Hektoen International

A Journal of Medical Humanities

Book review: The Big Necessity: Adventures in the World of Human Waste

Howard Fischer
Uppsala, Sweden

Common problem: a water well (foreground) is in close proximity to a pit latrine (brick building at the back), leading to groundwater pollution. Crop of photo by Kennedy Mayumbelo, 2006. SuSanA Secretariat on Flickr, via English Wikipedia. CC BY 2.0.

Its title might seem frivolous, but this book is serious, and the problems Rose George describes are a matter of life and death. Her take on the disposal of human waste is clearly detailed in her introduction. She avoids euphemism and favors clarity.

Forty percent of the world’s population has no access to a latrine, toilet, or waste bucket. One gram of human feces can contain ten million viruses, one million bacteria, one thousand parasite cysts, and one hundred worm eggs. Ninety percent of the developing world’s sewage ends up “untreated in…rivers and lakes.” Dirty water usually means water contaminated by feces. A great number of organisms may be found there: salmonella, shigella, Vibrio cholerae, giardia, cryptosporidium, E. coli, and campylobacter. Other infectious agents include the hepatitis A virus, leptospires, hookworms, roundworms, and tapeworms. One billion people have an intestinal infection with the roundworm ascaris and are constantly shedding eggs in their feces. George repeats this information later in the book. It is her main message.

She also holds the reader’s interest with trips through the sewers of London and New York and describes high-tech Japanese toilets, that in addition to providing anal washing and warm air drying can measure the occupant’s weight, blood pressure, and the quantity of glucose in their urine. Two chapters discuss the difficulty in placing usable toilets in India and convincing people to use them. One chapter covers the production of methane and its use as fuel by putting feces in biogas “digesters” in China. She also discusses the uses and dangers of biosolids as fertilizer in the UK and the US. These biosolids are the sludge (as it is more truthfully called) left over after sewage has been treated and reduced to a minimum. What is left may still contain infectious agents and a number of long-lived, nearly indestructible chemicals like dioxin and PCBs.

“Proper sanitation,” she writes, “is a system involving containment, emptying and disposal.” Without all three steps it is a failure. George also includes a filmography. One striking 54-minute documentary about public toilets in India is called Q2P.

The Big Necessity: Adventures in the World of Human Waste
Rose George
London: Portobello Books, 2008

HOWARD FISCHER, M.D., was a professor of pediatrics at Wayne State University School of Medicine, Detroit, Michigan.

Fall 2022 



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