Disparities in sanitation and wastewater

Community-based research & advocacy in Lowndes County, Alabama brings national attention to environmental injustice

Sylvia M. Rivera, RN

Cover image: "Civil Rights Marchers Selma to Montgomery March" by TradingCardsNPS

Introduction

The United Nations Human Rights Office of the High Commissioner, the General Assembly on the 28 of July 2010, “Recognizes the right to safe and clean drinking water and sanitation as a human right that is essential for the full enjoyment of life and human rights; [and] calls upon states and international organizations to provide financial resources, capacity-building and technology transfer, through international assistance and cooperation, in particular to developing countries, in order to scale up efforts to provide safe, clean, accessible and affordable drinking water and sanitation for all” (General Assembly 64/292, July 2010).

Overview

While the United States (US) is considered one of the most resource rich nations on earth, marginalized communities continue to experience health inequities influenced largely by the social determinants of health (SDOH) (Baciu A, Negussie Y, Geller A, et al 2017); compounding income, wealth and employment inequality leaves community members at increased risk for health problems (Center for Disease Control and Prevention, September 2021; Kochhar, R., & Cilluffo, A., 2020). Furthermore, evidence demonstrates that structural and institutional racism are drivers of poor health outcomes for Black, Hispanic/Latinx, and Native American/American Indian and Asian peoples, to name a few (Jones, C.P., 2000; Williams, D., 2018; Center for Disease Control and Prevention (CDC), October 2021).

According to a 2019 report by The Alabama Center for Rural Enterprise (ACRE), The Columbia Law School Human Rights Clinic, and The Institute for the Study of Human Rights at Columbia University, rural communities experience inequities in sanitation and wastewater systems across the US (Flowers et al., 2019). Absence of such systems puts individuals at risk of developing "tropical diseases that were thought to be eradicated in the United States [such as hookworm]"(Flowers et al., 2019). Finally, repeated exposure to human waste leaves community members in a perpetual state of emotional, and psychological stress.

Within this population, disparities exist in basic sanitation and wastewater treatment services for rural communities of color such as Lowndes County, Alabama, a predominantly Black community (Flowers et al., 2019). While county residents continue to fight for access to such services today, their research and self-advocacy has brought national attention to this environmental injustice; this critical work can be viewed as a ray of light and as a model to be utilized by other communities experiencing similar public health crises.

Current Status: Lowndes County, Alabama

Video source: John Hope Franklin Humanities at Duke; Jacob Rosenberg

Lowndes County residents offer testimony regarding their lived experience without sanitation & wastewater treatment

Image Author: Margaret Shear

Geographical Distribution of Hookworm

Additional study information can be found in PLOS Medicine

Demographic Data

Population size: 10,079 / Racial/Ethnic makeup: African American= 74.4%, White (non-Hispanic) = 24.7% / Median household income= $30,036 / Poverty rate= 26.8%

Source: Lowndes County, AL. Data USA, 2019

Deteriorating sanitation infrastructure, straight piping systems and sewage “ponds" that reside next to residents' homes, represent the panorama of sanitation and wastewater systems in Lowndes County. With heavy rainfall, these open-air sewage ponds overflow into surrounding areas, including the immediate area around members' homes, and local bodies of water. (Flowers et al., 2019). Furthermore, although the predominant narrative- that Hookworm is largely only seen in developing countries (Hotez et al., 2005; See Fig 1 above)- is commonly reported, lack of safe and consistent access to sanitation and wastewater treatment has led to a reemergence of Hookworm in Lowndes County, Alabama (Flowers et al., 2019). Hookworm is an intestinal parasitic disease that is transmitted via fecal contaminated soil and penetration of human skin (Hotez et al., 2005). Eggs from worms are eventually excreted- via wastewater discharge- into the environment surrounding residents' homes, further contributing to transmission of disease (Hossain and Bhuiyan, 2016). Infection can result in gastrointestinal illness, anemia- and in more serious cases- growth and developmental delays (CDC, September 23, 2020; Mckenna et al., 2017). Given these disease characteristics and the constant movement of peoples across varying borders, Hookworm infection also represents a global health issue- impacting those regions most affected by poverty and other SDOH (Hossain and Bhuiyan, 2016).

Data: We do not have any current, comprehensive, national data on sanitation systems disparities. Disaggregated data collection by the US Census Bureau has not existed since 1990 (Flowers et al., 2019). While not a complete picture of sanitation and wastewater systems, findings from Gasteyer et al., (2016) show that rural counties predominantly made up of people of color are more likely to experience lack of access to complete plumbing than counties with majority-white households. Information provided by local Lowndes County residents, and the Center for Rural Enterprise and Environmental Justice (CREEJ) demonstrates that most county residents continue to lack safe, and consistent access to sanitation/wastewater systems (Flowers et al., 2019). Each system is briefly outlined below:

Municipal Systems: Those residents who live in one of the counties’ towns are generally able to access centralized wastewater systems, but because of age, poor maintenance, and the unique soil composition (high percentage of clay), sewage often overflows. Overflow has made it into nearby public waters such as creeks, as well as individual homes (Flowers et al., 2019).

