Alabama’s Lowndes County, which lies between Selma and Montgomery, has been coping with basic sewage problems for decades.

Most residents of this rural county, who are predominantly poor and black, live too far from cities to attach their homes to sewer systems. So they rely on septic tanks. But installing and maintaining those septic systems is difficult -- not only because they're so expensive but also because they have to be specially designed to work in the region's clay-rich soil.

As a result, many people who live in Lowndes County have open pits of human waste in their yards or raw sewage backing up into their homes after heavy rains. Neither the county nor the state seems to be in any position to help, and at times, they’ve arguably made things worse.

The situation has received little attention outside of Alabama -- until recently.

After Baylor University researchers found evidence of hookworm, a tropical disease that's largely been eradicated in most developed countries, in more than a third of the residents they sampled in Lowndes County, a United Nations poverty investigator visited the area last December.

“I think it’s very uncommon in the First World. This is not a sight that one normally sees. I’d have to say that I haven’t seen this,” remarked Philip Alston, the UN’s Special Rapporteur on extreme poverty and human rights, as he toured a nearby county.

Suddenly, national and international media are taking an interest in Lowndes County’s long-festering issues. But they’ve been slower to recognize how widespread the problem of poor sewage treatment is in the United States.

“It’s not just in Alabama. A lot of rural communities are experiencing the same problem,” says Catherine Flowers, who has been the area’s most prominent advocate for improving its sewage disposal and the associated problems. “This is a problem around the country that shouldn’t exist.”

Flowers has talked with advocates dealing with similar issues from nearly a dozen states, including Alaska, California, Kentucky and Virginia. Leaky septic tanks cause algae blooms that close beaches on New York’s Long Island. They threaten dolphins and other aquatic wildlife in Florida. Fewer than half of homes on Native American reservations are connected to sewers.

One thing that many of the areas have in common, Flowers says, is that they are already poor and populated by members of marginalized groups. Certainly that’s the case in Lowndes County, where African-Americans make up 73 percent of the population.

“The problem with Lowndes County is that Lowndes County has no money,” says Flowers, who previously worked for the county trying to attract economic development -- a difficult job, she says, because it didn’t have the infrastructure to support new business ventures.

In other words, the county remained poor because it was already poor.

Asking the state for help isn’t much of an option either, Flowers says. Alabama is the sixth-poorest state in the union. It can’t afford to bear the brunt of paying for infrastructure upgrades, especially for private residences.

Because of this, advocates are looking to Congress and to outside innovators for solutions.

Making a Bad Situation Worse

Over the years, the county and the state have exacerbated this crisis.

In 2002, the government threatened to jail more than 37 residents for inadequate sewage treatment. (Alabama state law makes it a misdemeanor “to build, maintain or use an insanitary sewage collection, treatment and disposal facility.”) But most of them couldn’t afford to spend thousands of dollars to upgrade their equipment. Judges had a hard time forcing them to put in new sewage systems, and residents rallied against the harsh enforcement tactics.

Eventually, the county backed down.

As part of the resolution, the Alabama Center for Rural Enterprise, a group that Flowers founded, agreed to help residents install new septic systems in partnership with the state health department.

But after a few years, many of those new systems failed too.

The types of septic systems that work in most places in the country don’t function properly in the Black Belt, the swath of central Alabama and northeast Mississippi known for its dark, fertile soil as well as its large population of African-American residents. Unlike sewers, which whisk wastewater away through pipes to a water treatment center, septic tanks filter the water on-site and release it underground. They rely on the natural filtration of the soil to eliminate the worst contaminants. But in the Black Belt, layers of chalk and clay under the topsoil prevent the wastewater from spreading properly underground.

So after the new systems failed, Alabama activists decided they needed a better handle on what the underlying problems were. It took eight years, but they eventually got federal funding for researchers to do a house-to-house survey of sewage systems.

They discovered that the problem was more complex than many had believed.

