Scientists think Alabama’s sewage problem has caused a tropical parasite.
”The state has done little about it.”
LOWNDES COUNTY, Alabama — On one of the first cool days in October, Catherine Flowers parked her SUV in front of a beige-paneled mobile home with aqua window shutters. She got out and hugged its owner, 63-year-old Alabama native Walter McMeans, and introduced him to the two scientists who’d followed her there.
“We’re here today just to test some of the water and the soil,” said one of the researchers, Megan McKenna, an infectious disease specialist at Baylor College of Medicine in Texas. “We will notify you, and let you know about any particular parasites. Everything will remain confidential.”
Then, McMeans took the researchers behind the trailer, to show them what they’d come to see, and couldn’t help but smell: a four-foot-long puddle of raw sewage, seeping from a failing septic system.
“You have too much rain, you’ve got problems. You do too much washing, you got problems,” McMeans said, as the researchers took water and soil samples. “The ground is just not suitable for this.”
Raw sewage–soaked lawns are a common sight in and around Lowndes County, where more than 70 percent of the area’s 10,000 residents are black and 26 percent live in poverty. Close to a third of Lowndes households report having sewage back up into their homes or pool in open areas in the past year, according to a small survey of residents conducted in May by the Alabama Department of Public Health. And the problem isn’t limited to Lowndes; a quarter of the state’s 850,000 private onsite septic systems are failing, according to a 2015 infrastructure report by the American Society of Civil Engineers.
That probably explains the presence of the parasite the researchers were there to investigate: the blood-sucking hookworm.
Until recently, there was little reason to suspect that hookworms could pose a risk for Lowndes County residents; the gut parasite is usually found in developing countries. But in 2017, McKenna and her partner, parasitologist Rojelio Mejia, published a study that revealed that, out of a small group of county residents, 34 percent were infected, a finding that contributed to a United Nations official calling out the United States for the persistence of “extreme poverty” within its borders.
Now, the same research team is performing a follow-up study that will investigate the link between open sewage, hookworm infections, and any potential negative health impacts.
McMeans’ yard, which is located just outside Lowndes County, is in bad shape, but he’s actually better off than some of his neighbors. Those who can’t afford septic tanks resort to “straight-piping,” a term that refers to plastic pipes that collect raw sewage from people’s homes and unceremoniously discharge it on the ground nearby. That’s what the scientists found at the second mobile home Flowers led them to that day.
Pamela Rush, a Lowndes County resident, avoids certain parts of her yard because of the open sewage she might find there.
“In the summertime, it smells and stuff,” said Lowndes County resident Pamela Rush, the mother of two who lives there. Rush can’t afford a septic tank at all, so she copes by avoiding the sewage when she can, she explained. “There’s a certain part of the yard we don’t go out in.”
After surveying the yard, Mejia didn’t mince words. “It’s an infectious disease nightmare,” he said.
The CDC estimates that as many as 740 million people are infected with hookworm worldwide, but today few Americans would consider themselves at risk. In the research and medical community, it’s known as a “neglected tropical disease” that’s associated with poor communities in developing countries.
People with hookworm release eggs through excrement; in areas with poor sanitation or open sewers, they end up on the ground, where they turn into microscopic, infectious larvae that dig into human skin when people walk by. Once inside the body, the hookworm gets in a person’s veins, and travels up past the heart and into the lungs.
When the parasite makes the jump from the vascular system to a person’s airways, it climbs up the trachea to get to the esophagus, where its human host swallows it — finally giving the hookworm access to its favored mating environment, the digestive system. “It’s a human-to-soil, soil-to-human infection,” Mejia said.
Hookworms feed on the blood of their host, so people who have a lot of them in their gut can suffer from diarrhea, abdominal pain, anemia — causing fatigue — as well as intestinal inflammation. Hookworm can have particularly devastating effects in children, Mejia said, including malnutrition and cognitive impacts. And all of that begins with poor sanitation.
The reason Lowndes Country has so many failing or nonexistent septic systems is in part due to geology: The soil here has a clay-like consistency, which means it doesn’t absorb much water. Standard septic systems tend to back up and flood raw sewage in people’s yards, or even clog toilets and sinks.
To avoid this, locals have to buy specialized septic tanks, which can run upwards of $10,000 — about twice the cost of a standard system. In Lowndes County, where the median household income is just under $30,000, many residents can’t afford them.
“In a place like where we are now, they’re going to need an engineered system that could be anywhere from $15,000 to $16,000, upwards,” Flowers said. “And a lot of people are living in homes that are not worth $15,000 or $16,000 — so it doesn’t make sense. It doesn’t make sense at all.”
