“Public health is a load of crap!” Not quite. More like, “Public health is about a load of crap!” Abdul talks about how separating the water we crap in from the water we drink is literally the foundation of public health. Then he interviews Rose George, author of “The Big Necessity: The Unmentionable World of Human Waste” about everything having to do with $hit.

TRANSCRIPT

[AD BREAK] [music break]

Dr. Abdul El-Sayed, narrating: The Tennessee state legislature expels two members for protesting school shootings. Idaho makes it illegal to help people travel out of state for an abortion. A Texas federal judge overturns the FDA’s approval of a critical abortion bill nationwide. Deaths among young people are skyrocketing in the U.S.. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. Look, you hear a lot of crap on podcasts. But you know what? You don’t hear a lot about crap. Which is why today we’re going to address that injustice. We’re talking about all things crap. Because you know what crap matters, and particularly in public health, avoiding crap matters. The reason why should be obvious. Our minds are uniquely attuned to the smell of it. Think about it. There are a lot of bad smells in the world. A lot. But none of them are as odious as the smell of doo doo. We know immediately when we smell it and do everything to distance ourselves from it. Why? Because not only is it nasty, but it’s also potentially deadly. And through tens of thousands of years of evolution, we’ve developed a life or death need to distance ourselves from it. So today, I wanted to spend a bit of time explaining exactly what crap is beyond what you already know, why crap is harmful and how it sits at the very foundation of public health. This part should be obvious, but crap is what gets left over when your body processes food. But it’s actually pretty complex. And here’s the crazy thing. A huge proportion of it is made up of other beings. What? Yeah, that’s right. 25 to 55% of the solid, dry biomass of scat is made of bacteria from your large intestine. In fact, if you blew up all the bacteria so that they were the size of a grain of sand, you’d have enough to coat the earth several times over. Those bacteria are really important too. Think about the idea of a probiotic. It’s literally trying to get the right mix of the right bugs in your large intestine. Your crap also contains undigested protein, carbs and fat, but it also has a lot of byproducts from critical biological processes. For example, when red blood cells break down, your liver converts the byproduct into bilirubin and emulsifier that helps digest the fat you eat. And then those bacteria in your gut. They break down bilirubin further into a compound called Stercobilin, which gives poop its characteristic brown color. That smell, it’s skatole. A compound that’s produced from the digestion of tryptophan, the amino acid that everybody blames for making you feel tired when you eat turkey. And this part’s wild. Skatole in low concentrations smells like flowers. In fact, it’s a critical component of orange blossom. So, yeah, orange blossoms literally smell like shit. I remember learning a lot about poo in medical school. 

[clip of song from Scrubs] Everything comes down to poo. Everything comes down to poo. Cardiovascular and lymphatic. Yes, the nervous system, too. All across the nation, we trust in defecation. Everything comes down to poop. 

Dr. Abdul El-Sayed, narrating: It’s not quite as important as the hit TV show Scrubs would have you think. But your dookie can unlock a lot about your health. Bright red blood cells in the storm. You’re bleeding somewhere near the anus. Black stools, though, are the ones you have to worry about. That means there’s a serious bleed above your small intestine. It turns black because the blood has been digested. I know that sounds disgusting. Hard stools usually mean you’re not consuming enough fiber or are severely dehydrated. Soft stools, that can mean one of two things. You consume something that is pulling water out of your body into your stool. On that note, do yourself a favor and look up the Amazon reviews for sugar free gummy bears someday. There’s a simple explanation. The sugar alcohols they use to sweeten the gummies instead of sugar aren’t digestible, which is, of course, the whole point. But when they get to the gut, they pull water in to dilute them to the same level of dilution of the rest of the body because water always tries to even things up. Well, that causes extremely watery stools like the poor folks with harsh things to say on Amazon can attest. The other reason your stools may be so soft, though, is because you get the wrong kind of bacteria in your gut and that, that can be a deadly problem. In human history, bacterial diarrhea such as cholera or typhoid fever are among the worst killers. Cholera is a particularly terrible disease characterized by extreme diarrhea. Literally described like rice water that cannot be controlled. It sucks a person dry. Though we think of it as a problem of history. It’s a reflection of our privilege. Upwards of 4 million people a year get cholera today. In Yemen, where the brutal civil war subsidized in part by U.S. weapons given to Saudi Arabia raged, the most common form of death wasn’t war itself or even malnutrition. It was cholera. And that’s because cholera thrives where basic infrastructure fails. These diarrheal diseases are spread when and I know this is disgusting. We literally consume the bacteria that causes them. From the feces of an infected person. We call it quote “fecal oral spread” to avoid having to imagine it. That usually doesn’t happen directly. It usually happens when water that someone else has taken a deuce in mixes with water we drink before we’ve had the chance to treat and purify it. In fact, the apocryphal story at the heart of the founding of my science epidemiology centers around exactly this, an outbreak of cholera in 1854. This was back before the germ theory of disease, which postulates that small particles, which we know to be bacteria, viruses and sometimes fungi can cause disease. An enterprising anesthesiologist named Dr. John Snow thought that the prevailing logic of the day, which held that these diseases were the consequences of a poisonous gas, a miasma, was bunk, and he set out to prove his theory. In the midst of the outbreak, he counted and mapped cases of cholera to demonstrate that the folks who were getting cholera all happened to be drinking from a particular pump, the Broad Street pump, which was spewing contaminated water. He petitioned the Board of Guardians, the local government, to remove the pump and stop the outbreak in its tracks. Look, I love me some John Snow, don’t get me wrong. King of the north and all. But the real magic, the real magic only happened ten years later when the City of London built a sewer system to manage the flow of waste, vastly reducing the cholera burden in the city. In fact, that sewer system made a cameo in one of TV’s most popular shows set in London. 

[clip of soundbites from TV show Ted Lasso] Come on down fellas. That’s it. All right. Greyhounds. Behold the majesty of the London sewer system. 

[clip of soundbites from TV show Ted Lasso] Disgusting. 

