Organizers of this year’s New York City marathon braced for a massive toilet incursion. The New York Times reported that the marathon would haul in 2,250 toilets into the city for race day—requiring more than 80 six-axle trucks, tens of thousands of dollars in rental fees, and a gaggle of 16,000-gallon tankers to suck them dry afterwards. Spread out evenly over the 26.2 mile distance, that’s an average of 86 toilets per mile. Why? Because, as the event organizers knew, toilets are a big necessity.

UK-based journalist Rose George would have agreed. On October 22, she visited Washington, DC for an event co-sponsored by PATH and Water Advocates and spoke to a crowd of 70 at the Equality Center about her new book, The Big Necessity: The Unmentionable World of Human Waste and Why It Matters. As a series of stories that collectively highlight the plight of the 2.6 billion people in the world who do not have access to a toilet, the book also showcases the world’s “toilet crusaders” and the solutions they are employing to address the problem in their own countries. She describes these individuals in many of her recent interviews, including on Chicago Public Radio.

Lack of toilets causes some of the world’s most destructive diseases. Pneumonia and diarrhea, two sanitation-related illnesses, are the leading killers of children in the world today by a landslide. A World Health Organization report released last week points out that diarrhea is not only the world’s leading cause of illness, but that pneumonia and diarrhea stand as the first and third causes of overall death in low-income countries. By increasing coverage rates for sanitation and hygiene interventions in low-income countries, we could significantly decrease this staggering burden and make major progress toward the Millennium Development Goals.

Rose George believes that one of the greatest obstacles to this is not lack of technology or know-how—after all, the solutions are so ubiquitous we take them for granted every time we flush—but our lack of willingness to discuss icky issues. Topics like sanitation and diarrhea are not cocktail conversation—but perhaps, George suggests, they should be.

But whether sanitation becomes the next celebrity cause (we hope it does), this is a crisis our generation must face today. Despite the horrible death toll—as Rose points out, “the number of children who have died from diarrhea in the last decade exceeds the total number of people killed by armed conflict since the Second World War”—the economic impact puts a stranglehold on communities trying to escape poverty. A study by the Water and Sanitation Program in the Philippines estimated that lack of sanitation costs the country $1.4 billion each year in health expenses and lost economic opportunities. Return on investment in sanitation can reach $34 per $1 invested; the problem is generating that investment.

The sanitation sector not only lacks pizzazz, but also qualified people to undertake efforts to improve the situation in developing countries. But there are increasing opportunities for youth to be a part of the solution, and by participating in these volunteer opportunities they may choose a career related to sanitation. The jobs that will make death-by-poor-sanitation a thing of the past include engineers and marketing experts, as well as other jobs related to building, planning, and maintaining sanitation systems in low-income countries.

While the challenges are great, an increasing number of organizations around the world are facing them head on. What we need today is a level of will and commitment that equals the scope of the problem. Rose George’s book reminds us that making sanitation available to all is not only about improving health, but dignity—and she challenges us to reach toward that goal, one toilet at a time.

-Janie Hayes, PATH (jhayes@path.org) and John Sauer, Water Advocates (jsauer@wateradvocates.org)