It wasn’t just that people were “straight piping” their sewage into backyard lagoons or trenches. Septic systems that had been installed were failing at high rates, too. In fact, even residents on municipal sewer systems complained about sewage back-ups.

Despite these issues, most people weren't complaining to government authorities.

"If you complain to the health department, you’re mandated to fix it yourself. So people don’t complain, because at the end of the day, they’re going to be held responsible and maybe even subject to arrest," says Flowers.

Disputed Findings

Flowers got a firsthand view of the potential health consequences of the poor sanitation several years ago. It was October when she visited the home of a young, pregnant woman who was being investigated by the county. Flowers walked around the back of the house and saw a pool of raw sewage in the yard, with mosquitoes flying around it. It was an unusual sight, she says, because October is usually past mosquito season, even in Alabama. Several mosquitoes bit her, and the next day, she broke out in a rash all over her body that didn't go away for months.

Flowers asked her doctor to run tests to see if she had contracted an illness from the mosquitoes near the raw sewage, but nothing came up.

A year later, Flowers saw an op-ed in The New York Times discussing the growing spread of tropical diseases in poor areas of the United States. Soon, she was in Atlanta talking to the author, and the plans for the hookworm study came out of those conversations.

It took the Baylor researchers three years to conduct the study and publish the results in a peer-reviewed journal (Flowers is listed as one of the authors). They found evidence of hookworm in 19 of the 55 residents they tested.

“The discovery of these parasitic diseases within the United States begins to shift the idea behind global health. One concept … reveals that many of the world’s neglected tropical diseases are paradoxically found in some of the wealthiest countries, especially in these regions of extreme poverty. With the introduction of more advanced diagnostic techniques, emergence of rare, endemic infections may eventually become less defined by geographic location, but more by economic status,” they wrote.

Alabama’s state health department disputed the findings.

Dr. Mary McIntyre, the state’s epidemiologist, said the Baylor-led study “used an experimental technology that was not FDA-approved.” Using more conventional methods, McIntyre reported that “no evidence of hookworm infection was found” among the residents tested in the original study. (The Baylor researchers said in their paper that their approach was more sensitive and, therefore, could detect lower levels of infection than the method used by McIntyre.)

Outside Help

With little hope of getting state or local resources to solve the problem soon, the region is looking for outside help. Researchers from several universities and federal agencies have spread throughout the 17 counties of Alabama’s Black Belt to get a handle on the scope of the problem and determine how it’s affecting the local environment.

Meanwhile, Flowers has been talking with Kartik Chandran, a Columbia University environmental engineering professor and a recipient of a MacArthur genius grant. Chandran’s work focuses on how to use human waste and other wastewater to generate energy, produce agricultural fertilizers and other practical applications.

Chandran says the problems faced by Alabama’s Black Belt are similar to issues that many communities face worldwide, especially in places where it’s not practical to lay sewer pipes and build wastewater treatment plants. One-fifth of the U.S. population uses septic systems, he notes. But pollution regulations for septic systems tend to be more lax than they are for big sewer systems, which means that they lead to more contamination.

“We know this is a significant problem, and we need to start to addressing it,” he says.

Chandran suggests that the solution in Alabama may be treating more waste in buildings and, if feasible, connecting more residences to sewer systems. But coming up with a plan would require more research, he says.

“We have to go there and come up with a holistic solution.”

Meanwhile, there is a chance that the federal government could step in, too. U.S. Sen. Cory Booker, a New Jersey Democrat, has visited Lowndes County to find out more about the sanitation issues there.

“People are literally being poisoned,” he told reporters after his visit. “These are our children and elderly folks living in a toxic environment.”

Last month, Booker worked with U.S. Sen. Doug Jones, the newly elected Democrat from Alabama, and U.S. Sen. Shelley Moore Capito, a West Virginia Republican, to allow low- and middle-income homeowners to use a federal grant program to help install or maintain septic systems. The amendment came as part of the Senate’s version of the farm bill this year, but the language was not included in the House’s version of the legislation.

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