Are Toilets a Good Measure of a Country's Health?

Rose George argues in her book The Big Necessity: The Unmentionable World of Human Waste and Why It Matters (Metropolitan, October) that the "big necessity" is a toilet.

For 2.6 billion people, George writes, the lack of access to a hygienic toilet can result in "crippled guts and killed children." Every 20 seconds a child dies because of abysmal sanitation conditions, mostly from exposure to infectious agents, like the Vibrio cholerae bacteria, which move from gut to gut by way of feces. Contain the feces and the pathogens are contained, too.

It is a simple and straightforward story that George tells with ease as she crisscrosses the globe profiling efforts to improve sanitation for the world's poor.

But the problem is more complex than she allows. There is nothing simple about toilets -- or "necessities," as they were once called.

A toilet can be a hole in the ground (as in the case of an outhouse) into which urine and feces are deposited, which then can seep into the groundwater. Or it can be the means via which this human excreta is flushed into a sewer system, where it is joined by storm water and industrial wastes. But can either disposal system be considered hygienic?

Transnational institutions, such as the World Bank and WaterAid -- a British charity started by large private water corporations -- play an enormous role in framing the entire discussion of what proper "sanitation" entails.

The tropes promoted by such organizations seem unquestionable.

First, poor people will defecate anywhere if they are not provided "toilets" (here a euphemism for latrine); and they must pay for these "toilets" or they will not value them.

Second, where there is institutional funding, sewers and sewage treatment are the best ways to manage domestic and industrial waste.

These two postulations are related because latrines -- stinking, unpleasant devices -- drive people to flush toilets and the accompanying sewer systems.

Sewers are big business for corporations, governments and donor agencies. In the United States, total spending on sewer and water from 1991 to 2005 was $841 billion.

In the '70s and '80s, for example, the U.S. Agency for International Development spent $3.45 billion on water and sanitation projects in Egypt. Every penny of this money went to U.S. corporations.

George is an unapologetic fan of sewers. She calls them "unassailable as the default option of how to dispose of human excreta in sophisticated, wealthy places." This is a mistake.

Sewers look good on World Bank loan portfolios and the income statements of the companies that build them. But from the point of view of long-term, sustainable public and environmental health, they are a disaster.

It is true that deaths from typhoid and cholera -- the great waterborne killers of the 19th centuries' open sewers -- were greatly reduced with the combined use of closed pipe sewers and drinking water treatment. But a greater and more complex group of killers is now in the sewage or result from sewage treatment itself. And this is a threat that George gives short shift.

In the '40s, wartime production and a subsequent push by government and the chemical industry to get new synthetic chemicals into commercial use resulted in massive quantities of such chemicals entering the sewers after being discarded by industry and households, as well as "run off" from roads.

Current sewage treatment is designed to address only a handful of parameters: biodegradable organics like proteins, carbohydrates and fats from food and excreta; and suspended solids.

Yet each day, 42 billion pounds of chemical substances are produced or imported in the United States for commercial and industrial uses. George ignores the fact that no technologies exist to "treat" or make "disappear" carcinogenic, mutagenic, teratogenic and endocrine-disrupting chemicals once they are added to the sewer.