Policy Brief: Health implications of ARPA funding dedicated to on-site wastewater systems in the Black Belt area of Alabama

March 14, 2023 | Kimberly Randall, LHC Staff

A number of Alabama residents, particularly in the Black Belt area, are unable to connect to centralized water and sewage utilities and instead rely on on-site sanitation systems, or septic tanks. These systems are costly, particularly in comparison to the household income of the area, and often fail due to the unique geological structure of the region (He et al., 2011). Homeowners who are unable to afford a proper on-site sanitation system may resort to “straight piping” instead, dispensing raw sewage into nearby fields, ditches, or waterways (Loveless & Corcelli, 2015).

The Black Belt has a uniquely structured geologic profile that results in a rich, dark soil high in nitrates which gave the region its name. The unconfined aquifer, or layer of soil above the first layer of clay, is only a few feet deep and much more shallow than in other areas of the state. Traditional septic tanks are buried just below the ground level which results in the tanks potentially being buried in a layer of montmorillonite clay rather than soil.

This poses two issues. This type of clay is hydrophilic, meaning that any moisture leaving the system via drainage fields is not able to be naturally filtered the way soil composed of minerals and microorganisms is. Additionally, the clay expands and contracts in extreme temperatures found in Alabama which can cause the concrete septic tanks to crack and expose extreme amounts of waste into the groundwater, known as interaquifer leakage. Consequently, the area requires an engineered or “mounded” sanitation system that artificially creates a larger unconfined aquifer of sand and soil on a property, but the cost is upwards of 5x that of a traditional septic system.

Ineffective sanitation infrastructure poses a number of health and environmental risks. Common pathogens related to groundwater contamination include but are not limited to shigella, hepatitis A, norovirus, giardia, and salmonella (EPA, 2015). Additionally, parasites like hookworm have historically been present in the area due to poor sanitation (McKenna et al., 2017).

While many Alabama residents struggle to access adequate sanitation, the problem is especially severe in the Black Belt counties of Dallas, Perry, Sumter, and Wilcox. As some of the poorest areas in the state, the cost of an effective sanitation system is often unfeasible. However, under state law, it is the financial responsibility of the homeowner to install and maintain a state-permitted on-site sanitation system and risk fines, arrest, and a potential lien on their home for not doing so (Alabama Code § 11-68) It is estimated that tens of thousands of homes in the Black Belt area that have outdated, ineffective, or substandard on-site sanitation systems.

Currently, the Alabama Department of Environmental Management (ADEM) is the facilitator of all government funding for sanitation projects in the state. However, ADEM does not offer a mechanism to provide financial assistance for on-site systems to homeowners or non-municipal entities such as non-profit organizations.

On Tuesday, March 7th, Governor Ivey called for a special session of the Alabama legislature to distribute the remaining $1.06 billion in federal funding granted by the American Rescue Plan Act, a portion of which is expected to go toward sanitation infrastructure in the Black Belt. ARPA funds could be highlighted as a way to assist with on-site sanitation repairs via grants distributed through ADEM to begin tackling this problem.

To download this Policy Brief in PDF form, CLICK HERE.

Other facts of note:

  • According to one survey, 90% of land in the Black Belt is not suited for conventional on-site sanitation systems (He et al, 2011).
  • The average income in Wilcox county is $19,231 (US Census, 2021).
  • A survey conducted in Wilcox County showed that 90% of unsewered homes had an unpermitted sewage system, 60% of homes had a visible straight pipe, and 33% of homes had a buried straight pipe or other unpermitted sanitation systems (He et al, 2011).
  • Researchers estimate that upwards of 550,000 gallons of raw sewage are being put in the watershed each day due to inefficient sanitation (Walton, 2017).
  • One study estimated groundwater contamination from failing septic systems could affect up to 340,000 low-income people in rural Alabama, placing them at an elevated risk of disease (Wedgeworth & Brown, 2013).


