Not every American has access to basic sanitation. This leader is out to change that.
America’s dirty secret

Waste Not, Want Not

A new book calls attention to the lack of basic sanitation in the rural South.

on Nov 19, 2020

Catherine Coleman Flowers is the rural development manager for the Equal Justice Initiative and an environmental health researcher working to bring basic sanitation to rural communities — a campaign she details in Waste: One Woman’s Fight Against America’s Dirty Secret. In this excerpt, which has been lightly edited for clarity, the Grist 50 Fixer and MacArthur Fellow recounts two key moments that focused worldwide attention on the unsanitary conditions many Americans live in.


I was in D.C. on business in December 2016 when I received a call from Senator Cory Booker of New Jersey. His staff had let me know to expect it, but when I heard him on the other end of the phone, I was still a little stunned. He told me he wanted to be “the environmental justice senator.” It was my first and only time hearing that from a senator. He asked about the parasite study (a study that found hookworm rampant in the American South due to poverty and poor sanitation) and how the idea to do it had come about. I told him the whole story, starting with the mosquito bites. He was interested in finding a way to address neglected diseases of poverty, and he told me he wanted to come to Lowndes County, Alabama.

Six months later, he arrived in Montgomery. We planned to meet for dinner the night before I took him to Lowndes County. He is a vegan, so I arranged for us to eat at Central, a restaurant that offered a few vegetarian options and that was conveniently located next door to the Equal Justice Initiative. Standing near the door, I waited with my brother for him to arrive. Soon Bryan Stevenson, EJI’s founder and executive director, joined us, and then Booker walked in, looking very unassuming in his jeans. This was a first meeting for all of us, but we knew each other’s work. Being at the table with one of the best social justice attorneys in the world and a Rhodes scholar who aspired to be the leading environmental justice senator was like being in social justice heaven. When we were joined by Mustafa Santiago Ali, vice president for environmental justice at the National Wildlife Federation, it got even more heavenly.

The next day, it was time to come back down to earth in Lowndes County. Our first stop was at a single-wide mobile home where a disabled veteran lived near the Lowndes Interpretive Center off of Highway 80. A short walk from the civil rights trail, the veteran’s backyard held a pit full of waste piped straight from his toilet.

I had been riding in the car with Booker and two aides. Before getting out of the car, I rubbed Skin So Soft on my arms to fend off mosquitoes. My sinuses flare up when I use insecticides, and Avon’s Skin So Soft Bath Oil usually does the job. This time it didn’t. When I stepped outside, I was immediately attacked by mosquitoes, and soon my arms were covered with bites. As if on cue, the bugs reenacted the scene that had started the hookworm study. Booker remarked on how the bugs seemed to be drawn to me.

Waste book cover
Courtesy of The New Press

As we walked to the back of the house, other people joined us, including a crew from National Geographic Explorer. We reached the pit, and Booker stared in disbelief. I had once filmed the pit because it was often full of both sewage and life. Mosquitoes were visible, and so were the bulging eyes of frogs semi-submerged in the human effluent.

The next home we visited had a failing septic system. The homeowner had disconnected it after sewage backed up into her bathtub. It was now flowing into a wooded area behind her house. Again, the mosquitoes descended. This time, a National Geographic producer sprayed Booker’s clothes with a repellant that she said they used when filming in tropical areas. Yet we weren’t in a developing nation. We were in Lowndes County, near the Alabama state capital.

The home was on the family’s land along the Selma-to-Montgomery march trail. The owner’s grandmother had housed marchers there. The owner’s mother had been a plaintiff in a major civil rights case that challenged the exclusion of women from jury service. And the owner herself was one of the volunteers who had conducted our house-to-house survey to document problems with sewage.

The final home we visited was in the town of Hayneville. There, I witnessed a conversation that struck me as miraculous between Booker and the homeowners’ daughter. I had been visiting this home for years, sometimes with visitors and sometimes alone. Each time I went there, I talked to the owner, Ms. Charlie Mae, or her husband. Her adult daughter, Steviana, would be present but rarely reacted beyond nodding her head or saying hello.