[clip of soundbites from TV show Ted Lasso] Yeah, that’s what I thought of first as well. 

Dr. Abdul El-Sayed, narrating: Got to love Ted Lasso. So, yeah, the foundation of public health really is all about managing poo. If you’re privileged enough to live in a society where you have clean flowing water, that is poo-less, be thankful. It’s a real privilege. Shit’s deadly. But that doesn’t mean that we fully manage the problem. Those awful norovirus outbreaks that happened this year. Fecal oral transmission. Oh, and there’s the weird way folks manage cleaning after we go to the bathroom. Or the fact that every time we flush the toilet without closing the lid, we’re pushing plumes of gut bacteria into the air in our bathrooms. You know where our toothbrushes are. We do some weird shit. We’re going to get into it. And there’s literally nobody better to talk us through it than our guest today, Rose George. A while back, she wrote a book about caca, thinking about it from the top to bottom, big to small. I wanted to have her on to digest this through with us, [laugh] I’m a dad had to do it. Here’s my conversation with Rose George. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Rose George: My name is Rose George. I’m an author and journalist, and I am the author of a book called The Big Necessity about Sanitation and Toilet and Human Waste. 

Dr. Abdul El-Sayed: I really um appreciate the euphemism in the title, but like, you literally wrote a book about shit and um–

Rose George: I did. 

Dr. Abdul El-Sayed: And I just want to ask you, [laugh] like, what what compelled you to do that? 

Rose George: Well, actually, seeing as we’re talking about the eh such a yeah, the subtitle. Um. I actually strongly protested the use of the word human waste because I strongly believe that it should not be waste and can be useful and is useful. But yeah, uh so if I could have put the word shit on the cover, I would have done it. But at the time I couldn’t. But anyway, why why did I want to write a book about shit? Well, you know, someone has to. I don’t know. It was um– [laughter] 

Dr. Abdul El-Sayed: Well, actually, all of us have to, to be fair.

Rose George: Well we all do it. [laughter] We all don’t think about it. Um. So I was working for a magazine called Colors, which was run by Benetton, the clothing company, and I was living in a lovely office in Italy with a view of the Dolomites. And my my boss is this a guy called Oliviero Tuscany, who was the famous advertising guru at Benetton, did all those famous scandalous Benetton adverts in the sort of eighties and nineties. 

Dr. Abdul El-Sayed: As in, like, the United Colors? 

Rose George: Exactly. Yeah. 

Dr. Abdul El-Sayed: Love it. Okay.

Rose George: So. So he came in one day and he said, right, we’re going to do a book about shit. I said okay. [laugh] So we did this coffee table book about shit which was called Cacas, and it was beautifully photographed, lots of beautiful artistic pictures of shit. And then alongside it, we had these little captions, sort of maximum 200 words, just about things that we came up with. And I then left Colors years later, was sitting in a publisher’s office at Granta trying to get him to publish another book that I had an idea about and he didn’t want to. And then he said, well, what else have you got? And so I said, well, toilets are pretty interesting, actually. And then I said, [?], I think I think I did my at the time, 2.6 billion people don’t have a toilet, which still blows my mind. Um. And I think I I threw a few statistics at him and he was he’d started off on with his a look of kind of disgust on his face. And by the end of it, he’d actually got out of his chair and was walking around the room going, Yes, let’s do a book about shit. 

Dr. Abdul El-Sayed: I love it. 

Rose George: So there you go. That’s how I that’s how I got to do a book about shit. 

Dr. Abdul El-Sayed: Well, I want to tell you, you’re a hero. And uh– 

Rose George: Thank you. 

Dr. Abdul El-Sayed: I really appreciated the book. And I think it is something that we need to uh think and talk about a whole lot more. Um. And, you know, it’s sort of our own evolution that leaves us not wanting to think or talk about it. Um. I also happen to think that, you know, it is it is among the most innately humorous topics. There is like, I just I just think that a fart is the funniest thing there is. It’s like it makes a funny sound, it has a funny smell. It comes out of a funny part of your body and it’s like, it’s like a natural gift to our humor. Like, it’s just. If you ever need to lighten the mood, just, you know, it’s hilarious. And so, like, I actually think that it’s both a lot of a lot of joy in having this conversation, but also probably most importantly, a lot of healing. And one of the things I really appreciate about the book is that you lean into um what is the central problem in public health for most of human existence, which is how do you make sure that we are not drinking and or eating where someone else has shat. Like that is the central problem. Figuring that problem out in its own right saved probably more lives than any other thing we did, including the discovery of vaccines or antibiotics. Um. But it has fundamentally reoriented uh human society. Um. The challenge right with that is, is that that story doesn’t often get told because you don’t want to talk about it. Um. You know, as you were doing your research, how did the centrality of the don’t eat where you shit problem come up in your reporting, in your writing, and become a central pillar of the book? 

Rose George: Well it was I mean, it was a very difficult book to write in in one way and that I had to get the balance right. So I had to make it something that was readable that people would pick up for a start and that people would read the first page and then carry on. So I had to tread a really fine line between poop humor, which I think is what you were talking about when you were talking. 

Dr. Abdul El-Sayed: Yes. 

Rose George: I didn’t want to write a poop humor book. Other people have written poop humor books. I didn’t I thought, you know, there was a lot of serious stuff going on in the world about sanitation, but I also didn’t want to make it dry and academic because– 

Dr. Abdul El-Sayed: Right. 