EPA. (2015). Groundwater contamination Guide – US EPA. Retrieved March 10, 2023, from https://www.epa.gov/sites/default/files/2015-08/documents/mgwc-gwc1.pdf

He, J. et al., (2011). Assessing the Status of On-site Wastewater Treatment Systems in the Alabama Black Belt Soil Area. Environmental Engineering Sci, 28. 693-695.

Loveless, A., & Corcelli, L. (2015), Pipe Dreams: Advancing Sustainable Development in the United States, EPA BLOG, https://blog.epa.gov/blog/2015/03/pipe-dreams-advancing-sustainable-development-in-the-unitedstates/.

McKenna, M. L. et al., (2017). Human Intestinal Parasite Burden and Poor Sanitation in Rural Alabama. The American journal of tropical medicine and hygiene, 97(5), 1623–1628. https://doi.org/10.4269/ajtmh.17-0396

U.S. Census Bureau. (2022). Income and Poverty, July 1, 2022 (V2022) — Wilcox County, Alabama data table.

Walton, B. (2017). Diseases of poverty identified in Alabama County burdened by poor sanitation. Circle of Blue.

Wedgworth, J. C., & Brown, J., (2013). Limited Access to Safe Drinking Water and Sanitation in Alabama’s Black Belt: A Cross-Sectional Case Study. Water Quality, Exposure & Health, 5. 69-71.

Policy Watch: Alabama Bill Looks to Decrease Correctional Incentive Time in State Prison System

March 6, 2023 | Kimberly Randall, LHC Staff

As the 2023 Alabama Legislative Session begins on March 6 with Governor Ivey’s State of the State Address, dozens of bills have been pre-filed over the last few weeks. This year starts the first of a four-year term with new committees, new legislators, and new leadership. As a part of a five-part series, the Lister Hill Center for Health Policy has identified five pre-filed bills that could have substantial health implications if passed in 2023.

Inmates sitting on bunks wearing white jumpsuits

SB1 – Deputy Brad Johnson Act

Sponsored by: Sen. April Weaver (R-Brierfield)

This bill has also been pre-filed in the House of Representatives as HB-9 by Rep. Russell Bedsole (R-Montevallo)


Under current Alabama law, § Section 14-9-41, individuals incarcerated within the Alabama Department of Corrections had “good behavior time” calculated by a specific equation. Referred to as correctional incentive time, inmates can have time reduced off of their sentences for serving portions of their time in various amounts depending on their classification, a ranking system determined by the length of time spent incarcerated and the deemed trustworthiness of each individual.

Proposed Legislation

The legislation, SB 1, would decrease the correctional incentive time for each classification of inmates.

Class 1 inmates (considered trustworthy and able to work without supervision) are eligible for a maximum of 75 days to be removed from their sentence per 30 days served. SB 1 would reduce this amount to 30 days.

Class 2 inmates (able to work under supervision) are eligible for a maximum of 40 days of correctional incentive time per 30 days served, which would be reduced to 15 days.

Class 3 inmates (special assignments) are eligible for a maximum of 20 days of correctional incentive time, which would be reduced to 5 days.

Additionally, SB1 doubles the length of time that inmates must spend in each category before advancing to the next class.


Alabama has been scrutinized by the Department of Justice and legal advocacy organizations for being unsanitary, overcrowded, and dangerous. The state has one of the highest incarcerations in the country, with a mortality rate of more than twice the national averageAlabama is home to the most dangerous prison in the United States, as determined by the number of violent and often fatal incidents at St. Clair Correctional Facility. While funding was diverted from the American Rescue Plan in 2022 to build new facilities, the Alabama Department of Corrections Commissioner, John Hamm, has declared that the new buildings will not have a higher capacity than the existing ones.

SB1 would increase the number of incarcerated persons in the state at any given time. Under the existing guidelines, an incarcerated person who was given a five-year sentence could be released after 28 months if maxing out the correctional incentive time. Under the proposed changes, the same person would be released no earlier than 36 months. Without proper procedures to increase capacity, medical access, and staffing, this increase in prison populations could have significant adverse health implications for incarcerated persons and prison staff.

