Editor's Note: This story was originally published in September and has been republished with updates about the U.N. investigation of extreme poverty in Alabama and other U.S. locations.
The United Nations is investigating extreme poverty in the U.S.
"Some might ask why a U.N. Special Rapporteur on extreme poverty and human rights would visit a country as rich as the United States. But despite great wealth in the U.S., there also exists great poverty and inequality." That was part of a statement issued by Philip Alston, a New York University law and human rights professor, who is leading the mission.
This month, his team set out to visit cities and towns in Alabama, California, Puerto Rico and West Virginia, as well as Washington, D.C. The findings will be made public on December 15.
As NPR reported this fall, one sign of the poverty in Alabama is the reemergence of hookworm, documented in a new study.
Hookworm thrives in regions of extreme poverty with poor sanitation and affects some 740 million people worldwide. Developing nations with warm, moist climates, in regions like South America, South Asia and Southeast Asia, are most susceptible to the worm.
Hookworm primarily spreads when an infected person defecates outside, leaving behind stool contaminated with hookworm eggs. Once the eggs hatch, the soil becomes infested with worms, which can latch on to the bare feet of anyone walking by. The microscopic worms burrow into the body through a hair follicle and ultimately worm their way into the small intestine to feed on blood. One form of hookworm can be ingested via contaminated soil or food.
Hookworm was rampant in the U.S. more than 100 years ago. It thrived in the poor south, where many families could not afford proper outhouses and sewer systems were rare.
Thanks to widespread treatment efforts, education and economic development, the parasitic worm was eradicated in the U.S. although the exact date isn't clear — somewhere between the 1950s and the 1980s. Hookworm was now just a problem of the developing world — or so we thought.
In the study, 19 of 55 individuals in an Alabama community tested positive for the hookworm, which was thought to have been eradicated in the U.S. by the 1980s.
"I was very surprised by this," says Dr. David Diemert, a hookworm expert at George Washington University. "There has not been any documentation of people being infected in the U.S. for the past couples of decades."
How is it possible?
Lowndes County, Alabama, is one of the poorest counties in the U.S. — so poor that many residents lack proper sewage systems. Unable to afford a septic system, residents concoct their own sewer line using PVC piping, the researchers observed. The pipe runs from the toilets in their homes and stretches off some 30 feet above ground until it reaches a small ditch.
"This seems safe to [the residents]," says Dr. Rojelio Mejia, a pediatrician and infectious disease specialist at the Baylor College of Medicine who led the hookworm study. "But Alabama is very hilly and any drizzle of rain causes flooding, so whatever they delivered to the site spreads to the entire area, including their neighbors' area."
The soil in the area, Mejia adds, also drains poorly, worsening the situation.
When the trenches overflow, the soil becomes contaminated with waste. Anyone walking outside barefoot, or even with bare ankles, risks hookworm infection — that's because the worms are expert at latching on to passers-by.
What's worse, even homes can become contaminated. Nearly three quarters of study participants reported that at one point or another, raw sewage had made its way back into their house. Flooding often carries sewage to their doorways, Mejia says, and drainage pipes can become overwhelmed with rain, flushing waste back into the home.
Concerned about the sanitation situation and its potential health implications, the Alabama Center for Rural Enterprise — a nonprofit organization that helps address poverty in the state — approached Mejia's team. Mejia's colleagues had previously reported that poor U.S. communities with poor sanitation were at risk for "neglected tropical diseases, which we ordinarily think of as confined to developing countries."
Mejia's team tested for multiple parasites prevalent in the tropics, including hookworm. Stool samples revealed that community members had one or two hookworm eggs per gram of stool.
That differs from what researchers see in other countries where hookworm is a problem.
"In poorer [areas of] Argentina, I have seen people with 1,000, 5,000 or even 20,000 eggs per gram of stool," Mejia says,
The reason is likely that there are more hookworms infesting the soil in poorer countries, perhaps because of high rates of open defecation.
"Hookworm does not replicate inside of you; they don't mate inside of you and have baby worms," Diemert explains. "The only way to increase the number of worms in your gut is to be exposed to more larvae outside."
Diemert hypothesizes that residents of the Alabama community are only periodically exposed to worms.
Treatment is easy. One dose of albendazole — two 200mg pills — can clear the worms out. But the cost of the drug in the U.S. can be a problem.
And as we've learned in other countries, treatment is only a temporary fix.
"We can't prevent people from getting re-infected until they deal with their sewage problem," Diemert says. "You can give as much education as you want, but if they still have flooding and no resources for proper plumbing, you can't do much to stop it from happening again."
Fixing the problem is next to impossible for much of the community, according to the research team. The average income in Lowndes County is $18,036 and a septic system for a single home would cost about $15,000.
"In my study, we have a very poor, disenfranchised population here that is being neglected," Mejia says. "Everybody was African American and living below the poverty line."
Study participants were alerted if they had hookworm and encouraged to follow-up with their primary care physicians for treatment.
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