Rose George: Who wants to read a book about feces that’s dry and academic? So I had to find a way of talking about these huge issues which are, you know, pretty terrible that children are still dying of diarrhea, which is it eminently preventable, um easily preventable, um and yet they’re still dying of it. And um the reason that the book was actually really easy to write was two reasons. One, if you look at the world of sanitation, the people who work in it are just the most fabulous characters because you have to be to work in that in that world. So from everyone, from the flushes who work in the London sewers to um the guys who run the World Toilet Organization, to anyone who’s in this world, even the people working in NGOs in what you would think were quite dry jobs, they’re just fabulous and they just open their mouths and talk. And it’s just a gift to a writer. And the other thing that made it really easy is that people, as soon as I approach this topic with them, let’s say just general, anyone, anyone suddenly thought, oh my God, it is okay to talk about this. And they would pour out these stories. Um. So that’s that’s how I did it. I did it through characters, I think, and that’s how I conveyed the seriousness of the situation um without wanting it to be off putting or I wanted it to be galvanizing rather than depressing. And I wanted people to, you know, finish the book and go, hmm shit, I didn’t know any of that. What can I do about it? And then, you know, maybe go and give some money to a good toilet building charity or something like that. 

Dr. Abdul El-Sayed: Yeah. And I think you captured that balance really quite nicely. Um. And I really appreciate the point that you you’re making here, which is that inconsistent access to sanitation is not a former problem. It is a problem for which we have a solution, but that because of all sorts of sources of inequity, whether it’s racism or the excesses of capitalism, we have robbed access to that from whole communities of people. And I want to I want you to think a little bit about that with me. Why do you think it is that we have this extraordinary public health intervention that just hasn’t been invested in in communities across the world? Why is it, for example, that we have huge vaccine drives but but less so investment in, you know, building sanitation infrastructure um in uh lesser developed lower income parts of the world? 

Rose George: Well, I mean, it’s not even in lesser developing uh, you know, developing world. I mean, the US is in a right state. 

Dr. Abdul El-Sayed: Right. 

Rose George: Your sewer infrastructure is terrible. Um. I think it generally gets graded a D by the American Society of Civil Engineers. You have like a million people with no sanitation. I think that’s actually um growing rather than decreasing. Um. You had a situation in San Francisco beginning in 2014 where kids were stepping over human shit to get to school. Um so I’m just making that point that it’s even though there is massive inequity, even though it is about capitalism, even though it is about access, it’s more complex than that. And actually I don’t think it is that easy to fix. It’s easy to fix diarrhea. You give someone you remove them from a potentially dangerous substance, which is human waste, which can carry a lot of disease, um bacteria and [?] and worms and all sorts. But um you then cure it by giving them salt and sugar and water. But then you that water has to be clean. And that’s also difficult because providing clean water is harder than you think. Um. But the other issue is that the reason that this isn’t [?] seems sometimes like an intractable solution and the reason that we’re in 2023 with still nearly 2 billion people without any sanitation whatsoever, not even a box or a bucket. Is that people uh yeah, that’s my it’s just people are sometimes not resistant, but more complex than you think. So, for example, if you look at India, which is kind of the poster child of sanitation, has been since Narendra Modi um took power in 20– uh can’t remember when he took power, but in 2014, he declared this huge program called the Swachh Bharat, which uh means clean India and the government put $30 billion dollars into it, allegedly built 100 million toilets all over India. Um. Now, this wasn’t the first sanitation campaign in India. Um. Plenty had been done before, you know, right from when you know, right from Gandhi saying that a toilet was more important than independence. You know, India has known that it has a big problem and it’s poured money into it. But yet, even after Swachh Bharat, even after money has been allegedly thrown at resolving these inequities of infrastructure and um access to sanitation, you still have millions probably of unused toilets standing all over India because people think that it’s cleaner to go and do open defecation, particularly if they’re living in a rural situation. Um. And that’s a cultural belief. Um. And also you have a systemic problem as well. The government gave people money like $160 or something to build a toilet. Great. But then there was hardly any monitoring of whether the toilets actually got built. And when I traveled around India, um what, 2006 or something for the book, um I was shown these toilets that had been turned into storage, you know, storage sheds, there were bags of grain stuck in them, and people were ignoring these pretty shabby latrines and toilets and going off into the bush and defecating, which is what causes the huge public health problem, because, as you say, one of the best things that happened in human history was the realization that we have to be separated from human shit. Um. And one of the greatest, one of the greatest public health measures was the installation of sewers and toilets and handwashing with soap in in London in the late 19th century. And one of the greatest heroes was probably Joseph Bazalgette, who built the London sewer system. But um so it’s it’s a very, very, very complex situation. You think it’s as easy as, you know, giving someone a toilet, but then you give someone a toilet say in a developing country, you then have to install the rest of the waste stream. 

Dr. Abdul El-Sayed: Right. 

Rose George: So you need the sewers and you need the wastewater. You need the wastewater treatment plan. Do you have money for that to operate? Do you have the staff for that to operate them? Where do you discharge the treated waste? Does it just go into a river? Does it go into the sea? Um. Is that the best method these days to use? You know, Teddy Roosevelt in 1910 said surely civilized people had a better way of dealing with shit than putting it in the drinking water. And we’re still doing that. Um. And it’s it costs money and it costs energy. And it’s just not particularly sensible to do that. Um. But because that is now considered the system, then that’s still being installed all over the world, this kind of Western intensive infrastructure, heavy energy intensive um wastewater treatment system, whereas in fact, um depending on the situation where you are, if you’re a farmer in Malawi, maybe your best solution is a composting toilet. Maybe it’s a latrine that you fill in and plant a banana tree and um maybe you don’t need a fancy Western toilet with all this expensive tail behind it. Um. Very efficient tail that has saved millions of lives and probably put 20 years on our on our lifespan. But um it’s I mean, it’s it’s really been fascinating the last 15 years since my book came out to watch how things have changed. In one way, and there’s a lot more talk about different solutions and how one size does not fit all. And the paradigm of the you know clean ceramic toilet and the sewer and the wastewater treatment plant is not necessarily the solution. And even when it is the solution. So in the US or in the UK where we have these systems, they’re not working um they’re overloaded. In the UK we’ve got massive problems of water companies just pouring sewage into the rivers untreated and unpunished. I’m pretty sure you’d have the same situation in the US. 

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Rose George after this break. 

[AD BREAK] 

Dr. Abdul El-Sayed, narrating: And we’re back with more of my conversation with Rose George. 