On-Site Septic systems: Most households in Lowndes County are using some form of a failing on-site sewage system (Flowers et al., 2019). The United Nations Report of the Special Rapporteur on the human right to safe drinking water and sanitation in 2011: Mission to the United States of America, reported similar data from findings in 2002 stating, the approximate “number of households in Lowndes County with inadequate or no septic systems range from 40-90%" (De Albuquerque, C. 2011; Loveless, A., & Corcelli, L. 2015; Flowers et al., 2019).

Straight Piping: Given the current rate of poverty in Lowndes County, sanitation systems are cost prohibitive for residents (Flowers et al., 2019; Lowndes County, AL. Data USA, 2019). Thus, those who do not have access to a municipal or on-site system are forced to direct sewage and wastewater to their yards, ditches or surrounding surface waters (Flowers et al., 2019).

Other states, nations & colonies with communities experiencing disparities in sanitation & wastewater systems:

Alaska. Navajo Nation, Mississippi, Ohio, Tennessee, California, Louisiana, Michigan, Virginia, West Virginia, Puerto Rico (US colony) (Flowers et al., 2019)

Photo by Clay Banks at Unsplash

Photo by Gayatri Malhotra at Unsplash

Background / Research

Regulatory

In Lowndes County, Alabama, Black residents live under the constant threat of possible arrest for what is viewed as a “failure to comply with sanitation requirements”- even when financially unable do so (Flowers et al., 2019).

Regulations that govern sanitation and wastewater in rural communities is a complex issue. At the federal level, the Clean Water Act and the Safe Drinking Water Act are two pieces of legislation that establish standards for “regulating discharges of pollutants into the waters of the US” (Environmental Protection Agency (EPA), Clean Water Act, 2021) and ensuring the provision of safe drinking water for the public (EPA, Safe Drinking Water Act, 2021). Both address the need to keep public waters clean but most regulation governing household sanitation systems is developed, implemented and enforced at the local and state level (Flowers et al., 2019).

Due to differing or absent state and municipal laws and regulations, and split oversight between multiple agencies, many rural regions have minimal regulatory support. As a consequence, many rural community members do not have access to centralized or on-site sanitation systems (Flowers et al., 2019). According to Alabama legislation, those Lowndes County residents whom do not have access to a centralized sanitation and wastewater system are required to purchase, install and maintain their own without financial support from local and state agencies (Flowers et al., 2019). In addition, state laws decide the type and severity of consequences for an insufficient system. Under existing Alabama legislation, "the threat of criminalization, arrest, and prosecution, as well as mounting fines, reinforce historic inequalities and continue cycles of marginalization" (Flowers et al., 2019).

Economic

Lowndes County residents are required to purchase and maintain their own sanitation and wastewater systems. Most community members do not have the economic means to do so (Flowers et al., 2019).

Most of the financial support available to states for sanitation infrastructure comes from the federal government. According to Flowers et al., (2019), “Federal funding for sanitation is principally earmarked for municipalities, tribes, organizations, or other public bodies, rather than individual households [and] are not designed to reach small rural communities.” Securing the limited monies that are available for decentralized systems from the Clean Water State Revolving Fund Program (CWSRF)- the greatest source of funding for sanitation and wastewater needs- presents a number of challenges. While funding can be used to address a wide range of water and sanitation initiatives, “project funding and eligibility requirements vary according to the priorities, policies and laws within each state” (EPA, 2016).

In short, financial support from local government for Lowndes County sanitation and wastewater systems can only be achieved if it is deemed a priority by local and state officials- a step they have yet to take. Additionally, property taxes- a method commonly utilized to generate some of the financial resources necessary for sanitation systems- do not provide enough funding for the development of such infrastructure in Lowndes County specifically (Flowers et al., 2019). Furthermore, residents in some rural communities- such as Lowndes, are at an increased risk for an absence of essential services as many are located in unincorporated regions of the US (Flowers et al., 2019). An unincorporated community must then rely on those services provided at the county level. Because Lowndes County regulations do not provide the economic support necessary for household sanitation needs, residents are left to do the best they can with what little monetary resources they have; such actions demonstrate a lack of political will (Flowers et al., 2019).

Racism

Disparities in sanitation and wastewater treatment in Lowndes County, Alabama are inextricably linked to historical and contemporary forms of racism (Carrera and Flowers., 2018).

