Waste Happens: A Q&A With the Author of The Big Necessity

INSERT DESCRIPTIONPhoto: Felicity Paxton

I’ve never thought much about my toilet. (Though we’ve discussed toilets on this blog here, here, and here.)

It usually does its job; sometimes it needs a little help from the plunger.

Rose George‘s new book The Big Necessity: The Unmentionable World of Human Waste and Why It Matters not only got me wildly interested in my toilet, but also in what happens after I use it.

In her book, she discusses why we should pay a lot of attention to an issue that affects everyone — several times a day — and why aversion to it (on a personal and global level) isn’t doing us any good.

George holds a master’s degree in international relations from the University of Pennsylvania. She has written for The Nation, Slate, Details, The New York Times, and many other publications.

She has agreed to answer our questions about her book. But first, she has a question for Freakonomics blog readers:

Do you ever wonder what happens after you flush the toilet? If you don’t, why not?

Post your answers and comments below.

Q: What does the U.S.’s current level of sanitation do to health care costs? What would you suggest we do to improve our sanitation and what could the effects of that action be on health care?

A: I don’t have figures for nationwide health costs, but you can guess by looking at the few studies that have been done. For example, a study out of Stanford in 2006 found that sewage outfalls near 28 California beaches caused up to 1.5 million excess gastrointestinal illnesses, which cost California up to $51 million in health care costs (in year 2000 dollars). And that’s just 160 kilometers of coastline.

Sewage outfalls are common in all water bodies across the U.S., and discharges of raw sewage are far more common than most people realize; because most sewer systems are “combined” (meaning they also take in surface water from streets), and because of population growth and the fact that many sewers are decades and sometimes centuries old, they are very vulnerable to heavy rainstorms. Every week, New York discharges over 2,000 Olympic swimming pools worth of untreated sewage into waters nearby.

And the case of Peru might also give some indication of costs that can be incurred: when Peru had a cholera outbreak in 1991, losses from agricultural revenue and tourism were three times greater than the total money spent on sanitation during the previous decade.


Q: What is the best way to change public perceptions about waste/excrement/(insert preferred euphemism), and why is it important that we do?

A: It will sound simplistic, but what the deeply neglected world of sanitation needs is a champion. I don’t much mind who that is, but it has to be someone with star power who is willing to stand in front of a nice clean school latrine and point out how cool it is and how life-saving (when toilets and sewers were introduced in London in the 19th century, child mortality dropped by a fifth).

But I’d also like people to understand that it’s not just a developing-world issue. It’s not only a poor person’s problem. Public perceptions about sh– tend to veer between toilet humor and embarrassment.

In between those two poles lies a lot of unspoken dissatisfaction. Major western cities like London and New York have a shameful lack of public bathrooms, and city authorities continue to close the ones that do exist. Why are there no protests? The social pact is surely that citizens pay taxes and get essential services in return. Waste disposal is an essential service, and I’m not talking about garbage collection. Get out on the streets and protest!

Q: You mention that the way the benefits of sanitation are calculated is a roadblock to progress; how so?

A: They’re not calculated and that’s the problem. Health economists — particularly Guy Hutton at the World Bank and his colleagues — have figured out that if you invest $1 in sanitation, you save $7 on health care and lost labor costs. That’s a lot of money.

To put it another way, if a minister doesn’t invest $1 in sanitation, he/she will lose $7 in health care and lost labor costs. That, to a minister on a tight budget, seems like even more money.

Now that those calculations have been done, perhaps the messages can be conveyed in a more compelling way. The trouble is that in most countries, responsibility for sanitation is fragmented between various ministries; it’s in health, education, and local government. No one has final responsibility; so no one does the math.

INSERT DESCRIPTIONMumbai, India (Photo: Rose George)

Q: Why, as you write in the book, is a toilet still only a distress purchase in the U.S., while it’s constantly being developed and advanced in a country like Japan?

A: For all sorts of reasons. The Japanese toilet revolution has happened over 60 years and for several reasons. Transforming the toilet into a must-have product appealed to the Japanese love of gadgetry, for a start. Having toilets with inbuilt bidets that can massage you, but are totally hands-off, appeal to the Japanese sense of wabi sabi (i.e. a love of cleanliness and purity), but also enable Japanese to have no contact with their excrement.

Clean, hands-free. It was a winnable concept.

As for why Americans haven’t been convinced yet, it’s because, like most of us with flush toilets, as long as they flush and work, we don’t notice them. Until you use a Japanese robo-toilet, you won’t get it. Perhaps when they make more headway in the U.S., Americans might start to see the light. But they’d have to be cheaper first.

