Carolyn Edelstein never planned to be a poop banker. No one really does, which is why, when Edelstein’s friend fell ill with a stubborn C. difficile infection, poop transplant options were limited. Such transplants, which are used with increasing frequency to rebuild stomach and intestinal bacteria populations, are precious to patients and not that hard to produce. Giving poop, after all, is like giving blood, except we don’t all hemorrhage several times a day. More disgusted by the fecal status quo than bowel movements, Edelstein decided to do something and helped found OpenBiome, America’s first stool bank.

Today, Edelstein is an important member of the fertile fecal transplant field, responsible for collecting, testing, and distributing samples and presiding over an immensely valuable, if foul-smelling collection. She spoke to Inverse about the ins and outs of the medical poop industry, how fecal microbiota transplantation helps, and what constitutes a “beautiful stool.”

Why do people need a poop bank?

So, C. difficile is a really nasty gut infection. It’s the most common hospital-acquired infection in the U.S. Half a million Americans get it every year. And it’s pretty resilient to antibiotics. About one in five people will get these recurring infections — so they’ll take antibiotics, then the infection will come back — at that point, they try antibiotics again, and the chances of the infection coming back are even greater. For those folks who get into these multiple recurrent cycles of infection, it turns out that fecal transplants work about 90 percent of the time to get rid of the infection. It’s pretty crazy. These are people who may have been sick for months or years, and when it works, they’re basically better the next day.

Where did people get fecal transplants before you guys came along?

People would usually have to find their own donors, or physicians would find a donor, and each patient would basically have to pay to get their person screened. It was pretty hard for this patient population to do that, because a lot of them are geriatric and don’t necessarily have someone who can come in and do this. But once they’ve found that person, the physician has to pull together the logistical and administrative pieces to be able to process the stool on site, and when that’s all arranged, the donor has to come in the day of the procedure and…perform on demand, which wasn’t always a given. Then, hopefully, there’s a good performance, and they could go ahead and process that stool and then perform the procedure. It was pretty involved. It was a lot of work.

How does one go into the poop banking business?

We got this going when a family member of mine got sick with C. diff and was trying to find somebody who could perform the procedure for him. He couldn’t find anyone who would do it for him. It was through his experience that Mark Smith, our co-founder, got the idea to start just banking stool to make this a whole lot easier for everyone involved. The stuff that we do — rigorously screen healthy donors, collect the material, process it, freeze it, and then just ship it to physicians on dry ice so they can just focus on the treatment aspect.

How do you convince someone to fund a stool bank?

We started with a grant from a family foundation. And Mark, when he started, was in the Alm lab at M.I.T. We started out just using our corner of the Alm lab, and Mark and his co-founder James [Burgess] shared a desk with a couple of other people. We got off the ground pretty modestly. We charge per treatment, and we also collect a user fee from hospitals — that’s predominantly where our money comes from. We also have research collaborations, so money comes in that way, too.

So, can anyone who can perform donate their poop?

Only 3 percent of people pass through our stool screens. We’re more rigorous than a doctor would be in a hospital doing this as a one-off treatment because we can afford to be. It’s not every person who’s fit to be a donor. It can cost a thousand dollars to screen somebody once. And they just have to hope they pass.

Real talk: How do you get your donors?

It was hard at first. We compensate our donors per sample just because it’s such a huge commitment on their part. It’s not like blood donation, where you come in and do your thing and that’s the end of it. For stool donation, because it’s so hard to find someone who qualifies, when we find them, we want them to come in as much as we can get them to come in. So we ask people to come in four or five times a week. We screen them, not just at the beginning, but also 60 days after they’ve been donating for a while. We’ll keep everything in quarantine between those two screens. It’s really a two-month commitment. So, the donors will earn $40 a sample for participating. Because I think there’s that compensation component, word has spread a lot. Ninety-nine percent of the headlines are: “You can earn thousands of dollars just for pooping!” I think that story has really gotten around, and that’s awesome.

What makes a person a good poop donor?

So, there’s a clinical interview and blood and stool screens. Across that whole process, we’re looking for everything we know is going to be infectious. It’s all the things that exclude you from being a blood donor and then a whole bunch of other things that could potentially be mediated by the microbiome or be transmissible through stool.

Okay, so I’m a donor and I’ve been screened. How do I prepare to donate?

It’s actually pretty easy. We have a little stool collection kit. It basically looks like a little container hanging on this frame that fits over your toilet seat. So, y’know — you come into the lab, do your thing, and then you fill out a little questionnaire about your health and you talk to one of our physicians about how you’re feeling and how things are going, and that’s it!

You don’t have to eat anything in particular beforehand?

We exclude extreme diets — so, if you’re on a paleo diet we won’t take you as a donor — but at the moment there aren’t any requirements in terms of what we want you to eat. We do encourage a lot of fiber.

So what do you do with my poop once you have it?

The process is a lot easier than you think. When we first get the stool, we’ll log it, weigh it, transfer that into our database. Then our technicians do a quick assessment of whether it’s a “good” stool. Have you heard of the Bristol stool scale? I don’t know why you would have.

Tell me all about it.

It’s a scale that goes from one to seven. On the one end, it’s a very hard, very small, pebbly stool, and on the other end it’s very watery stool. The “beautiful” stool is kind of in the middle.

The what?

I used the word “beautiful.” Well-formed, not too watery, somewhere around a 3 and a 5.

Of course.

They’ll do a Bristol stool assessment where they just kind of make sure that it’s looking the way it should, and we’ll do random spot checks as well. Once they’ve got the stool, they just put it into a bag with a fine mesh lining in the middle of it, and then they’ll add glycerol and saline solution, and then send it through a press, and then they’ll pipette the liquid into bottles and freeze it. That’s it. It arrives frozen on dry ice as glycerol-saline stool solutions.

How does it get into the body?

If you’re doing it by colonoscopy, you can just kind of send a scope up, like you would for a diagnostic colonoscopy, and then you can kind of infuse it in. Enemas — you just kind of stick it in there. And you can also just send it through a nasogastric drip or a nasoduodenal drip — a tube that goes through your nose, down your throat, into either your stomach or, ideally, beyond into your intestines.

Do patients ever just freak out about FMT and refuse to do it?

I’ve heard the opposite, actually. It’s usually patients going to their doctors and saying, “The antibiotics aren’t working for me, can I please just try this?” C. diff is just really, really terrible. You’re pretty much housebound because you have to to the bathroom, like, twenty times a day, and people talk about how it just takes over their lives. Patients, by the time they’ve exhausted the antibiotic route, are ready to do whatever they need to do to get better.

In talking to just friends and people I know, I’ve never gotten anyone who was like, “Oh God, that’s disgusting.” People are usually pretty intrigued, and I think that’s because there’s something a little bit intuitive to this story, so patients are kind of like, “This makes sense, there’s this bacteria that I can get rid of, and if I can out-compete them with a bunch of other bacteria it’ll go away.”

You’ve got to have a sense of humor about this job.

Oh, for sure. So our donors have to be anonymous, so for fun, instead of just giving them a donor number, we would also let them pick nicknames. So, yeah, “Vladimir Pootin” was our first donor. Some of the other ones I liked were “Dumpledore”, “Ninja Turdle”. It’s fun.

Photos via https://www.flickr.com/photos/edkohler/