Dr. Abdul El-Sayed: You’re bringing up a couple of different points here, which are that whether it is investing in a early 20th century style water based collective sewer infrastructure, or it’s investing in research and development to free us of that high infrastructure, high lift kind of approach. The either of those solutions require a lot of collective action and they require a lot of investment. And it kind of comes back to this, this notion that this is a problem that has a fundamental fixed solution uh and it takes a lot of people deciding that they’re going to put their shoulder into the work. And the hard thing about collective action is that there are more nodes of disinvestment and failure. And, you know, you talk about uh this investment in India. My uh my spouse is Indian, spent a bit of time traveling in different parts of India. And um there is you know, there is as you as you talk about it, there is a sort of a norm and a culture of this is how we go to the bathroom and look a little bit askance at um at that toilet. And at the same time, there is such I mean, India is is a mass of people and there is such a um a disconnect between decisions that are made at the very top and um decisions that are made in the nooks and crannies of villages in the country. And it takes everybody kind of saying, all right, we’re going to we’re going to do it this way and make this investment. And then also recognizing that any investment in a resource um limited context is implicitly competing with a bunch of other needs that people might identify as more important than this one. Um. Similarly, right in in this country, the point that you made about our failure to invest in functional or continue to invest in functional sewer systems uh is a really important one. And even then when we talk about inequities, it’s not the high income communities in states all over this country that suffer for lack of infrastructure. Um. It is uh lower income communities. In Michigan, for example, where I live, we had massive flooding a couple of years back in the summers and uh you had wastewater flowing back into people’s basements, but it wasn’t high income people’s basements. It tended to be poor people’s basements. You go to uh some of the communities, and in Alabama, we’ve had um uh a hero, an activist named Kathryn Flowers, on this podcast in the past. And her work is fundamentally about the environmental injustice of our failure to build and update um functional sewer systems. But again, you’re talking about the poorest um region of the country and you’re talking about predominantly Black folks who are suffering it. But it’s that that ability to sort of invest in collective action and all decide that we are going to put our minds to this work to stay ahead of it, um that matters. And the problem is, is that where that usually falters it’s when we’re talking about systems that would service the lowest income, most marginalized people. Um. I want to ask you. Right, because another example of this is ongoing cholera outbreaks. Cholera is the is the worst of all diarrheal diseases. When you look at just the number of people who have died of it and where you end up getting cholera, almost always you end up getting you end up talking about places where the ability to upkeep infrastructure has failed. So where we’ve had the worst cholera over the past several years has been in Yemen, where um a brutal, you know, US uh funded civil war um has fundamentally decimated basic infrastructure and led to both famine and cholera epidemics sweeping and killing mainly kids. Um. I want to sort of sort of just pivot off of this conversation that we’ve been having about the centrality just of of infrastructure um around this question. Uh. You tend to see these two things go hand in hand, where you can invest in infrastructure. You can prevent these kinds of diseases, where you can’t you don’t. Um. We don’t talk about this, though, right? This is not a conversation. When you talk about the civil war in Yemen, it’s rare that people talk about oh man like it’s bombed out sewers that are leading uh to cholera outbreaks. What does it take for us as someone who’s who’s made an intervention on the public conversation and what we’re trying to do here on this podcast? Talk a bit more about this to make sure that this is the thing that people connect. This is the killer. This is how people die over the long term when people make war on each other, what does it take for us to make sure that that is what people think of? That is what people talk about in these contexts? 

Rose George: You know what, I have no idea. Um. It’s a failure of imagination and it’s a failure of empathy, isn’t it? If we can’t, we and those of us who have a relatively functioning toilet and sewer system and we can flush it and forget it and we don’t need to worry about it unless we’re in a lower income neighborhood where, you know, flood and wastewater come backs up into our basement. So those of us in that flushed and plumbed world. It’s it’s very difficult to move people into a place where they can imagine being a seven year old kid, having, you know, having to poop outside and whose entire family is dying of cholera. I mean, I went to Haiti um several years ago, which along with Yemen, has had one of the worst chronic cholera outbreaks. It’s been going on for years. Um. It was actually brought into the country by U.N. peacekeepers. Um. But then, of course, because of the situation in Haiti, which was has deteriorated even more now, but even at the time was extreme poverty, extreme lack of clean water and toilets. And of course, it was just it’s just cholera’s absolute playground, loves it. Um. And also with high population density people living very much cheek by jowl in very poor neighborhoods. Um. How do we fix that is what [laugh] is what you’re asking me. And I just think it’s just we just have to imagine and imagine that things can break down very easily. And nobody really wants to think about that, do they? We don’t want to think about being a Ukrainian where one day is normal and the next day everything is absolutely devastatingly terrible and you’re getting bombed and or you don’t want to until you experience being someone in Michigan whose basement is suddenly filled with liquid shit. You possibly haven’t ever thought about that before. And I think as humans, I think we’re not very good at um imagining risk or calculating risk properly. And because you don’t want to think about it, you don’t want to imagine yourself in a disastrous situation. So I think it is that failure of imagination um in people who are equipped and served properly by infrastructure and sanitation. And I honestly I wish I had an answer for you, Abdul, but I don’t know what the solution is beyond just keeping plugging and emphasizing the commonality between us. We all, you know, we all have to defecate and urinate every day. We all could possibly be one day in a very normal situation, and the next day everything’s gone. The sewers don’t work, everything backs up. And um who wants to think about that? 

Dr. Abdul El-Sayed: Right. 

Rose George: Who who wants to when everything is so bleak already? And I’m not defending people. I’m trying to explain to myself why these situations are allowed to continue. 