Prison systems are hot spots for disease transmission and often have understaffed medical facilities. The Alabama Department of Corrections utilizes a co-pay system for incarcerated persons to use healthcare resources which are often 5-10x their daily wages. Additionally, the cost of medical treatment within the prison system is significantly higher than for unincarcerated persons, resulting in a higher percentage of undiagnosed and untreated diseases. It is also important to note that some disease transmission, such as SARS-COV-2, can impact the prison staff and inmates.

Next Steps

The Alabama Legislative Session officially begins on Wednesday, March 7. SB1 has been scheduled for a first reading that day, which will be sent to the committee for deliberation. Should it pass in committee, a second reading on the Senate floor will place the bill on the official Senate calendar. Then, a third reading will occur where the entire chamber will debate the bill.

If you want to make your voice heard on this or future legislation, click here to identify your elected officials, and check out this guide from the ACLU on how to write a letter to your legislators.

Stay Informed

Want to learn more about this bill and other issues impacting the Alabama prison system? Join the Lister Hill Center for Health Policy, the UAB Institute for Human Rights, and the Southern Poverty Law Center on Wednesday, March 22, at 4 PM at University Hall, Room 1008, for a special discussion on Criminal Justice Reform & Human Rights in Alabama. Registration can be found here.

Additionally, we recommend the following organizations for more information on criminal justice reform:

Student Reflections from APHA 2022

The mission of the Lister Hill Center for Health Policy (LHC) is to connect and support those seeking to improve health outcomes through policy. A key aim in achieving pursuing our mission is to empower students to affect policy change. We support students’ growth in public health policy and advocacy through our Health Policy Ambassadors program, internship opportunities, and resources available to all UAB students. We have also collaborated with the Sparkman Center for Global Health on the annual Global Health Case Competition, connected students with community partners, and hosted MPH internships. In 2022, thanks to the initiative of a group of four students, we supported four students in attending the American Public Health Association’s annual meeting in Boston, Massachusetts.

The American Public Health Association hosts its Annual Meeting and Expo (APHA) in late October or early November each year. This is an opportunity for over 12,000 public health professionals – clinical researchers, health officers, lawyers, academics, and so many more – to engage with and learn from one another. Hundreds of concurrent sessions over four days feature the latest developments on programs, policies, commentaries, interventions, and research in public health. Four students who had participated in LHC programs decided to submit two abstracts to the conference organizers. Both were accepted!

Four Exceptional Students

From left to right: Banks Stamp, Emma Kate Sellers, Katie Lovelady, and Sarah Van Winkle

Students who participated in last year’s Global Health Case Competition and Health Policy Ambassadors cohort submitted abstracts to APHA in the spring semester. These students include:

  • Katie Lovelady, an undergraduate Industrial Distribution major;
  • Emma Kate Sellers, who graduated in the fall with her MPH;
  • Banks Stamp, an Accelerated Bachelor’s/Master’s student pursuing an MPA; and
  • Sarah Van Winkle, an undergraduate Physics major.

The 2022 Global Health Case Competition tasked participants with addressing the health needs of Maasai elders in southwestern Kenya. The case was developed in close partnership with the Nashulai Maasai Conservancy, with the goal of generating innovative solutions to promote lung health, eye health, and cancer prevention. One group – comprised of Lovelady, Stamp, and Van Winkle – submitted their proposed intervention as an application to Clinton Global Initiative University, a program which supports college students in their commitment to change the world. Their proposal was accepted, and they have diligently worked with Conservancy leadership and UAB faculty to fine-tune their proposal for implementation. This team participated in the roundtable “Promoting Education and Awareness Across the Cancer Continuum.”

