Yes, Shit

The Conversation had a provocative article by Stanford professor Richard White about how America has a bad pattern of wasting infrastructure spending.  In light of the surprisingly bipartisan $1 trillion infrastructure bill recently passed by the Senate, this seems like something we should be giving some serious thought to. 

I’ll posit that we’re doing it again, by not adequately addressing the potential that our excreta, to be polite, offers to detect health issues, including but not limited to COVID-19. 

Illustration by Ori Toor for The New York Times

No shit: excrement can be an important tool in public -- and personal -- health. 

COVIDPoops19 Twitter picture

Take wastewater monitoring.  It is not a new concept – for example, to track polio – and has been used during much of the current pandemic.  According to the COVIDPoops19 dashboard, run by UC Merced’s School of Engineering, there are 55 countries with 89 dashboards monitoring the wastewater in 2,428 sites for signs of COVID-19.  The project even has its own Twitter handle (@CovidPoops19). 

According to Kaiser Health News, the University of California San Diego’s program has identified 85% of COVID-19 cases over the last year, using a largely automated monitoring system.  Infected people shed virus particles long before they show symptoms, allowing such programs to act as an early detection system. 

“University campuses especially benefit from wastewater surveillance as a means to avert COVID-19 outbreaks, as they’re full of largely asymptomatic populations, and are potential hot spots for transmission that necessitate frequent diagnostic testing,” said UCSD study first author Smruthi Karthikeyan, PhD.  Any university debating vaccine or mask mandates in order for students to return to campus should seriously be considering this kind of monitoring mechanism.

Similarly, the University of Minnesota has been sampling the wastewater of 65% of the state’s population, and has correctly predicted the rise and fall of each of the three waves in the last year.   North Carolina has also had success. 

Credit: Biobot Analytics

Biobot Analytics, an MIT spin-off, is one of the leaders in this field, now is helping nearly 500 communities, in all 50 states, and recently got an HHS grant to collect and analyze data from 320 waste treatment plants, covering 100 million people.  As its site points out: “Everybody pees and poops, every day.” 

What else can you say that about?

The CDC is piloting the National Wastewater Surveillance System (NWSS) to create a federal database of such data.  “We think this can really provide valuable data, not just for covid, but for a lot of diseases,” Amy Kirby, a microbiologist leading the CDC effort, told KHN.

Wastewater monitoring is an important tool, but it suffers from a few weaknesses.  It is most effective at a macro-level: a city, a neighborhood, perhaps a building (e.g., a dorm).  Heavy rainwater can distort results.   And, as results begin to drill down to the DNA level, privacy starts to become an issue (as controversy about using wastewater data to spot illicit drug use has already shown).

So, where’s the money in the new infrastructure for this kind of monitoring? 

The infrastructure bill does include an eye-popping $55b for water and wastewater infrastructure, but spending is more focused on threats like lead pipes and emerging contaminants.  Building 21^st century public health monitoring systems against threats like COVID-19 doesn’t seem to be a top priority. 

As Professor White points out about our infrastructure history:

Many of these projects did not end well. The problem wasn’t that the country didn’t need infrastructure – it did. And the troubles weren’t the result of technical failures: By and large, Americans successfully built what they intended, and much of what they built still stands.

The real problems arose before anyone lifted a shovel of earth or raised a hammer. These problems stem from how hard it is to think ahead, and they are easy to ignore in the face of excitement about new spending, new construction and increased employment.

We’re not thinking ahead.  Getting rid of lead pipes and cleaning water of contaminants is basic 20^th century infrastructure; we should expect it.  Automated monitoring of public health threats is 21^st century infrastructure. 

Even wastewater monitoring is not thinking far enough ahead.  If comprehensive wastewater monitoring should be a universal 2130 infrastructure, smart toilets should be a 2150 one. 

Smart toilet illustration.  Credit: SciTechDaily

I don’t mean the kind of smart toilets that warm the seat and perhaps add a bidet.  I mean the kind that can track your health.  It doesn’t get much more personal than that.

There is lots of progress in the field.  In April, Stanford researchers reported on a smart toilet “that can detect a range of disease markers in stool and urine, including those of some cancers, such as colorectal or urologic cancers.”  The monitoring add-ons can be mounted on traditional toilet bowls.   

Lead researcher Sanjiv Gambhir pointed out: “The thing about a smart toilet, though, is that unlike wearables, you can’t take it off.  Everyone uses the bathroom — there’s really no avoiding it — and that enhances its value as a disease-detecting device.”

In May, Duke researchers presented smart toilet advances that categorized stool images using A.I., allowing much more accurate and objective reports about things like consistency, frequency, and bleeding.  That kind of information is important for people with I.B.S. or who may have cancer. 

Sonia Grego, PhD, a lead researcher on the study and founding director of the Duke Smart Toilet Lab said: 

We are optimistic about patient willingness to use this technology because it's something that can be installed in their toilet's pipes and doesn't require the patient to do anything other than flush,

An IBD flare-up could be diagnosed using the Smart Toilet and the patient's response to treatment could be monitored with the technology. This could be especially useful for patients who live in long-term care facilities who may not be able to report their conditions and could help improve initial diagnosis of acute conditions.

The Duke Smart Toilet Lab, in case you weren’t aware, “is dedicated to the opportunities that human excreta offer to empower people to manage their own wellness.”  It now has its own spin-off, Coprata.  We're going to see lots more start-ups like it and Biobot.

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Our politicians are proud of including broadband in the infrastructure bill.  That’s so 2010.  We should be thinking much further out, making investments now for the infrastructure our health will depend on.  We don’t like to think of bodily wastes, but we should be building the infrastructures to take advantage of them.  What else aren’t we thinking enough about?