Dr. Abdul El-Sayed: Hmm. I really appreciate that perspective and also realize that um conversation and what you point people’s minds to uh is one of the most powerful things that we can do. No one word is ultimately powerful, but continuous flows of words that occupy brain space. Um. They can be that’s what that’s what changes the course of history. So I you know I appreciate you being someone who’s who’s tried to force us to pay attention and the kindness with what you’ve done it. Because I think humor sometimes is the best way to talk about very difficult things that other people don’t want to talk about because we all like to laugh, um but sometimes we don’t. Uh. We don’t appreciate that the things that we get to laugh about, other people cry about. Um. I want to move to you know some of the lighter parts of the book, you know, about things that people do when it comes to this issue that are sometimes less than hygienic. [laugh] Um. You know, you talk about uh about about how men urinate. And I’ll be honest with you, um it is always uh astounded me. I do not use urinals as a matter of course, because [laugh] of the obvious physics of urinating into a ceramic wall. Um. And then what happens to that urine uh seemed pretty clear to me when I was like a little boy watching– 

Rose George: Yeah. 

Dr. Abdul El-Sayed: –at the ground level being like, oh, that’s just piss going right back on that person’s pants. Um. Why do you think we use urinals? And like, why did we why did we build them this way? Um. And what is the consequence of that? Like in reality, I know you’ve done some, some, some inside research about it. 

Rose George: Well, they’re cheap aren’t they? I mean, it’s just a hole in a wall, essentially um a plumbed hole in the wall. You can install them quite easily. Um. Men have no societal um pressure not to whip their bits out and pee everywhere. Um. And it’s what’s called I think it’s um it’s a cognitive dissonance, isn’t it? You cannot allow yourself to think that you are getting sprayed with urine every time you use a urinal. So you don’t think it. It’s like every time it’s not just urinals, every time someone flushes a toilet and leaves the lid up or seat, um your entire bathroom is being sprayed with fine particles of whatever is in your toilet. And I do I do like a bit of cultural relativity. So I like it when people from other cultures are absolutely bewildered that we we do not question something like leaving a toothbrush in a glass next to a washbasin in a small room that also has a toilet in it, and then leaving the lid up when you flush it. I mean, it’s just, you know, once you think about it you’re like hmm. 

Dr. Abdul El-Sayed: It’s like so just just to, like, really just just connect the point home, because that’s what we’re doing in this episode. It’s literally like taking a Windex spray. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: And spraying it. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: And letting all those particles settle on your toothbrush. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: That you’re then going to use in your mouth at least two times a day. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: That’s, that’s what we’re doing consistently. 

Rose George: Yeah that’s what you’re doing yeah consistently, [laughter] consistently. And the other thing that I’m saying, we as in, you know, in the flushed and plumbed world, but actually now we I’m going to say in the paper world, so the world divides into paper and water. Now you you come from both worlds– 

Dr. Abdul El-Sayed: Oh I know. 

Rose George: –don’t you right? 

Dr. Abdul El-Sayed: I know you. Yeah. No, no, no. That that world I’ve had to translate to people.

Rose George: Yeah. I know. 

Dr. Abdul El-Sayed: My whole life.

Rose George: And I want if you if you grew up in the toilet paper culture, as I did once you realize what you’re doing and once you realize that you are using a piece of dry tissue to cleanse the dirtiest parts of your body, whereas you use water for everything else, including washing your car. Um. Once you realize that you’re not actually removing feces by doing that, but just moving it or removing a bit of it, you can never go back. Once you realize that water is there’s a reason that half the world is using water to cleanse themselves. And there was um there was a story I I mentioned in the book, which you’ll probably remember, because perhaps you can sympathize with it um or empathize with it um was the like the secret Lota. So there was um people I think it was Indians. There was a there was an exhibition in New York and it was secret Lota stories. And the Lota is a cup that in is an Indian word. So it’s the cup that, you know, you use a cup of water, you cleanse yourself and obviously you wash your hands. Um. And um so these these young um people from water cultures, so either Muslims or Hindus or Sikhs or, you know, from from the water water, anal, anal water, washing part of the world. [laughter] So um anyone who does– 

Dr. Abdul El-Sayed: AWW is what we’ll call them. 

Rose George: Yeah um so they would, you know, have to disguise the fact that they were using water because they were living in a paper culture where toilet paper was the exception. And so they would sneak in, you know, like a watering can or something like that. And now that I have transitioned to the water world. So I have a portable bidet by my toilet. I take a portable bidet with me. Um. I cannot– 

Dr. Abdul El-Sayed: Welcome. 

Rose George: –and and in public bathrooms, but I still find that I am embarrassed too so in a public bathroom obviously, if I don’t have a portable bidet with me, I have to wet some toilet paper. But then I feel embarrassed to go up to the washbasin, wet the toilet paper, and then go into a toilet stall. So I’m trying to get over myself and just like, you know, be proud. But I understand there’s young people in there, you know, trying to disguise their lota stories because the societal pressure or the societal expectation that toilet paper is it. And actually, we’re all walking around with uh well, not all of us, but those of us who only use toilet paper are walking around with very dirty anuses. Um. [laughing] 

Dr. Abdul El-Sayed: You know, I, I so I grew up in a hybrid. Uh. And, you know, it’s the most effective approach is is paper, water, paper. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: And um uh– 

Rose George: But minimal paper, water, minimal paper. 

Dr. Abdul El-Sayed: Minimal paper, water– 

Rose George: Yeah. 

Dr. Abdul El-Sayed: –paper. Right. And um you know, my whole life when we were a kid, we always had what’s with our flowering watering cans. And I remember my friends coming and they’re like, why do you have a, what do you have a watering can next to the toilet? I’m like, why don’t you? 

Rose George: Yeah. 

Dr. Abdul El-Sayed: Like this is really the question you ought to be asking yourself is, why don’t you? Uh. But like, you know, growing up, there’s always the the stereotype that you work against when you are Brown. Uh. And most of us from from AWW cultures [laugh] um are uh is that you’re dirty right and that that’s what you’re always called, right? That’s the– 

Rose George: Yeah. 

Dr. Abdul El-Sayed: –euphemism. And and it doesn’t help that you have very pungently smelling food. And then you walk out of your house smelling like onions and people are like, yo, you smell like, you smell like food. And I’m like, well, another another question is why don’t you? But, but anyway, um and so you were always told that this was like a dirty thing to do. And I’m and it was always like being gaslit by the whole culture. You’re like, no, no, it is not. It’s actually really clean comparatively. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: And if I had to choose right. I don’t understand. I don’t understand how it’s done. Anyway, um I digress. One of the best things to come out of the pandemic is it seems as though a large swath of of Internet culture um discovered bidets for the first time. 