I do think there’s a market in the U.S. for washing rather than wiping: I did a Q&A for Salon recently, and of the 70 or so comments that were left, nearly all were about washing your butt and how much better it was. I was astonished.

Q: Do plungers sell in Japan?

A: I have no idea. I never saw one. I think plungers are a strangely filthy concept. Also, those Japanese toilets are so coated with non-stick chemical stuff, and so beautifully engineered — except the ones that caught fire a year or so ago, but that’s electricity in the vicinity of water for you — that plungers are, I suspect, unemployable.

Q: So is it better to squat or sit?

A: To put it simply, sitting squeezes bits in the body that you don’t want to be squeezed when you’re trying to evacuate stuff. So biologically and ergonomically, squatting is a much more efficient position to use to empty the bowels. But centuries of toilets and chairs have weakened our thigh squatting muscles, and squatting is not easy for elderly or disabled people. So sitting has its place.

INSERT DESCRIPTIONShanti Nagar, Mumbai, India (Photo: Rose George)

Q: In the book, you mention that euphemisms for waste can be destructive. How so?

A: I don’t think euphemisms are destructive, and of course I’m not advocating that people begin to use words they find uncomfortable or upsetting. Euphemisms have their place. But I think when a euphemism gets into the corridors of power that can do something about the parlous state of sanitation in the developed and developing worlds, and the euphemism is being used as a way to avoid the issue, that’s a problem.

If we can’t find forthright ways to talk about this — and if we persist in talking about “water-borne diseases” when we mean sh– -related diseases — then we will continue to be handicapped and we will continue to have a child dying of diarrhea — diarrhea! — every 15 seconds.

Q: Everyone in New York has told me that you can drink New York City tap water straight from the sink. What’s likely in that water? Should I use a filter anyway?

A: I drink tap water on principle. I prefer it filtered, but that’s my preference.

But studies have found trace elements of pharmaceuticals in there, which is unsurprising when you learn — as the Associated Press did in an investigation earlier this year — that many hospitals and clinics simply pour their unused drugs down the toilet or sink. It all ends up in sewers. The trouble with sewers is that anything can go down them and there’s a limit to what can be removed. It’s hard to remove things when you don’t even know what’s in there in the first place.

The pharmaceutical levels are small — you’d have to drink a lot of sewage effluent to get even a pill-full of ibuprofen, probably — but the issue to my mind is how pharmaceuticals combine. They’re prescribed carefully above ground but not once they get to the sewers. I’m not being alarmist — and I drink tap water wherever it’s safe (not in Delhi, India, where I am now) — but I do think questions should be asked.

Q: What could a Hollywood celebrity do for world sanitation?

A: It’s very basic, but sanitation is so neglected that a Hollywood celebrity could move mountains by simply talking about it. They could pose in front of a school latrine, for example, with a young girl who had dropped out of school because she was mortified there were no latrines, and who is now back in school, and whose future is much shinier than it was.

It’s a no-brainer: Good sanitation reduces disease by 40 percent. To be fair, Matt Damon did talk about latrines at the Clinton Global Initiative rally, and that’s great. He already does wonderful stuff with clean water supply.

It’s only logical he should see the link with sanitation. You can’t have one without the other. You can’t even feed a child without good sanitation; you can stuff a child with calories, but if the food or water is infected with fecal bacteria, he’s not going to keep those calories in.

Sanitation is often why you get malnourished children in well-fed families.

Q: Why do people hate biosolids and should they hate them as much as they do?

A: People don’t like biosolids because they believe that they’re not safe; because sewage sludge — to give biosolids their real name — is, after all, the dirt that is removed from sewage, and can contain whatever has been put down the sewer, including strong antibiotics, heavy metals, and all sorts of chemicals.

So there is a growing grassroots movement of activists who strongly object to this stuff being put on fields near their homes. And there is also a growing collection of anecdotal reports — collated, for example, by Ellen Harrison at Cornell — of people who claim they are being made ill by biosolids.

That said, the E.P.A. insists that biosolids are safe as long as regulations are followed, and the people who work in the industry told me they’d happily let their kids roll around in it, they’re that convinced.

It’s not for me to say whether people should or shouldn’t hate them. I think more epidemiological studies should be done, and the two sides should talk more.

The trouble is that if sludge isn’t applied to land, where can it go? It can’t be dumped at sea, as that’s now banned. Landfills are also out. The only other credible option is incineration, which can be expensive and also unpopular with people.

