The safety of ecosan systems in terms of pathogen destruction during the various treatment processes is a continuous topic of debate between proponents and opponents of ecosan systems. However, the publication of the WHO Guidelines on Reuse, with its multiple barrier concept, has gone a long way in establishing a common framework for safe reuse. Nevertheless, the question remains whether ecosan systems can ever be scaled up to reach millions of people and how they can be made sufficiently safe to operate. The initial excitement in the early 2000s by the ecosan pioneers has changed into a realization that changing attitudes and behaviors in sanitation takes a lot of patience.