Rose George: Really? 

Dr. Abdul El-Sayed: And yeah, like there was a whole moment where everyone was was discovering like Tushy and these other sort of bidets. 

Rose George: Alright. 

Dr. Abdul El-Sayed: Uh. There were some viral Internet videos from like random influencers being like y’all, I just discovered this thing and like, meanwhile– 

Rose George: Now I have a clean bum. 

Dr. Abdul El-Sayed: –um all of all of the Middle East and South Asia are just like and Africa are just like, yeah, we’ve been we’ve been trying to say it for a while. [laughing]

Rose George: Yeah. And if well that if that– 

Dr. Abdul El-Sayed: Um. 

Rose George: –is true that I’m fully in favor. I mean and also I mean, you know, um moist toilet tissue has been, you know, keep trying to launch moist toilet tissue. And I’m not particularly in favor of that because obviously it has to be chemically treated and you’re then putting it in the sewer system. But yeah, everyone should have a watering can next to their toilet. And if you don’t, then what is wrong with you? 

Dr. Abdul El-Sayed: I mean, you said it, you have the cultural positioning to say it. I mean, in my case, I’ve always just been like, listen, you do you, I’m a do me? Actually, I’m a do me and you’re probably not going to do you. But it’s all good. Like, you know. [laughing] Not not my choice to make.

Rose George: So what do you do in a public bathroom if you need to do a number two? How do you how do you– 

Dr. Abdul El-Sayed: Oh, I, I carry around a um a silicone, uh a silicone water bottle. 

Rose George: Oh okay. 

Dr. Abdul El-Sayed: That I can wrap up. Right. And it like literally I have it in every bag I use. 

Rose George: Uh huh. 

Dr. Abdul El-Sayed: And if I need to use it, then I just fill it up and yeah, I’m gonna get some weird looks, but like I’m also Muslim and I have found myself washing my feet in the sink. So, like, I know what it’s like to get weird– 

Rose George: Yeah. 

Dr. Abdul El-Sayed: –weird looks. Um. I also have never been told I lack for confidence, so most of the time I’m just like, hey, you know, I am washing part of my body in a sink meant for washing. I don’t know why that’s astounding to you. And I guess the question you ought to be asking is why are you not washing parts of your body in the sink? Because, like, that’s what we do. So like, you know, you get used to just being like, this is how we do it. And um and usually making light or joking about it. And, you know, I’ve gotten either dirty looks or comments in the past. Um. And uh fortunately, I’ve always had a quick and sharp tongue. And so most of the time, you know, I leave those interactions feeling [laugh] I fought my good fight. And also I’m going to walk out of this bathroom clean and you’re not so there’s that. [laughing]

Rose George: But I mean, I suppose I suppose more seriously, it comes back to like what you were talking about earlier, which is how do you how do you change people? How do you get them to care about things that they don’t necessarily identify with? I’m absolutely paraphrasing what you said, but um it’s just when you look at things like the AWW world versus the paper world, I mean, the force of habit is so powerful. And yet if you look at it, it’s really not that old. It’s only like, you know, 150, 200 years old. But there is this absolute certitude that this is how things are done and not even a questioning of it, which is strange. 

Dr. Abdul El-Sayed: We’ll be back with more with Rose George after this break. 

[AD BREAK] 

Dr. Abdul El-Sayed: So there is this um phenomenon that happens when people will um become Muslim who don’t come from predominantly Muslim cultures. 

Rose George: Hmm. 

Dr. Abdul El-Sayed: And about how we clean and why you clean a certain way. And I remember sitting with a friend of mine, so my mother, um uh my stepmother converted to Islam, you know, back when I was a little kid. And so we’d often she took it upon herself to just sort of be an ambassador um to help folks who are new to this, you know, faith and sort of system learn about how we do it. And part of the problem is I think a lot of folks just don’t understand the physics of it. So when you’re a kid in an AWW culture, you’re taught this is how you go to the bathroom. Right. And like– 

Rose George: Yeah. 

Dr. Abdul El-Sayed: You know, in a lot of AWW cultures also, there is a very, very clear differentiation between what you do with certain hands, which is to say, obviously you wash your hands very, very vigorously, but you know, you eat with your right hand and you wipe with your left hand and like that’s just a known thing, right? Um uh. And so the physics of how you do this thing and what and literally, like play by play what you’re doing to make sure that however you’re cleaning yourself, you’re not, you know, inadvertently moving fecal matter elsewhere. Like, I think a lot of people stumble on the physics, right? Because they’re just like, I don’t I don’t know how to do this and do it cleanly. Like, I think it’s just you’re making a really great point, but at least when I’m using paper, there’s a clear barrier between that in my hand. And I think for a lot of folks who are like, okay, so so what do I do there? And you’re like, well, there’s a lot of ways to just make sure that you’re not making anything else dirty, but you’re also in the process of cleaning yourself. And that that I think that that moment, that physics is a big stumbling block for folks. And they’re like, meh I just can’t I can’t get past that. So I actually think that like one of the things here is, you know, as bidet culture um continues to take hold, there’s also just a space for like the kind of education that you give to a, you know, three, four year old who is just learning to use the bathroom is like, this is this is how you do this in a clean way. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: Um. And uh and and sort of move people past the the barrier there, which I think is like a really I think a very real thing just and having had conversations uh about this, but like, it’s also just an uncomfortable thing. I mean, like– 

Rose George: Yeah. 

Dr. Abdul El-Sayed: This whole episode is premised on the idea of how do I protect myself from something that comes out of my own body, which is kind of a weird thing. Like most of the time there is this notion of like, oh, this is part of me, but like, you know, shit and piss are two things that are just like, yes, this is this once this leaves my body, I want nothing to do with it ever again. And so you have this odd moment which is like, well, I got to deal with the fact that like, you know, this is not a a surgical removal of this stuff. And I have to figure out like that, that interim moment when this is part of me to not part of me, how do I make sure that less of it is part of me when I walk away. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: Um. Which is an uncomfortable thing to have to think about. 