Q: What do you do differently now as far as sanitation/toilet habits? What’s the main behavior you try to promote in others?

A: Ever since a toilet designer told me that wallpaper changes color from all the urine spray flying around from the flush, I always put the toilet seat lid down. I try very hard never to put cooking oil down the sink or drain (I wait for it to dry and put it in the trash or pour it on soil) ever since I saw huge mounds of dried fat blocking a sewer stairwell. I wash my hands more carefully, but not obsessively. Sometimes I don’t flush if it’s just urine; it can wait and it saves water.

I’d encourage people always to wash their hands and to think about how to reduce using water; that’s clean drinking water; it’s precious. For rural people who can bear to think about it and deal with it, I’d suggest thinking about composting toilets. But they aren’t for everybody, and I’m realistic about that.

But really the main behavior I’d like to see is for us to be open about this. It’s a huge problem; it’s not going to go away. Let’s talk about it.


The sanitation world's new champion: Mike Rowe from Discovery's Dirty Jobs. http://dsc.discovery.com/fansites/dirtyjobs/bio/bio.html

Joe Smith

"Do you ever wonder what happens after you flush the toilet? If you don't, why not?"

No. because I have a pretty good idea how my city's system works although now that you mention it I do not know what ultimately happens to the sludge.

It is entirely possible that modern sanitation has saved more lives than modern medicine and that sewer workers are more important to public health than doctors.


Girls don't poop... everyone knows that.


Why do we have to spread biosolids on land can we not digest them to make methane gas and burn it to produce electricity? There should be very little residue and most of the bugs will be dead by then. Perhaps my view of the world is too simplistic.

Mark B

Such improvements would seem to be fairly low down on the priorities list. The cost-benefit calculations would suggest greater payoffs for underdeveloped nations, than in developed countries.


@paul - I may be mistaken, but the biosolids/sludge should be what's left after all the digestion into methane is done. It's basically all the other crap (pun intended) that's left behind after processing.

Thomas B.

I used to work on the 96th floor of the World Trade Center in NYC and I often thought about it.

I wondered how long it took my #2 to get down to street level. Did it go straight down or were there turns along the way. Did the pipes get progressively larger as my "shipment" met with others on the way down? On an average day how many shipments did my building produce?

Alas I never did find any of the answers.


I know right where my flushings go: down into my septic tank and out into my leach field and from there into the ground and the trees. Heck, it probably goes from there to my well (on the other side of my property), and up to my toilet for another go at the whole cycle!



It's true - nobody wants to talk about poop. However, in my personal social circle, it is not such a taboo topic. I am, in fact, in this very moment feeling the first rumblings of what may become a very intriguing entry into our oral tradition.

Bobby G

I would have liked a few more puns in this article. For example, the pinultimate sentence: It's a huge problem; it's not going to go away.

So many possibilities... on the downside now I do feel like one of the jerks mentioned in the article hah.

Leland Witter

I'm with Philippe - my sh*t stays on my property, but I have been curious about how well (no pun intended) a septic field system works. From my personal perspective it's great - no cost and very minimal maintenance, and it "feels" like it's better overall than the alternatives, but is it?

Chris S.

Never wondered a bit until I worked for a while as an engineer in the wastewater industry.

One of the more pressing infrastructure problems in the US is the use of lower flow faucets, showerheads, toilets, etc, which lead to a more concentrated waste stream.

During the time it takes your waste to flow from your house to the treatment plant, it decomposes anaerobically (no oxygen) into - among other things - hydrogen sulfide. Aside from smelling like rotten eggs, hydrogen sulfide dissolved in water makes sulfuric acid which eats away at iron and steel pipe as well as concrete.

Since waste streams are now more concentrated, so too is the sulfuric acid, accelerating the "sewer rot". The design life of such infrastructure is constantly being revised down - the stuff simply doesn't last as long as it used to.

So now I am environmentally destructive both by using more water and by using less. Hooray...

So to help ease the load on our local waste treatment plant, I removed my garbage disposal. What used to go in, I now either throw in the garbage (animal-based) or compost (vegetable-based).


Nuclear Mom

What excellent timing. The US will be looking for infrastructure projects to put people to work, and so many cities have 100-year-old sewers and water mains. A match made -- well, maybe below heaven, but still.