The Health Policy Ambassadors program pairs interdisciplinary teams of students with Birmingham-area community partners to identify and address policy issues. Sellers, Stamp, and Van Winkle participated in the 2021-2022 cohort on three separate teams and decided to share their experiences in the program at APHA. The objective of the presentation was to encourage other public health programs to adopt similar strategies to promote engagement in advocacy among public health professionals. This group presented in the “Student Training and Public Health Workforce Development” poster session. All four students were asked to reflect on their experience at APHA. General themes from these reflections are outlined below.

Project and Professional Development

When asked why they decided to go through with attending the conference, each noted the potential benefit to the projects they were presenting. The Conservancy group sought to learn from experts in cancer prevention and global health. “I knew I needed to learn from experts on how to successfully collaborate with international partners on a joint program,” recalled Van Winkle. “Because we were able to present to national global health leaders, our team was able to refine our plan and build a more successful program.” The Ambassadors group also sought to learn from public health experts engaged in advocacy, with an additional goal to encourage other academic public health programs to engage students with advocacy. All four students were determined to use the conference to improve their work.

All four students noted that their professional skills and networks developed in addition to their projects. Sellers had presented other conferences before, but due to the pandemic those opportunities were virtual. For her, this “first opportunity to present a poster in person was a really great opportunity for personal and professional growth.” Stamp described taking full advantage of the opportunity to “practice skills in networking, public speaking, and communicating academic research to subject-matter experts and the public.” Indeed, all four students identified networking as a key benefit to attending the conference. Lovelady added that connections she made with industry professionals have already proven beneficial to her!

A Sense of Learning and Community

APHA showcases the broad scope of public health. In addition to attending their own sessions, students found they were able to learn from presenters in other sessions with topics unrelated to their own expertise. Sellers recalled attending her peers’ roundtable session, noting that it became a highlight for her. “I have not learned much about cancer or done any research on the topic, but I learned so much from the presentations and was able to relate the content to migrant health,” said Sellers. “I learned about cancer screening within specific migrant communities in NYC, a cancer education pilot program used for migrant farm workers in Oregon, and cancer caused by H. Pylori which mainly affects immigrants from East Asia.”

As a Physics major, Van Winkle worried she might not find people with similar interests or sessions that aligned with her academic background. However, she this worry “was quickly washed away” by the interdisciplinary nature of public health. Van Winkle recalled attending the “Innovations in Global Health Technology” session, saying it “stoked my growing passion for leveraging my background in physics and medical technology in my future career to create healthcare technology for resource-limited environments.”

“I was not expecting everyone to be so open to connecting and meeting new people,” recalls Lovelady. “Overall, the sense of community among the attendees was great.” Reflecting on the School of Public Health Alumni Reception, Stamp appreciated the “respect and spirit” that alumni hold for our school. Each student attended networking sessions and the 150th anniversary celebration. Sellers, the only public health student in the group, noted that she “gained a sense of unity within the public health workforce and felt rejuvenated and hopeful about public health upon returning home from the conference.”

4/4 Would Recommend

All four students said that they would encourage their peers to submit abstracts to APHA in the future. As Stamp puts it, “This experience is perfect for those who are determined in their mission, passionate about social impact, and desire to be active change-makers in our world!” Tips from these students for future presenters include practicing and reviewing your presentation/project, planning a schedule beforehand, taking breaks throughout the conference, and being open to connect with anyone you run into. APHA was a great benefit to these students, and we hope to support others in the future.

Policy Watch: Alabama legislature authorizes enhanced lead regulations

September 6, 2022 | Anantha Korrapati, LHC Intern

Lead is a natural chemical commonly used in various products such as household paint (before 1978), gasoline (before 1995), and plumbing pipes and fixtures. However, it is a potent neurotoxin that harms people, especially children, and pregnant women. 

According to the EPA, lead can be absorbed into the body through inhalation or ingesting lead dust from paint coatings or contaminated drinking water. It then travels through the bloodstream to accumulate in the bones. Depending on the level of exposure, lead can adversely affect the nervous system, kidney function, immune system, reproductive and developmental systems, and cardiovascular system. It has been shown to cause brain damage and cognitive deficits in children, even at low exposure levels. Lead exposure also affects the oxygen-carrying capacity of the blood. Levels should be checked through blood tests since there are no apparent symptoms of elevated blood lead levels (BLL). In Alabama, a BLL of five micrograms per deciliter (µg/dL) or higher is considered elevated.