Rose George: Yeah. 

Dr. Abdul El-Sayed: And like I would argue is like central to the human experience. It’s like central to the human experience that we we are not immaculate beings like we are we are um are deeply non sterile. And this is that moment of being like, well, I have to like I have to figure out this transition from carrying this stuff to not carrying this stuff and do it cleanly. And it’s going to be uncomfortable no matter how I do it. 

Rose George: Hmm. But you’re going to be cleaner if you do it with water. 

Dr. Abdul El-Sayed: I agree. I agree with you. You and you and I are both uh– 

Rose George: Maybe we should just, like, get the president to pass a law to to require AWW training of three year old or four year olds in kindergarten. 

Dr. Abdul El-Sayed: Part of the pre-K curriculum, Head Start curriculum. [laughing]

Rose George: There was um um I had this very small anecdote in the book, which was really sweet, which was a child in Norway who and Norway and Sweden, Scandinavia in general when they go away to their summerhouses they have dry toilets because they don’t, you know, they’re on little islands and they don’t have infrastructure. Um. And so a lot of Scandinavian kids grow up used to a dry toilet. So you would just it would be just a hole and maybe you’d put in some sawdust or something. But obviously that’s a whole it’s a whole different situation. The noise is different. It doesn’t or it shouldn’t smell, but, you know, it’s a different it’s a very different situation. Um. And this kid had grown up and then the first day that she went to kindergarten and they had a regular flush toilet, and I think she must’ve done a poop. And she was absolutely horrified. She was like, oh, it’s floating in the water. That’s disgusting. [laughter] And I just thought that was so funny because it’s like you can so children are so malleable at that age. And honestly, if we gave them all AWW training, we would have an AWW world very quickly. 

Dr. Abdul El-Sayed: That that might be the sequel to this book. 

Rose George: You go ahead and write it. 

Dr. Abdul El-Sayed: [laughter] Like I’ve already written my I’ve already written– 

Rose George: I’ve done my poop book.

Dr. Abdul El-Sayed: –my book about shit. [laughter] Um. Uh. Have you uh I don’t I don’t know if you you watch, but it’s too difficult um uh not to bring this up uh with a um a Brit who uh who wrote a book about poop. But I don’t know if you watch Ted Lasso and it’s not as um it’s not as popular in the UK as it is in the U.S., but it’s about this football coach who becomes a soccer coach in the in the U.K. and, you know, antics and hilarity ensue. Um. But he takes his team. This is in the most recent season. That episode just came out about a month ago. He takes his team down to the London sewer as a metaphor for trying to separate negative emotions from positive ones. Um. And uh he actually namechecks um the the founding of the London sewer system. 

[clip of soundbites from TV show Ted Lasso] [?] my friend [?] will help these fine fellas with some fun facts about this here feces factory. 

[clip of soundbites from TV show Ted Lasso] Well, back in 1859, an engineer called Joseph Bazalgette and his team built more than 1200 miles of interconnected tunnels and sewers, and his creation helped cure a massive cholera outbreak after untreated human waste found its way into the River Thames. 

Dr. Abdul El-Sayed: So it was sort of one of those moments where you’re like, Oh, hey, uh look at this. It all comes around. And obviously he’s an epidemiologist. Our apocryphal namesake founder is is the one Doctor John Snow. 

Rose George: I’m so pleased you mentioned him. Yes. Hero, along with Semmelweis.

Dr. Abdul El-Sayed: Yep. Semmelweis. All these people who kind of realized like, hey, guys, there’s something there’s something problematic about um about drinking water with poo in it uh–

Rose George: Yeah. 

Dr. Abdul El-Sayed: Or touching dead bodies that have died of infectious disease and then going to touch live bodies that you wanna protect from infectious disease. But, you know, and both of them got um poo pooed for their ideas. 

Rose George: They did get poo pooed. Yeah. 

Dr. Abdul El-Sayed: [laughing] I want to finish on one last one last question. What do you wish more people understood about shit? 

Rose George: Um I wish that I understood how useful it can be once, once it’s excreted from the body. So it can be. Uh. It’s difficult when it goes into an industrial sewer system because you get all sorts down the sewers. But if it’s if it’s in a relatively pure situation, it can be a very useful fertilizer, compost. Um. It can be, you know, you can burn it to make electricity. You can there’s all sorts of things that can be done with it. But yet it’s often still too easily discarded because that’s the that’s the public health paradigm that arose in the 19th century is you just get rid of it. So I wish people understood that human waste is not waste and we do not need to waste it. Um. I wish they understood that. Well, we we just talked about this at great length. I really wish they understood that they should clean their butts better. Um. But I wish I wish that people understood that sanitation is maybe unfashionable, still underfunded, definitely. But an absolutely crucial public health issue around the world, not just in the developing world, but even you know even in the U.S., as we’ve talked about. Um. Yeah. And then I wish they’d go and read up on Joseph Bazalgette and John Snow and Ignaz Semmelweis and then go and, you know, hug their toilet. 

Dr. Abdul El-Sayed: But only when the lid is closed. 

Rose George: Only when the lid is closed and I wish they’d I wish they’d close the lid when they flush. 

Dr. Abdul El-Sayed: And stop pissing in uh in in latrines and uh in urinals. 

Rose George: Yeah, urinals. Hmm.

Dr. Abdul El-Sayed: All right. Well, our guest today was Rose George. Um. She wrote a delightful uh book about um human waste, non waste, um and how we ought to be thinking about it. The challenge that persists and uh and where we have yet to go. Rose, this was a fantastic conversation. I really, really appreciate you making the time. 