Some states have programs to help residents pay to repair or replace failing private septic systems. Harris pointed to a program that installs septic tanks for free. This program, run by the Alabama Onsite Wastewater Association, doesn’t receive state funding and operates on a $10,000 yearly budget, according to its executive director. A spokesperson for the department declined to comment on a follow-up question on whether the state provides financial support to any septic assistance programs.
The Alabama Department of Public Health does, however, have a history of fining people for open sewage violations. Residents like McMeans and Rush live in fear of being reported to the authorities. In the past 15 years, the department fined about one person a year, on average, Harris said.
That’s where Catherine Flowers, a 60-year-old rural development manager for a nonprofit called the Equal Justice Initiative, in Montgomery, comes in. Flowers spent most of her childhood in Lowndes County; when she vouches for someone — even scientists determined to scoop up water and soil near open sewage — locals listen.
Flowers was a longtime resident of Lowndes County; in 1982, she ran for Circuit Clerk.
She still remembers vividly what it was like to grow up there. Her family moved to Lowndes in 1968, and during that time they used an outhouse, then an underground reservoir that holds sewage, called a cesspool, and finally a septic tank. “We had problems with raw sewage coming back into our home,” she said.
But back then, tropical diseases weren’t something she worried about. That started to change in 2009. While visiting a pregnant woman’s mobile home to see the pool of raw sewage outside her back door, Flowers was bitten by mosquitoes and later developed a rash. She was given a clean bill of health, but she still wondered whether disease might be spreading.
Three years later, Flowers, who’d been advocating for attention to the crisis, still didn’t have an answer to that question. So she emailed the head of the Baylor College of Medicine’s National School of Tropical Medicine, in Houston, and told him about the raw-sewage problem plaguing Lowndes County.
That email turned out to be the catalyst for Mejia and McKenna’s study, which began in the summer of 2013.
Flowers had prepared Mejia for this moment, but he was still stunned by the extent of the sewage problems he saw during his first trip to Lowndes County. “The conditions I saw matched several conditions that I’ve seen in countries such as Honduras and Guatemala,” Mejia said. “We wouldn’t expect to find these types of conditions in the U.S. — in our own backyards,” said McKenna.
Back at Baylor, in Texas, Mejia tested stool samples obtained from study participants using a test called qPCR that was designed to detect hookworm DNA. He had helped develop the test, which was first used in the field in 2011, at the National Institutes of Health. He found that out of 55 Lowndes County residents tested for hookworm, 19 were infected.
“We said, ‘Well maybe there’s a contaminant, because how can we have 30 percent of our samples test positive?’ We just kept on repeating it, and then doing different parts of the test,” he said. Those who tested positive had low levels of hookworm DNA in their stool, but the results were undeniable: At least 19 people in Lowndes County had hookworm.
As shocking as the results were, they aren’t unprecedented. Hookworm was once widespread in the American South, including in Alabama. In 1905, more than 40 percent of Southerners, both white and black, were infected. This likely had a significant health impact — one that lives on today in the form of a painful cultural trope.
“One of the thoughts is, especially in Alabama, that the myth of the slow-speaking sharecropper, usually African-American — there’s some evidence that it was because of the hookworm burden,” Mejia said.
One of the richest men in American history often gets credited with eradicating hookworm in the U.S. In 1909, John D. Rockefeller launched a million-dollar campaign to treat children infected by hookworm. The campaign estimated that more than 7 million people in the southern United States were infected — and vowed to eradicate the infection.
But despite Rockefeller’s claims that the five-year campaign had accomplished its chief purpose, studies continued to find hookworm in Tennessee in the 1950s, and then in 1970s in Georgia.
As for Alabama, there doesn’t seem to have been much work on hookworm in the latter part of the 20th century. One small parasite study was conducted in Wilcox County in 1993, and it found that some children were infected with hookworm, as well as other parasites. But today, hookworm screenings aren’t commonplace.
“It is not the standard of pediatric care in the United States to routinely screen for parasite colonization or hookworm colonization — nor is it the standard in this part of the state,” said Morissa Ladinsky, a pediatrician at the University of Alabama at Birmingham who works in Wilcox County. “This is not a routine test, and it maybe should be.”
That’s not to say things haven’t gotten better. As people moved to cities, and sanitation improved in both urban and rural areas, hookworm likely became less prevalent. “It’s a problem that kind of goes away with development,” said Hoyt Bleakley, an economist at the University of Michigan who’s studied the economic impact of hookworm eradication efforts in the South.