Lead dust can be caused by air pollution near ore and metals processing centers and piston-engine aircraft operating on leaded aviation fuel. The highest lead particulate matter is found in soil near lead smelters at about 50-400 parts per million. 

According to the EPA, there are two extensive lead smelting facilities in Alabama that are superfund sites–nationally contaminated sites with improperly managed hazardous waste that are under the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), allowing the EPA to clean up contaminated sites and forces responsible parties to assist or reimburse them for cleanup services. 

The Interstate Lead Company, or ILCO, had a secondary lead smelter and lead battery recycling facility operating in Leeds, Alabama, from 1970 to 1992. It was named a superfund site in 1986 due to contaminated groundwater, sediment, soil, and surface water resulting from facility operations. The EPA, the Alabama Department of Environmental Management (ADEM), and the ILCO Site Remediation Group, the site’s potentially responsible parties (PRPs), have investigated site conditions. Site contamination does not currently threaten people living and working near the site. The other facility is the Sanders Lead Company in Troy, Alabama. The complete list of lead mines in Alabama can be found here.

Proposed Legislation

SB158, sponsored by Senator Bobby D. Singleton, is titled “Lead reduction, Alabama Lead Reduction Act, lead abatement and further regulation of lead hazard reductions” and aims to regulate lead hazard regulations further, revise the authority of the State Board of Health to conduct lead inspections, enforce the Alabama Lead Reduction Act of 1997, and provide criminal penalties for violation. 

It was signed into law in April 2022 by Governor Kay Ivey. 

The act will establish a program to educate owners on renovation, risk assessments by health officers, a state-accredited program for lead hazard training, enforcement of the Alabama Lead Reduction Act of 1997, and fines for violations. 

Many homes and public buildings designed before 1978 may have lead-based paint on surfaces or fixtures, and this act establishes abatement and renovation accreditation programs for both individuals and firms under “Safe State,” the state accreditation agency for lead hazard training through the University of Alabama. These programs are in accordance with Title IV of the Federal Toxic Substances Control Act. 

Abatement is defined as the removal of lead-based paint or contaminated dust, replacement of lead-painted surfaces or fixtures, and the removal or covering of lead-contaminated soil. 

Renovation is defined as fixing painted components and removing building components with weatherization projects and any interim controls that disturb painted surfaces during the conversion of a building.

The legislation also establishes risk assessments where “the State Health Officer may conduct investigations of general lead contamination problems or conditions in public buildings and upon request of the building owner of commercial buildings, or the request of the owner or occupant of residential buildings.”

The Alabama Lead Contractor Certification Program established by the Alabama Lead Reduction Act of 1997 consists of Lead Hazard Reduction Contractor Certification (Abatement) and Alabama Lead Renovation Contractor Certification. This new legislation defers this training to the “Safe State” program.

Violations of this legislation depend on the number of incidences and can apply to individuals and firms. The fines are as follows:

  • First offense: $250
  • Second offense: $500
  • Third offense: $2500 – $5000


According to a study done in Kent County, Michigan (where over 50% of respondents live in homes built pre-1978), a lead safety course for parents was successful in promoting education and empowerment. However, the researchers stated that “longer-term solutions require advocacy at community and policy levels and cannot be prevented by individual behavior,” such as lead-safe mopping or collecting dust from window sills. Therefore, the legislation in Alabama will hopefully provide lasting changes through the renovation and abatement programs. 

