WARNING! This review contains explicit language referring to human waste. HANDLE WITH CARE.

"You can't be a doctor and be scared of blood," says Kamal Kar, an Indian scientist. "And you can't work in sanitation and be scared of shit. Anyway, no one understands you when you say 'sanitation.'"

This remarkable volume is in certain ways the story of euphemism, and the damage euphemism can do. We are, almost universally, at least a little disgusted by defecation and urination, and so our impulse is to turn away, to ignore the huge problems created when, several times a day, six billion of us shit and pee. Solving those problems—both at the level of the village, and of the globe—will require, Rose George says, fighting the urge to look the other way.

Here, for instance, is how Dr. Kar proceeds when he visits a Bangladeshi hamlet where there are, as in so much of the world, no working toilets—a village where people shit in the field. He asks residents to take him on a walk through their town. "It is important to stop in areas of open defecation and spend quite a bit of time there asking questions and making other calculations while inhaling the unpleasant smell and taking in the unpleasant sight of large-scale open defecation. If people try to move you on, insist on staying there despite their embarrassment. Experiencing the disgusting sight and smell in a new way, accompanied by a visitor, is a key factor which triggers mobilization."

Kar then sits the village down and gets them to calculate how much shit they're producing a day—person by person, family by family. They then try to figure out where it goes—"into their bathing ponds and rivers, and from there onto their clothes, their plates and cups, their hands and mouths." Eventually the villagers calculated that they were eating 10 grams a day apiece of fecal matter. And after that—after that they were far more open to the idea of building a good latrine and using it.

That's a good outgrowth of our natural sense of disgust. Here's a bad outgrowth: try finding a celebrity to raise awareness of the sanitation crisis. Water is easy—Matt Damon has launched NGO H2O, and Jay-Z hosted a three-part series on the need for clean water in Africa. But no celebrities "wanted to be pictured on a toilet." Even the civil servants charged with this work usually try to look the other way.

Many countries have a water supply and sanitation department—watsan is the shorthand jargon—but Wat is always the big brother. Politicians would rather be seen turning on taps then opening toilet blocks, and the preference filters down through the bureaucracy. "The best and the brightest of people don't generally end up in your environmental sanitation department. It's not seen as a particularly clever career move," says Darren Saywell of the (of course) International Water Association.

All of which is a big problem. Because while there are places on earth where there is simply a lack of drinking water, far more often it's clean water that's in short supply. And what's making it dirty? You guessed it.

In the last decade, diarrhea has killed more people than died in all the conflicts since the end of World War II. Diarrhea kills a child every fifteen seconds. And 90 percent of it is caused by fecally contaminated food and water. Add in your cholera, your typhus, your hookworm (a billion humans), your ringworm (another billion), your tapeworm, your scabies, your schistosomiasis and shigellosis. There are other costs: since most African schools lack decent bathrooms, onethird of adolescent girls drop out when they begin to menstruate. In Tanzania, India, and Bangladesh, school enrollment went up 15 percent when decent latrines were built.

And then there is the simple indignity. Travel by train through much of the developing world and you will see the same sight—bare bottoms as people defecate beside the tracks on the edge of crowded slums. "For an Indian," one expert tells George, "open defecation is the maximum embarrassment." The author adds, with real compassion, "That's not quite true. The maximum embarrassment for Indians is trying to defecate in traffic or in a wheat field, keeping one hand free to cleanse and yet managing to keep faces covered with saris, all the while watching for lurkers and lookers. Open defecation damages women most, because modesty requires them to do it under cover of darkness, leaving them vulnerable to sexual assault, snakes, disease, and infection. Blocking natural bodily functions like urination and defecation can cause bladder and urinary tract infections and worse."

None of this is insoluble. George estimates that "universal sanitation" could be achieved by 2015 at a cost of $95 billion. (Which is to say we could have done that job 7 1/3 times over for the cost of bailing out America's greed-infected banks.) And if we did, the savings in health care would be on the order of $660 billion.

But it's not just spending the money— it has to be spent wisely. The world is awash with bad latrine programs, which use government money to build latrine blocks so smelly and hard to maintain that people prefer to keep shitting in the fields or by the railroad tracks. (Westerners who have traveled much in poor parts of Africa and Asia will know exactly what I mean, and understand the impulse.) I can remember joining my friend, the great development pioneer Daniel Taylor, in a village in northern India where his team had recently installed a series of privies. He went to inspect and came back shaken— they were clean, unused. He came back an hour later, considerably relieved—it was only because they knew he was coming and were waiting for him to dedicate the new facilities before they were used. By next morning the path to the door was already well-worn.

This is a very important book. Its weaknesses— an overlong chapter on why the Japanese have such fancy toilets, for instance—can be easily overlooked. George has done us a great service by taking something that we don't talk about nearly often enough and putting it right in our faces. Anyone heading overseas on a mission trip should read this book first. And anyone who wants to understand what it means to be poor. So poor, to use an all-too-true expression for a majority of the world's population, that they don't have a pot to pee in. Or to shit.

Bill McKibben edited the anthology American Earth: Environmental Writing Since Thoreau, published last spring by the Library of America. Also recently out: The Bill McKibben Reader (Holt).

Copyright © 2008 by the author or Christianity Today/Books & Culture magazine.
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