When Catherine Flowers arrived at the home of a pregnant woman in Lowndes County, Alabama, Flowers immediately noticed the pool of raw sewage festering behind the house and swarming with mosquitoes.

Under state law, the woman was facing arrest for having an inadequate septic system, and Flowers, the founder and director of the Alabama Center for Rural Enterprise (ACRE), was there to counsel her. Shortly after the visit, rashes began blooming on Flowers’ torso, arms, and legs. Blood tests provided no diagnosis.

“That was when I asked if it was possible that I had something American doctors were not trained to look for,” Flowers said during a recent congressional hearing.

Flowers had good reason to ask, because something unusual was developing in rural Alabama. Hookworm, a parasitic disease long thought eradicated in the United States, has re-emerged in Lowndes County and other rural areas where basic sanitation remains unaffordable for homeowners.

A 2017 report found that over 30% of Lowndes County residents test positive for hookworm — yet they are not able to look to their local government for support. When presented with the study’s findings, the Alabama Department of Public Health published a notice on its official website, claiming that no hookworm was present in Lowndes County.

Represented by Earthjustice, ACRE is fighting for justice in their community. The organization has filed a federal civil rights complaint against the Alabama Department of Public Health and the Lowndes County Health Department, for violating the public’s civil rights and spreading misinformation about the public health risks of raw sewage.

Flowers and other community action representatives spoke to Congress in May to shed light on a national sanitation crisis. A new report from ACRE and Columbia University, which compiled data from other studies to analyze the human rights impact of lack of basic sanitation, cited that between 1.4 and 1.7 million Americans do not have a toilet, tub, shower, or running water. One in five American homes are not connected to municipal sewer lines.

Many of these homes are located in rural communities, which tend to have insufficient infrastructure and limited access to jobs. Due to historical discrimination and marginalization, these issues disproportionately burden low-income African American, Indigenous, and Latinx populations — as do state and local laws that make it the homeowner’s responsibility to take care of sewage when the government won’t.

In Lowndes County, the cost of upgrading a septic system far exceeds the capacity of median incomes, especially within the African American community. A septic system capable of withstanding the Black Belt’s dense, clay-like soil costs up to $30,000, yet the median income of African American families is only $27,000.

Residents who can’t afford the upgrade are forced to improvise, using simple PVC pipes that crack under pressure or end above ground some yards away. During heavy rains, failing septic systems cause raw sewage to flow back into people’s yards and homes, gurgling up into bathtubs and sinks.

Compounding the crisis is Alabama state law, which makes it a criminal misdemeanor to use a substandard septic system. The state has a record of aggressively prosecuting African American residents for wastewater violations, effectively punishing marginalized groups for lacking access to basic sanitation. Though arrests have decreased in recent years, the threat remains.

“The law is still on the books, so people are afraid to talk about it publicly,” says Flowers. “At the same time, any child living next to raw sewage on the ground is at risk. What do you do for poor families who don’t have the resources but want access to sewage treatment that works?”

Residents who live near raw sewage are at risk of severe health impacts, yet few options are available for treatment or education. Exposure to raw sewage is linked to reproductive and developmental harm, acute infections, and diarrhea. In the long term, people exposed to the parasites and bacteria that live in sewage are more likely to develop dementia, diabetes, and cancer.

ACRE’s civil rights complaint seeks an independent investigation of racial discrimination in Alabama’s enforcement of wastewater violations, and scientific analysis of the failing septic systems and sewage lagoons. It calls on the Alabama Department of Public Health to retract its false hookworm notice, and instead educate the public about their health risks and options for treatment.

“We hope that the Department of Health and Human Services will exercise its power under federal civil rights law to resolve the discriminatory conduct that has long deprived African American residents in the Black Belt from functional wastewater systems and adequate protections of their health,” says Earthjustice attorney Anna Sewell, who is representing ACRE.

Though the complaint targets state and county agencies, Flowers believes it is the federal government that should provide the funding for sanitation infrastructure.

“It’s a poor black county, with no sizable tax base,” says Flowers. “The county has no money to spend on it. It’s getting blood from a turnip. Ultimately, we need the federal government to take the responsibility of giving all citizens access to safe wastewater treatment.”

As climate change accelerates, the sanitation issues facing Lowndes County and other communities will grow even more pressing. Border states are experiencing longer, more erratic rainy seasons, which increases the risk of raw sewage being transported via floods and damage to inadequate septic systems.

At the congressional hearing, Flowers insisted that any federal funding include plans for extreme weather events, which could further damage septic systems in years to come.

“We can no longer treat this as if climate change doesn’t factor into it. Innovation is necessary to go beyond the immediate crisis in Alabama, and work toward real, long-term solutions,” she said.

Although the federal civil rights complaint was initially filed in September 2018, the Department of Health and Human Services has still failed to even open an investigation into the raw sewage and hookworm in Lowndes County.

People in this area are still waiting for justice and an improvement in public health. Earthjustice continues to represent the Alabama Center for Rural Enterprise in their fight.

Originally published on May 31, 2019, this article was updated with information on the Department of Health and Human Services’s inaction.