Rose George: You’re very welcome. [music break]

Dr. Abdul El-Sayed, narrating: As usual here’s what I’m watching right now. There’s a lot to watch. Look, I have a really short memory, so I don’t blame others for doing the same. But Tennessee legislature. What the F? It’s barely been two weeks since six people, including three kids, were killed in a school shooting in Tennessee. You might think that in that time the Tennessee legislature could do something about it. You know, passing red flag laws, expanding background checks, or even banning assault style rifles if you really want to go there. No. Instead, they expelled two of their fellow lawmakers for having the audacity of leading a protest to call out that hypocrisy. There are a couple of aspects to the story I want to speak to here. The first is the lengths some folks will go to protect the gun lobby. Make no mistake, the full throated defense of guns by politicians has nothing to do with principle and has everything to do with protecting a grift that helps them cement their grip on power. The gun lobby spends millions to help elect politicians who support their aims. After every mass shooting, every single one, gun purchases skyrocket as people turn to the very thing that caused this mess as a last resort to protect themselves when they know their government’s going to do nothing about it. Gun manufacturers make money. They then turn around and plow some of that into conservative politicians reelection campaigns to make sure that after the next mass shooting, there’s no regulation that might affect their profits. Those politicians all sing from the same hymnal, deflecting the obvious blame away from the guns themselves. This is that on steroids. Not only will they deflect, but now they’re moving to silence any voice that might call them out. There’s something more here. This is a frank assault on democracy itself in the name of guns, to expel democratically elected legislators for views that oppose the majority is to dismiss the votes of the people that elected them. Now, consider the fact that there were three legislators up for expulsion, two young Black men and a middle aged white woman. Guess which two got expelled? Both Black men from predominantly Black constituencies, in formerly Confederate Tennessee. Need I say more? Meanwhile, this week, another state legislature decided to wild out. 

[clip of unspecified news reporter] Republicans in Idaho are set to ban interstate travel for abortion. 

[clip of unspecified news reporter] A new Idaho law makes it illegal for an adult to help a minor get an abortion without parental consent. 

Dr. Abdul El-Sayed: That’s right. If you’re a pregnant minor in Idaho and want an abortion, not only will the state keep you from your right to bodily autonomy within its own borders, but they’ve criminalized anyone helping you leave, too. That can get you 2 to 5 years in prison in Idaho. Never mind the fact that the state government has now made the entire state of Idaho a prison for forced pregnancy. Just like Tennessee expelling its legislatures this new Idaho law raises a set of constitutional questions. States aren’t allowed to interfere with the free movement of citizens across state borders. Except that’s exactly what Idaho just did. All to exert control over other people’s bodies. Because you know how many of the legislators would have their ability to travel restricted by this? Zero. None. Zilch. Nada. Not to be outdone by Republican state legislatures, conservative court appointees raced to put limits on Americans lives this week too. 

[clip of unspecified news reporter] Developing now, a Texas federal judge has ruled to suspend FDA approval of an abortion pill that’s been used for more than two decades. 

[clip of unspecified news reporter] The Texas judge has halted the FDA’s approval of mifepristone, jeopardizing access to the abortion medication. 

Dr. Abdul El-Sayed: If you are a regular listener, you’ve heard me talk about this one before, how a collection of nonprofits aligned specifically to attack abortion rights in this country figured out how to bring a case in a district of a judge whom they absolutely knew would rule in their favor about how that single federal judge was poised to overturn the FDA’s entire science based process for approving medications. Just because he doesn’t like what one of the medications does. Well, this week he went ahead and did it. This is a direct attack on abortion rights, not just in states where legislatures have moved to ban it, like Idaho, but across the country. Remember, the majority of abortions in this country are medication abortions. And this ruling targets one of the two key medications used to perform them. And this ruling calls out the hypocrisy of the Supreme Court when they overturned Roe last summer, arguing that abortion rights should be a quote “states issue,” I guess not. But it also goes further. It puts the ideological bent of a single judge ahead of the science based processes we use in this country to make decisions about medication safety and efficacy. He called the FDA’s reasoning, quote, “unsound”. Oh, I didn’t know they taught clinical study design in law school. It’s a gigantic encroachment of ideology on science, but on the same exact day, literally the same day, another federal court judge, hero in Washington State, filed an injunction directly opposing the ruling, blocking the FDA from doing anything to limit mifepristone access. The Biden administration has also filed an appeal in the case. These dueling rulings, though, suggest that it’ll be headed to the Supreme Court. You know, the same Supreme Court that kicked all this off when they repealed Roe. For now, though, mifepristone remains available. And if it wasn’t, the second drug in the medication abortion regimen, misoprostol can also be used on its own, though there’s another case targeting that drug, too. We’ll be watching this. New data out shows just how dire America’s precipitous decline in life expectancy has become. And exactly who’s dying. U.S. life expectancy has been in freefall over the past three years, for which we have data. 2020 through 2022. The simple explanation is, of course, COVID, but that doesn’t explain all of it on its own. See, life expectancy also dropped back in 2015, the first time it did so in decades in this country. It dropped again in 2016. And while the next few years saw a reprieve. Everything went to shit with the pandemic. Before COVID this drop in life expectancy was attributable to what epidemiologists have taken to calling quote, “deaths of despair,” deaths by suicide or overdose, most among low income, middle aged, rural white men. But since COVID, there’s been a change in those numbers. Whereas life expectancy has begun to bounce back in nearly every other high income country in the world, it hasn’t in the US. Why? Deaths among young people. The probability of a five year old dying before they turn 25 in this country is 4%. That compares to right around 1% in similar high income countries. Kids and young adults are four times as likely to die here. And there’s one reason that jumps out above all of the others. Death by gun, whether homicide or suicide guns are killing young people. Now, which after three of them died in Tennessee, the legislature there would have done something about it. But no. Instead, they kicked out two young Black members. That’s it for today, on your way out don’t forget to rate and review. It does go a long way. Really please rate and review. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. We’ve got our logo mugs and t shirts and our science always wins sweatshirts and dad caps. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher, our associate producers our Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me. Dr. Abdul El-Sayed. Your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.