Steviana was sitting outside when we approached the house. Booker walked over to her, knelt beside her chair, introduced himself, and told her he was there to learn about the wastewater problem. For the first time, I saw Steviana perk up. She began describing the problem. I realized Booker had a distinct way with people, creating comfort and trust. He seemed deeply interested in what they had to say, and Steviana responded to that authentic concern.



She told how her family had struggled with sewage backing into their home for years, even though they paid a fee for municipal service. Steviana left Alabama for a time, only to return to the same problem. Sewage flowed not only into their neatly kept brick home, but also into their otherwise tidy front yard. Their street, lined with homes, is near the town’s sewage lagoon. Instead of reliable wastewater treatment, residents of the neighborhood get a different kind of service from the town: When they call to complain about sewage in their homes or yards, sometimes several times in a week, the city sends workers in a truck to pump it out of their yard. Steviana’s family had replaced their flooring numerous times.

Suddenly, Steviana asked everyone to be quiet and listen. She is blind and has a keen sense of hearing. “Do you hear that gurgling sound?” she asked. “Whenever we hear that gurgling sound, it is an indication that the toilet will overflow.” A few days later, their home again was flooded with raw sewage. This time her family had to take out a loan to replace the flooring.

We were getting closer to the publication of our parasite study. Back in 2015, I had told Paul Lewis of the Guardian that his publication could break the story when the time came. I kept my promise and let him know. It turned out that Ed Pilkington, chief reporter for the Guardian, would be writing the story. Ed is British, with a history degree from Queens College at Cambridge, and unlike many reporters who visit the area, he came with a refreshing historical perspective. He knew the history of the South, and he also made comparisons to what he had seen in India.

Ed was shocked to see raw sewage on the ground. It is always amazing to me to hear people voice dismay about something that I have known for many, many years. It reminds me that this is, indeed, America’s dirty secret. We have to unveil that secret if we are to find sustainable solutions.

The study went live on September 17, 2017, in the American Journal of Tropical Medicine and Hygiene. It drew international attention, not only because it was important medical news, but also because it revealed a little-known side of the United States, although in clinical terms. It remains the most downloaded article from that journal.

Now the Guardian was free to publish its story. Ed took a narrative approach, painting a stark picture of the raw sewage problem, the diseases associated with exposure, and the gaping chasm between rich and poor in the United States. The headline proclaimed that “in America, the world’s richest country, hookworm, a parasitic disease found in areas of extreme poverty, is rampant, the first study of its kind in modern times shows.”

The story ran internationally and provided a view of rural America that was unknown to most of the world and, strangely, even to most of the United States.

“Scientists in Houston, Texas, have lifted the lid on one of America’s darkest and deepest secrets: that hidden beneath fabulous wealth, the U.S. tolerates poverty-related illness at levels comparable to the world’s poorest countries,” Ed wrote. “More than one in three people sampled in a poor area of Alabama tested positive for traces of hookworm, a gastrointestinal parasite that was thought to have been eradicated from the U.S. decades ago. The long-awaited findings, revealed by the Guardian for the first time, are a wake-up call for the world’s only superpower as it grapples with growing inequality.”

catherine-coleman-flowers-protest
The author at a 2019 climate protest in Washington, D.C. Photo courtesy of Catherine Coleman Flowers

Most of the news coverage that followed focused on hookworm, but other parasites were detected as well. Stool samples were collected for 55 individuals. Of these, 19 (34.5 percent) were positive for hookworm, four (7.3 percent) for roundworm, Strongyloides stercoralis, and one (1.8 percent) for Entamoeba histolytica, a parasite that can cause severe diarrhea. Finally, the dirty truth about sewage and inequality in rural America was official.

It was about to become even more public.

On a brisk December morning in 2017, I became tour guide for a very special group. This time, our guest represented the United Nations, and with him came a media entourage to capture the story. It was a chance to take our fight to a new level.

I had worked with JoAnn Kamuf Ward and Inga Winkler of Columbia University on framing the sewage problem in human-rights terms. JoAnn is director of the Human Rights in the U.S. Project of the Human Rights Institute at Columbia Law School, and also supervises the Human Rights Clinic. She focuses on inequality and social injustice within U.S. borders. I met her through my affiliation with the National Coalition for the Human Right to Water and Sanitation. We have collaborated on research and coauthored briefings about the waste problem in rural America, as well as partnered on international and domestic advocacy to improve access to basic services.