As far as disposal of the "remains," education is a wonderful thing. We are FINALLY using treated effluent to recharge aquifers, hold back saltwater intrusion in wells, and, yes, to increase the supply of drinking water. After all, every drop of water you drink has been recycled many times (dinosaurs peed, water evaporated, rain fell, etc.). I look forward to becoming educated about biosolid options -- don't forget, it's not just people poop; we have dairy farms, hog farms, chicken farms that produce tons of the stuff. It could be GREAT organic compost... if safe.

Good luck with finding a celebrity spokesperson though. Who wants to be the Prince of Poop, the Sultan of Sh--, the King of Krap, the Tzar of Toilets -- hey, this is fun!



Garbage disposals are one silly appliance.

This is also something silly that we humans do. Maybe i am the silly one for thinking of this. Maybe it wouldn't make a big differance, but who knows.

We go to restaurants and order meals. We are served bread first. Italian style you might eat it, dunking it in oil and vinegar. Shouldn't at least one flatbread be served last to be used as a mop to clean up the last food bits on our plates. The oil and sauce left behind. that's less food bits going down the drain. Of course not many people eat everything on their plate. I usually do. I don't eat out often, but i usually eat it all if i go out. I then mop with a slice of bread and my dish just needs to be rinsed. maybe this is too sloppy for utensil users. I don't know. Anyway, food bits go in me not down the drain or garbage. It is rare that you can compost plate scraps as they are usually not solely vegetable based. In the garbage they do attract rodents.

stay hungry.



you might say that all that scrap I eat is gonna land in the crapper, anyway. at least I have gotten the energy out it first.


You mention pharmaceuticals left in water and potentially recycled back. From what I understand, this is tough to avoid because they're so hard to detect. I have read there's a machine to do this, but I don't know if it's for real. Saw it here
Is this legit?


Yep, I do think about what happens after I flush.

Eventually, it's this:

I don't know a whole lot about the middle steps though.


Wait a second: wabi sabi means finding perfection in imperfection, such as the sentimental feeling we get when we hold a simple clay bowl in our hands. Crafted by a poor worker, and surely inferior to a pristine, fabricated ceramic one, it nevertheless possesses a value that would compel us to buy it over the pristine bowl. Aside from that cultural misstep, I think this article has merit.

However, even if the social benefit (7 dollars) of a mild investment (1 dollar) yields a 700% ROI, that's not enough to convince politicians. I mean, they may not see any of that ROI, but suffer the consequences of an extra cost!


All i know is that a tour i took of san jose's (CA) waste treatment facility convinced me that they truly are amazing and unappreciated systems. And i'll drink tap water and water th yard with grey water all day long.


Caroline Snyder

Why do we hate biosolids? We don't hate it. We just don't want it spread on our nation's farms, fields, and forests.

Hundreds of sludge-exposed people living in rural areas where sludge was dumped, have experienced serious illnesses. Deaths have been linked to the practice of spreading sludge on farms. Prize winning dairy herds have been wiped out by ingesting hay grown on sludged land. Ground water and wells have been polluted. Good farm land, degraded. Forest ecosystems disrupted. This information is not just "anecdotal" but has been documented in the peer reviewed scientific literature and in sworn court testimony.
Sludge is not just human excrement. It is the complex and unpredictable mix of industrial pollutants that are legally discharged into the nation's sewers . Waste water treatment plants remove these pollutants from the waste water, where they concentrate in the resultant sludge. Hazardous liquid waste from industries, hospitals, businesses and superfund sites, run-off from parking lots during a rain storm. And lots of illegal dumping. Sludge generated in industrialized urban centers contains not only pathogens, but tens of thousands of man-made chemical compounds, most of which have not undergone basic toxicity tests, and others which are highly toxic, carcinogenic, and persistent.
Yet the US regulations --unlike those of other countries--have standards for only nine toxic metals.
Contrary to what George states, there are now several cost-effective, energy-efficient, environmentally friendly and sustainable alternatives, other than land application, or incineration. Many countries no longer spread sludge on their fields, but use it as a renewable source of non-fossil fuel energy. Flint, Michigan, following in the foot-steps of Sweden, is planning to run buses using biofuel made from sludge. St. Paul Minnesota's fluodized bed incinerator uses sludge as a feedstock. to run its waste water treatment plant. The system meets the most stringent air pollution standards anywhere and saves the city millions.
Sludge is the perfect feedstock for waste-to-energy plants.
To protect the nation's agricultural soils for future generations, reduce the use of fossil fuels, and reduce emission of green house gases, land applaication must be phased out and sludge used as biomass for renewable energy.