Unexpected Parasite Plagues the Rural South

Once thought to be eliminated in the 1980s, hookworm has made an alarming comeback in the rural south—particularly in Lowndes County, Alabama, one of the state’s most agriculturally rich but economically challenged areas.

Located near Montgomery, many residents of Lowndes live in abject poverty. With an average income of just $700 a month, most cannot afford septic systems—and live in fear of being evicted. During a house-to-house inspection by parasitologists earlier this year, it was discovered that an alarming number of residents’ make do with straight PVC piping which simply pushes raw sewage into backyards where adults gather and children play. Others who do have septic systems are not much better off. The systems are not conducive to the southern climate and soil type, and too often pump sewage right back into the homes.

A study published in the American Journal of Medicine and Hygiene in September found these conditions are creating an unexpected and alarming outbreak of hookworm. Among 24 households tested, 42 percent reported exposure to raw sewage in their homes and 19 of 55 participants tested positive for hookworm.

Hookworm, which affects some 740 million people worldwide, primarily spreads from the stool of infected persons. The worm usually latches onto the feet, then burrows into the body, ultimately attaching to the small intestine. Symptoms can include weight loss, fatigue, and anemia.

Catherine Flowers, a life-long Lowndes County resident and founder of the Alabama Center for Rural Enterprise Community Development Corporation (ACRE), is working with the EPA and other federal agencies to design cost-effective septic systems that will eventually eliminate the developing-world conditions that Flowers calls Alabama’s “dirty secret.”

Ms. Flowers discovered the hookworm crisis herself when she went to visit a pregnant woman (who asked to remain nameless), after being summoned there by Lowndes County officials and regional environmentalists from the Alabama Department of Public Health. They were threatening to arrest the woman because she could not afford a septic tank with her $600 monthly income. Instead, she was using straight piping which ran from her home into a pit that had been dug just outside her back door. The pit was a small hole and it was teeming with mosquitoes and overflowing with raw sewage. Although this was during the month of October, it had rained a lot and was still warm. The mosquitoes attacked Ms. Flowers’ legs. Those bites went away, but other problems emerged.

After noticing raised patches of skin on her legs and torso, she went to see her doctor. Ms. Flowers recounted the situation with the raw sewage and mosquito bites. She requested that she be tested for some sort of disease or infection. The tests came back normal. That is when she asked her doctor whether it was possible that she had contracted something American doctors are not trained to detect. She was right. Due to climate change, tropical diseases are migrating north.

“Neglected tropical diseases like hookworm not only occur in settings of poverty, but they also cause poverty,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston and one of the authors of the recent hookworm study. “Hookworms were definitely a major factor in holding back progress in the American South.”

The most significant impact of hookworm disease is on children. Unchecked, hookworms can prevent girls from ever menstruating or boys from reaching their growth spurt. Because iron is critical for brain function, hookworm infection can lead to permanent cognitive and intellectual deficiencies. A 1926 study of Alabama school children shows a direct correlation between the number of hookworms that students hosted and their IQ. As those authors wrote: “One has the impression that the [hookworm-infected] child is living in another, entirely separate world, and is only remotely in contact with the everyday world about him.”

Alabama public health officials say the study exaggerates the scope of the problem. Arrol Sheehan, public information manager of the ADPH, said the state health department was “actively involved” in the study but maintained it “did not obtain statistical significance.”

Authors of the study disagreed. “The ADPH was very helpful in our study, but they are limited by outdated diagnostic techniques,” said Dr. Rojelio Mejia, assistant professor of Infectious Diseases and Pediatrics at the Baylor College of Medicine. “In my article, we explain that the low burden of infection would be missed by stool microscopy, even if done by the CDC.”

Mejia added that his study was “a cutting-edge method of detecting very low amounts of parasites.”

Flowers said the study provides validation for the fears local activists have had for years.

“The irony is that this study illustrates how environmental justice, poverty, and climate change have intersected to produce inequality along the famous Selma to Montgomery March trail. We are thankful to the National School of Tropical Medicine at Baylor College of Medicine for validating our long-held belief that raw sewage within the United States is currently yielding tropical illnesses. Now the nation can no longer look away.”

Unfortunately, there are no quick and easy fixes for the hookworm infestation. Lowndes County does not have an infrastructure conducive to the average septic system because of the type of soil, abundance of rain, and climate change. Therefore, more studies are necessary to determine the optimal technology that is both affordable and permanent to address the waste water and hookworm problem in rural Alabama. ACRE has issued a call for an onsite wastewater challenge to find affordable and sustainable technological solutions. An announcement will come soon about partners in this effort.

Mejia’s team also is planning a repeated study that will comprise a much greater percentage of the Lowndes County population. The team will employ molecular assay, which can detect a molecule indicative of disease or risk in patient samples. As hookworms thrive in heat and humidity, the study is slated for the summer of 2018.

In another direction, Joe Brown, PhD, an environmental engineer and Assistant Professor in the School of Civil and Environmental Engineering at the Georgia Institute of Technology, is currently working on a sewage solution for Lowndes County.

Susan Marie Shuman is a freelance writer, editor and the author of two books. Currently residing in Birmingham, Alabama, she is the Susan of “SusanWritesPrecise.”