The first thing I noticed about Inga Winkler was her German accent. She is a lecturer at the Institute for the Study of Human Rights at Columbia University and the director of undergrad- uate studies for the human-rights program. Before joining Columbia, Inga was legal advisor to Catarina de Albuquerque, the United Nations’ special rapporteur on human rights to water and sanitation.

I met Inga when I presented testimony to de Albuquerque during an official visit to the United States. Now, Dr. Philip Alston was a U.N. special rapporteur and had been invited by President Obama to visit sites in the United States. When we learned he was coming, JoAnn and Inga helped me prepare a letter inviting Alston to Lowndes County. We set out to entice him with a compelling argument that the raw sewage issue was also a poverty issue. Our approach to addressing waste had not been taken in the United States before. This would be an opportunity to take the issue to the United Nations Human Rights Council and the world.

The letter succeeded as we had hoped. We were excited to learn Alston would come to Alabama, and as part of the trip, he would tour Lowndes County, accompanied by members of the international, national, and local press. Now we had to start planning logistics. We chose two locations to visit and decided to limit the number of vehicles traveling the back roads to minimize disruption.

Because the threat of arrests for raw sewage still loomed, I requested that the press not reveal the identities of the people we visited or their locations in the county unless the people themselves gave permission. No areas were to be photographed without the permission of the homeowners. Experience has taught me that the way to garner trust is to respect the wishes of people who put their freedom on the line in pursuit of solutions. Also, I wanted people to speak freely without fear of retribution.

This would be an important opportunity for Alston, his entourage, and the media. It’s vital for those who can influence policy to be proximate to the situation — to see things in person, as they are. One obstacle to finding sustainable solutions to rural problems is that policymakers and other influential people usually lack experience in the sorts of communities that need their help. Helicoptering into a town hall meeting or to talk to local officials does not adequately convey the gravity of human suffering.



That’s why it is crucial to have local guides with credibility and trust in their communities. The homes where we take guests are places that you will not find using Google maps or your GPS. We go to places that have been out of sight and out of mind for years. Dr. Alston’s visit would provide him and others with a rare perspective that few receive.

The day of the visit, the weather was unusually cold, and a rare snowfall was expected. I am sure it seemed like we were traveling forever as we left the interstate highway, drove through a small town, and crossed railroad tracks to reach a family compound of mobile homes. The patriarch of the family, a preacher, was waiting for us. Disregarding our instructions, one of the press crew approached the gentleman with his camera. The homeowner began to walk away out of fear of reprisals. Alston, in his stern Australian accent, told the crew to cut off all cameras.

This moment of empathy and understanding gave me profound respect for Alston. Photographs of the streams of waste around the trailers could have propelled the story into greater circulation internationally. Yet Alston was more concerned about hearing from the preacher, whom I’ll call Mr. B.

Alston told Mr. B that he was there to learn from him. Relaxing a little, Mr. B began to talk. He told Alston about the exorbitant cost of an onsite system that his family could not afford. Then he led him through the property, showing where sewage flowed. We stopped at one of the trailers and saw a pit of effluent outside the home and more waste underneath it. The entourage stood quietly in apparent horror, their breath steamy in the frosty morning.

The next location was another cluster of mobile homes. This visit was led by Aaron Thigpen, a local community organizer. Aaron was a relative of the homeowners and had lived in Fort Deposit for all of his 29 years. The homeowners chose him to speak on their behalf. He showed Alston around the site, where five members of his extended family, including two minor children and an 18-year-old with Down syndrome, live.

I had been here with Aaron many times before. Their house discharged its waste through straight pipes that released the effluent into fetid, open-air pools. As in many other rural sites, their sewage ran into wooded areas or across grassy fields. In this case, water lines ran along the area where the waste collected.

A reporter asked Alston if he had seen this before. His response: “I have not seen this in the first world.”


Copyright © 2020 by Catherine Coleman Flowers. This excerpt originally appeared in Waste by Catherine Coleman Flowers. Published by The New Press. Reprinted here with permission.