But in poor, rural regions of the South, the same risk factors that allowed hookworm transmission in the early 20th century persist today. “The number one thing — besides the proper humidity — is improper sanitation,” Mejia said.
And what the 2017 Baylor study suggested is that, at least among the people involved in the study, Lowndes County’s ongoing sewage problems were allowing hookworm transmission to continue.
Flowers has a commanding presence and a ready laugh, both of which made it easy to see why study participants felt comfortable around her. While Mejia and McKenna collected samples, Flowers checked in with the residents, inquiring about everything from their health and kids to the cost of their water bill. These were not data points to be included in the study; they were questions aimed at building trust with people who might otherwise not feel comfortable having out-of-state researchers scoop up water and soil around their homes.
“The only reason we’re able to do this study is because of her,” Mejia said.
“I trust her, you know. I believe in what she’s saying,” said Rush, who said she might not have participated in the Baylor study if Flowers wasn’t involved. “A lot of people don’t like nobody coming around the house, unless you know somebody,” she added.
As soon as Mejia and McKenna were done collecting soil samples and pipetting soiled water from the wooded area next to Rush’s home, Flowers took the researchers to the Lowndes County Interpretive Center for a bathroom break — but also to make a point.
To understand what’s going on in Lowndes County, you have to know the area’s history, she told me, leading me toward an exhibit. That’s how you’ll understand the intersection of civil rights and environmental justice, she said.
Amid displays recounting the county’s history of slavery, and its subsequent role in the birth of the Black Panther party, she told her own family’s history with scientific institutions — and medicine. Flowers said her mother, Mattie D. Coleman, had been among the black women in the South who’d been sterilized without their consent or knowledge in the 1960s. The procedure allegedly took place in 1965, right after Coleman gave birth to Flowers’ younger brother, her fifth and final child.
Flowers said her mother told her it happened at John A. Andrew Memorial Hospital in Tuskegee, where women with cognitive deficiencies are known to have been sterilized without their consent during that period. We haven’t been able to verify Flowers’ account. The John A. Andrew Memorial Hospital closed its doors in 1987, and the few records that were stored there after its closure “were destroyed during a renovation in 2003,” according to Tuskegee University archivist Dana Chandler. A Tuskegee University press officer said the university does not have records that could be used to confirm whether women admitted to the hospital had been sterilized without their consent during that time.
For black Americans, the history of medicine — and medical studies, in particular — can be painful. In Alabama, many remember that for 40 years, scientists knowingly withheld treatment from black men infected with syphilis to observe the long-term effects of the disease, a study known as the Tuskegee Syphilis Study. Some also recall that in 1951, scientists at Johns Hopkins Hospital performed a biopsy to gather cancer cells from a black woman named Henrietta Lacks, without requesting her or her family’s consent. Scientists use cells from that cell line, known as HeLa, to this day.
Despite this history, and her own mother’s experience, Flowers’ view of science is nuanced. “Science can be used for good, or it can be used for bad,” she said later, and in this case, Mejia and McKenna “are trying to use it for good.”
Mejia and McKenna’s 2017 hookworm study got a lot of attention when it was first published, and it wasn’t all positive. Despite having played an initial role in approving the study’s methodologies, the Alabama Department of Health contested its results upon publication, claiming in a letter published online that the study had “failed to prove hookworm infection.”
The department wrote that a microscope-based test conducted by the CDC had been unable to replicate the study’s results, adding that the DNA-based analysis conducted by Mejia was “experimental” and “not FDA-approved.”
Mejia said there is no FDA-approved test for hookworm infection — including the microscopy-based technique employed by the CDC. And although analyzing stool samples under a microscope is a valid diagnostic method, it’s not the most sensitive, Mejia added. He said it misses about 50 percent of cases, and can be influenced by a technician’s proficiency, as well as the way samples are stored. When people have smaller infections involving fewer eggs — as was the case with the Lowndes County residents — diagnosing an infection can be especially hard under a microscope. The DNA test, on the other hand, can pick up the presence of a single hookworm egg, according to Mejia.
Other scientists agreed. “I don’t think FDA approval is at all necessary or relevant, and PCR, when conducted properly, will give you a more accurate diagnosis,” said Rachel Pullan, an infectious disease epidemiologist at London School of Hygiene and Tropical Medicine.
