The sight of barren grocery store shelves in the first few weeks of the coronavirus crisis sent thousands of shoppers scrambling for basic supplies – including, in the United States, toilet paper. As of April 1, bathroom tissue remained a sought-after commodity nationwide, out of stock at big-box retailers like Costco and Walmart, and even online at Amazon.

This sudden scarcity has made toilet paper as valuable as any other paper currency. Neighbors using the NextDoor app are bartering toilet paper for eggs and other household essentials, reports Bloomberg, and a recently viral Tik-Tok video showed a man tipping delivery drivers with rolls of toilet paper instead of cash. There’s even been a wave of toilet-paper-related crime. In North Carolina, for instance, sheriff’s deputies found a stolen tractor-trailer carrying 18,000 pounds of bathroom issue, while in Florida, police arrested a man for stealing 66 rolls from a Marriott hotel. A surging number of price-gouging investigations have also focused on the exploitation of desperate shoppers; some chain stores, for example, have reportedly demanded $10 a roll, along with $26 thermometers and $40 for a single pair of face masks.

Americans, however, might be unique in their fixation on toilet paper, despite reports of toilet paper panic-buying in other parts of the world. Americans are not only the world’s largest producers of toilet paper, they are also its most prolific users. In fact in many places globally, toilet paper – along with basic sanitation – is an unimaginable luxury. Toilet paper shortages, it turns out, are truly a first-world worry.

In global toilet paper usage, Americans are on a roll

According to Tissue World Magazine (yes, there is such a thing), North American consumers used an average of 25 kilograms of toilet paper per person in 2018 – or the equivalent of 144 Charmin Mega-Rolls – far outstripping the average global per capita usage of just 5 kilograms a year. By comparison, consumers in western Europe and Japan used only about 15 kilograms per person, while toilet paper usage is close to negligible in Africa, the Middle East and many parts of Asia.

The vast bulk of the toilet paper Americans use is domestically produced. According to the market forecasting firm IndexBox, just 7.5 percent of Americans’ bathroom tissue is imported. Even so, the United States is still the world’s largest importer of toilet tissue, accounting for 9.4 percent of global imports, according to MIT Media Lab’s Observatory of Economic Complexity (OEC). China, meanwhile is the world’s largest exporter, followed by Germany, Japan, Poland and Italy. China, does not, however, export much of its toilet paper to the United States; rather, 80 percent of Chinese exports end up in other parts of Asia, Africa and Europe. What toilet paper the United States does import comes primarily from Canada and Mexico.

Unlike with other categories of consumer goods, Americans don’t rely on foreign toilet paper because its domestic production is so strong. Among the nation’s top manufacturers are global consumer products giants such as Kimberly-Clark (maker of Cottonelle and Scott); Procter & Gamble (the maker of Charmin and creator of Mr. Whipple); and Koch Industries’ Georgia-Pacific (maker of Quilted Northern and Angel Soft). Clearwater Paper Corporation, which reportedly operates one of the world’s largest toilet paper factories in Lewiston, Idaho, is the nation’s biggest maker of store-brand toilet paper, such as for the grocery chain Kroger and for Costco. (According to the Idaho Statesman, each of the factory’s 1300 workers received 36 free rolls of toilet paper, as well as 24 rolls of paper towels, in what another local news outlet described as a “pandemic bonus.”)

Why the world isn’t flush with toilet paper

Global trade in toilet paper totaled $24.4 billion in 2018 – a relatively small figure compared to other consumer goods such as cosmetics ($44.5 billion), shoes ($99.6 billion) or refrigerators ($43.1 billion). International trade accounts for about 22 percent of global tissue consumption, according to one market analysis.

One reason that toilet paper-dependent countries like the United States rely on domestic production is that it’s the cheapest option. The United States, for instance, has plentiful supplies of both virgin and recycled wood pulp, which are the raw materials for toilet paper. And because of its bulk, toilet paper is also expensive to transport, which means that foreign toilet paper would be more costly by comparison – at least as a finished product. In fact, more than a third of the global trade in toilet paper is in so-called “parent rolls” of tissue – giant rolls that are converted by paper mills into smaller rolls and then packaged into the plastic-wrapped six-packs you would (normally) find on the shelf.

But there are other reasons why there is no vast global market for toilet paper, despite the central role it seemingly plays in Americans’ everyday lives. One is the popularity of bidets in many parts of the industrialized world, including in Europe and especially in Asia. As Tissue World Magazine points out, today’s high-tech bidets are stiff competition for low-tech toilet paper. In Japan, for instance, “high-tech toilets based on water and/or air jetting with several additional functions, including automatic lid opening, music, ozone deodorant systems and urinalysis, seem to have had some negative impact on toilet tissue consumption.” Among the most popular of these luxury bidets is the Washlet “personal cleaning system,” manufactured by Japan’s TOTO. In October 2019, the company celebrated its 50 millionth sale of the Washlet.

Bidets are potentially even catching on in the United States – perhaps in part to the current toilet paper panic as well-heeled consumers look for ways to do without toilet paper altogether. Wired, for example, recently reported a spike in Americans’ interest in bidets, including a deluge of calls to domestic bidet manufacturing startup Tushy. “This could be the tipping point that finally gets Americans to adopt the bidet,” CEO Jason Ojalvo told the magazine.

But perhaps the most significant reason the rest of the world doesn’t share Americans’ attachment to toilet paper is that this most basic of human rights – access to sanitation – does not exist in vast swathes of the globe. Not only is toilet paper unavailable, so are toilets.

A global crisis in sanitation

According to the United Nations, more than half the global population – 4.2 billion people – live without access to “safely managed” sanitation, which the UN defines as access to a “hygienic, private toilet that safely disposes of people’s waste.” As many as 673 million resort to “open defecation,” which contributes enormously to the transmission of disease. More than 2 billion people drink water contaminated by feces, the UN further reports.

One tragic result is that 432,000 people die each year from diarrheal diseases as a result of inadequate sanitation, according to the UN, including 297,000 children under the age of five. According to Rose George, author of The Big Necessity: The Unmentionable World of Human Waste and Why It Matters, diarrhea kills a child every 15 seconds. In contrast, she writes, “Modern sanitation has added 20 years to the average human life.”

Unfortunately, just 40 out of 152 countries that have pledged to provide universal sanitation by 2030 are on track to reach this goal, the result of funding shortfalls, increasing water pollution, poor governance and conflict. The current global crisis with COVID-19, certain to ravage the developing world, will set back this progress even more. In fact, the lack of sanitation – including access to clean water for hand hygiene – could accelerate the spread of disease in many parts of the world, adding to the pandemic’s already shocking human toll.

While it’s only a matter of time before U.S. grocery store shelves are stocked again with what Americans consider the most basic of staples, many more nations have far to go before they can experience the luxury of that deprivation.

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