4,000 residents share just 26 toilet stalls in one community block-a half-hour walk away. Office workers and university lecturers live amid endemic filth where children squat over open drains among flies and vultures.
This represents our urban future-already nearly a billion people live in slums worldwide, with Africa's slum population doubling every fifteen years. One hundred thousand people move to slums daily, creating environments of corrugated tin, plastic sheeting, and open drains that defeat urban sanitarians.
The "big necessity"-a private toilet-remains rare in slums. Installing flush toilets for every slum dweller would be prohibitively expensive, requiring sewer lines that authorities refuse to lay in illegal settlements. Traditional sewers cost five times more than night-soil collection systems.
Alternative approaches exist: Brazil's "simplified sewerage" uses smaller pipes in shallower trenches, while Karachi's Orangi slum successfully implemented a community-organized sewer system serving 95,000 houses. In Mumbai, community toilet blocks represent the next best option, though historically these have failed due to poor maintenance.
In Tanzania's coastal city Dar es Salaam, sanitation statistics mask a grim reality. While 96% supposedly have pit latrines, many residents use "flying toilets" (defecate in plastic bags and throw them), makeshift facilities, or "passport toilets" with shoulder-height walls. Proper pit latrines cost $300 due to sandy soil-unaffordable for many.
During rainy seasons, many simply divert overflowing pit contents into streets, causing regular cholera outbreaks. Despite this health crisis, the municipal budget allocates less than half a cent per person for sanitation. To address Dar's pit-emptying challenges, engineer Steven Sugden developed the Gulper-a manual latrine-emptying pump designed to be affordable, portable by motorbike, and able to navigate narrow slum alleys. Following the generous tradition of sanitation innovators, Sugden refused to patent his invention, believing accessibility was paramount.
Chapter 10
From Space to Earth: The Future of Sanitation
NASA's Environmental Control and Life Support System represents necessity-driven innovation in waste management. Unlike early space missions where astronauts used primitive fecal bags and urine collection systems, modern space stations recycle urine into drinking water-a practical solution to the prohibitive cost ($40,000 per gallon) of transporting water to space.
This recycling approach may represent Earth's future as water scarcity increases. The planet contains a fixed amount of water (332 million cubic miles), with only 2% being fresh and two-thirds of that locked in ice and permafrost. Global water consumption doubled between 1960-2000, reaching approximately 1,700 liters per person daily, with 69% used for agriculture. By 2050, half of the projected 8.9 billion people will live in water-scarce countries.
We're wasting our limited water supply primarily by contaminating it. One cubic meter of wastewater can pollute ten cubic meters of water, and discharging it into oceans turns freshwater into less useful saltwater. Though water reuse is increasingly necessary in water-stressed regions, proposals like San Diego's "Toilet to Tap" face public rejection despite advanced filtration technology.
Ironically, recycled wastewater is already widely consumed. Londoners drink water that's passed through multiple people's systems, and American municipalities get drinking water from reservoirs containing treated sewage effluent. Sometimes sewage effluent is even cleaner than drinking water, revealing systemic inefficiencies in our water management.
In China's rural Shaanxi Province, ecological sanitation offers an alternative. Plan International's urine-diverting twin pit toilets separate waste for composting, reducing water usage by 80%. Despite initial resistance, locals have embraced these "techno toilets" that turn waste into fertilizer while closing the nutrient loop that sewers disrupt.
The sanitation field is shifting toward flexibility rather than the traditional "sanitation ladder" that positions flush toilets as the ultimate goal. With wastewater treatment consuming significant energy and pharmaceuticals in wastewater emerging as a concern, economic pressures may drive innovation toward more sustainable systems.
The economics of sanitation are compelling: every dollar invested in sanitation brings a $7 return in health costs averted and productivity gained. Globally, achieving universal sanitation by 2015 would cost $95 billion but save $660 billion. Real-world evidence confirms this: Peru's 1991 cholera outbreak cost $1 billion to contain but could have been prevented with $100 million in sanitation measures.
Yet sanitation remains a political football, kicked between government departments. Even in countries with dedicated ministries, "watsan" budgets average just 0.5% of government spending, with sanitation getting the smaller share. As one expert noted, "The evangelism comes first, the political process will follow." The ground troops of sanitation now include people like Trevor Mulaudzi-a South African geologist who calls himself "Dr. Shit"-who left his comfortable mining job to clean school toilets after discovering deplorable conditions that kept children from attending school.
As we face growing water scarcity, climate change, and rapid urbanization, our approach to sanitation will determine our future. The most promising solutions don't necessarily involve more sophisticated technology but rather a willingness to confront our most basic bodily function with honesty, creativity, and respect for both human dignity and planetary limits. The time has come to talk about crap.