According to a report by Hardy et al., (2018) titled, The Hamilton Project: The Historical Role of Race and Policy for Regional Inequality, “Black households are more likely to live in the South or in urban areas in the Midwest. The concentrations of poverty in the Deep South tend to overlap with the counties with disproportionately high black population shares- the [same] counties with large black populations before the Civil War.” Furthermore, because of historical, and structural forms of racial discrimination, black communities have been disproportionately affected by wealth, income and employment inequality, leaving most unable to afford costly systems (Carrera and Flowers., 2018; Hardy et al., 2018). This is upheld by what Carrera and Flowers (2018) refer to as colorblind public policy. They state, “[Colorblindness] seeks to erase the long history of slavery, Jim Crow and other manifestations of white supremacy [and] refuses to consider how discrimination and racism have changed over time. Efforts to improve sanitation in Lowndes require explicitly addressing historically racialized problems with substandard housing, lack of social and infrastructural support to meet basic healthcare and living needs, limited access to high quality educational opportunities, and barriers to employment opportunities” (Carrera and Flowers., 2018).

Thus, while leaders in these regions insist on framing this issue as a crisis of poverty, when viewed and analyzed through a socio-historical, environmental justice lens, the experience of Lowndes County residents is also a continuation of long-standing racism. Disparities in sanitation across Lowndes County, Alabama as well as in other Black rural communities cannot be resolved through the criminalization of poverty; meeting such needs necessitates significant socio-economic investments at the local, state and federal level.

Ray of Light: Catherine Coleman Flowers

Video: MacArthur Foundation

Center for Rural Enterprise and Enviornmental Justice (CREEJ), Founder

Equal Justice Initiative (EJI), Rural Development Manager

Center for Earth Ethics, Senior Fellow

The Climate Reality Project & Natural Resources Defense Council, Board of Directors

MacArthur Foundation, Fellow, Class of 2020

Catherine Coleman Flowers, MA, is a Lowndes County native, and the founder of The Center for Rural Enterprise and Environmental Justice (CREEJ), a grassroots organization based in Lowndes County, Alabama. For the past two decades Ms. Flowers, and other county residents have been working to address sanitation disparities in their community. As an Environmental Health Advocate, Catherine Coleman Flowers has been instrumental in bringing national attention to a largely neglected public health crisis. She is Lowndes County, Alabama’s ray of light.

Examples of her activism include but are not limited to: raising local and national awareness around the experiences of Lowndes County residents through, for example, media-based advocacy, and by developing local, state, and national partnerships with organizations, university experts, and elected officials. She continues to identify opportunities for interdisciplinary participation in an effort to develop effective solutions.

On March 7, 2019, Ms. Flowers testified before the Congressional Subcommittee on Water Resources and Environment. In her testimony she urged legislators to take the following concrete actions:

Sanitation & wastewater disparities has long been a neglected issue. National attention is required.
Elected officials at the local, state and federal level should use their powers to eliminate policies that criminalize the poor.
More comprehensive data on sanitation and wastewater disparities is needed. This could be achieved by reinstating its investigation under the US Census Bureau.
This issue requires federal funding. Monies directed towards such efforts should: prioritize technologies that prioritize climate change, involve affected community members, and prioritize communities experiencing poverty, and other social determinants of health. Finally, policies governing the use of federal funds should not penalize households where systems fail due to climate, and geographic variables. (116th Congress, Testimony of Catherine Coleman Flowers, 2019)

As a result of such advocacy efforts, on October 23, 2019, Senator Cory Booker (D-NJ) introduced Senate Bill 2675- "STOP Neglected Diseases of Poverty Act". This piece of legislation provides the federal resources needed to research, and ultimately eradicate preventable diseases such as Hookworm in the United States (Text - S.2675 - 116th Congress (2019-2020).

The work of Ms. Flowers and county residents is a powerful example of community-driven identification of public health problems and solution development; it serves as a model for other similarly affected rural populations of color.

Key Takeaways for other Rural Communities

Access to safe, consistently available, affordable and effective sanitation and wastewater systems are a fundamental human right for all people (General Assembly 64/292, July 2010). The public health community should prioritize work that addresses these basic human rights.

Disparities in safe, and consistent access to sanitation and wastewater systems are also present in other rural communities in the US (Flowers et al., 2019). Public health professionals, alongside affected community members, should undertake immediate research into rural populations in an effort to identify and document the extent of sanitation disparities.

Rural communities of color experiencing poverty are at increased risk for unsafe sanitation systems and related poor health outcomes (Flowers et al., 2019). Public health must prioritize these communities, and advocate for low-barrier, federal funding support that is responsive to unique geographic variables.

Affected community members are the experts in their lived experience. Public health efforts to tackle sanitation disparities should be community driven and center empowerment and capacity building; Community-based participatory research is an example framework for such efforts (Chávez et al., 2018).

The US lacks current & comprehensive, sanitation/ wastewater disparities data. The public health community should advocate for and work to develop national, disaggregated (by race, class, gender, SES, etc.) data collection in an effort to fully identify communities in most need (Flowers et al., 2019).

References

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Carrera, J. S., & Flowers, C. C. (2018). Sanitation inequity and the cumulative effects of racism in Colorblind Public Health Policies. American Journal of Economics and Sociology, 77(3-4), 941–966. https://doi.org/10.1111/ajes.12242

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