Lisette van Lieshout, a parasitologist at Leiden University in the Netherlands, echoed her, as did Tom Nutman, the lab chief for the laboratory for parasitic diseases at the National Institutes of Health and Mejia’s former mentor. He said the DNA-based test is “probably the gold standard at the present time.”
Judd Walson, an infectious disease research at The University of Washington added that the insistence on using a microscope — a “sub-optimal” tool in this case — could “perpetuate the neglect” of underserved communities.
The Alabama Department of Public Health also criticized the study for its small sample size. Mejia agreed, and said that’s why the Baylor team plans to include hundreds of participants in the new study that’s underway.
Dr. Scott Harris, Alabama’s chief medical officer, defended his department’s assessment of the study by stating that it had “startling conclusions and wasn’t supported by any other evidence that we had.”
Harris also lamented the attention the 2017 study had received, calling hookworms a “headline-grabber” that distracted from bigger problems like E. coli. “There are many diseases that are much worse that are related to the problem; the problem is wastewater,” he said.
Flowers had hoped to see change for Lowndes County residents after the hookworm study was published. Instead, she was disappointed by the Department of Public Health’s reaction. To her, it was a sign of its lack of interest in helping residents of color.
“I think they would have reacted differently if the participants were white,” she said, sitting on a picnic table outside McMeans’ home. “I think they would have found money right away to maybe address and remediate the problems with our onsite septic systems.”
Harris denied that his department would have acted differently had the study been conducted in a white community. “That’s not true,” he said.
In May, the Alabama Department of Public health conducted what Harris believes is the first assessment of sewage conditions in Lowndes County, surveying 192 households. The report revealed that close to 18 percent of survey respondents had experienced sewage backing up into their home in the last year, and eight percent had standing sewage or run-off near their homes.
When asked via email if the assessment was a response to the hookworm study, Harris responded that he’d tasked his staff in February to try “characterize whether there are any actual health issues related to parasites” in Lowndes County.
The University of Alabama, along with scientists from Georgia Institute of Technology, have also begun to investigate the prevalence of parasites — including hookworms — in Wilcox County, Alabama, which is adjacent to Lowndes. Harris said his department will “cooperate” with UAB in that effort, adding that the study will aim to recruit about 600 children, and may include people from Lowndes County as well. However, a spokesperson for the University of Alabama said the “entities involved haven’t completed all the discussions regarding how they will work together.”
Harris also said that his department had met with the governor’s office on a “couple of occasions,” though he did not appear optimistic about the outcome of those meetings.
“Ultimately, it’s about resources,” Harris said. “It’s a tremendous need for resources that we have, and the response right now has been really incremental and, you know, frankly not adequate.” A press secretary for the governor’s office declined to comment.
In September, the nonprofit group Earthjustice filed a federal civil rights complaint against the state and Lowndes County health departments, stating that the public health department’s “rejection” of the Baylor Study’s findings “misled the public by incorrectly assuring residents there is no evidence of a hookworm outbreak.”
Now, the department is reportedly planning to launch an initiative called the Lowndes County Unincorporated Waste Water Project to get working septic systems to residents, Fox News reported in November. According to the article, residents who wish to participate in the program would have to pay a one-time $1,000 fee for a specialized septic tank, followed by monthly $20 maintenance payments.
Flowers said those fees would be too high of a barrier for most Lowndes County locals. “The residents that would need that can’t afford it, bottom line.” She also said she’d only heard about the program through the Fox News story; neither McMeans or Rush had heard of the program at all.
According to the article, an Alabama Department of Public Health official said the United States Department of Agriculture “verbally” approved $2.5 million in funding to the project, and that the program would launch in January. The public health department declined to provide VICE News with information on the project’s goal, timeline, funding, or origins because a “filed federal complaint.” A USDA spokesperson said the agency had not received a completed application for this project yet, and hasn’t committed or approved any funding.
It’s not clear whether Harris thinks fixing Alabama’s sanitation problem should fall to his department at all. “I guess this is not really meant to be a rhetorical question, but I mean how do we help? What can we do to help them?” he said in October. “The health department nowhere in America installs people’s septic tanks. But I guess that’s kind of fallen to us, because people look to us to try to address that — so we are trying to address that.”
For people like McMeans, it’s hard to imagine that anything might change. “As the years go by, the problem’s getting worse and worse. I don’t know what we’re gonna do; this is not suitable for anyone,” McMeans said, gesturing to his yard and the nearby sewage. “No one should have to live like this. You feel embarrassed when other people bring their children and they see the situation you have — they’re not coming back, and I can’t blame them. I wouldn’t.”