This legislation will improve air quality, both primary and secondary air standards stated below:

National Ambient Air Quality Standards: 0.15 micrograms lead per cubic meter of air

  • Primary: publichealth protection, including protecting the health of “sensitive” populations such as asthmatics, children, and the elderly
  • Secondary: public welfare protection, including protection against decreased visibility and damage to animals, crops, vegetation, and buildings

According to a cost-benefit analysis from 2009, “Each dollar invested in lead paint hazard control results in a return of $17–$221”. This analysis compared the baseline cost of implementing lead hazard control programs to the health care costs and social behavioral costs incurred by lead poisoning, specifically in children. 

Specifically, in Alabama, ValueofLeadPrevention.org estimates $1 billion worth of lifetime economic burden of childhood lead exposure–including costs of “reduced lifetime productivity; increased health care, education, and social assistance spending; and premature mortality.”

Below is a map of the estimated percentage of children with elevated BLLs: 


More economical costs and benefits of lead hazard training can be found here with research done by the National Institute of Environmental Health Sciences. 

Next Steps

The Alabama Department of Public Health and UA are managing this legislation. 

UA SafeState now manages registration for Individual Accreditation and Firm Certification. Register Here.

Firms that seek to be certified to perform renovations must have certification from the Alabama Department of Public Health and at least one individual accredited by UA’s Safe State program.

Here are a few EPA guidelines for individual actions to reduce lead exposure and poisoning. 

  • Eat healthy foods with calcium, iron, and vitamin C. These foods may help keep lead from being digested. 
  • Regularly wash hands, toys, and horizontal surfaces with soapy water and disposable cleaning materials. 
  • Vacuum with a High-Efficiency Particulate Air (HEPA) filtered vacuum
  • Take shoes off before entering the home or living areas
  • Cover lead-exposed soil with fruitless plant materials
  • Hire certified lead professionals to assist with home renovations in pre-1978 housing
    • Homes built before 1978 are more likely to have lead-based paint. Performing home renovations may disturb this paint and be a source of lead exposure. Using lead-safe work practices is critical when renovating. For guidance on lead-safe renovations, please visit the EPA or hire a certified lead professional to do the work for you.

Policy Watch: Alabama Becomes First State to Enact Elder Abuse Registry

July 12, 2022 | Anantha Korrapati & Kimberly Randall, LHC Staff

Montgomery, USA State capitol building in Alabama during sunny day with old historic architecture of government and many row of flags by dome


Elder abuse is a prevalent issue in the United States and comes in various forms, such as physical harm, neglect or desertion, financial exploitation, and emotional abuse through verbal and non-verbal acts. According to the Alabama Department of Human Resources’ Adult Protective Services, over 9,000 reported adult abuse, neglect, and exploitation cases were reported in 2021.

Currently, the Alabama Code §13A, Chapter 6, Article 9 defines three degrees of elder abuse and elder financial exploitation:

The first degree of elder abuse and neglect occurs if someone intentionally abuses or neglects an elderly person resulting in serious physical injury, and the first degree of financial exploitation is if the value of the property taken from an elderly person exceeds $2,500. 

The second degree of elder abuse and neglect is defined by someone recklessly abusing or neglecting an elderly person resulting in serious physical injury, and the second degree of financial exploitation is if the value of the property is $500-$2,500. 

The third degree of elder abuse and neglect is defined by reckless neglect resulting in physical injury or emotional abuse, and third degree of financial exploitation is if the value of the property is up to $500.

Previous legislation, such as the APS Act of 1976, protected elderly and disabled adults by outlining the responsibilities of the Alabama Department of Human Resources, law enforcement authorities, agencies, caregivers, and individuals to report elder abuse cases, which has helped prevent over 1,700 cases in 2021.

In 2018, Shirley Holcombe was a victim of forgery by her caretaker, which inspired her daughter, Jo Holcombe, to campaign for the creation of a statewide elder abuse registry to improve protections for elders further and prevent future cases of abuse. 

Proposed Legislation

HB105, also known as “Shirley’s Law,” implemented the nation’s first elder abuse registry and was signed by Governor Kay Ivey on March 24, 2022, and became effective on June 1, 2022. 

Presented by Representive Victor Gaston and others, HB105 reads:

“To establish a registry for individuals convicted of certain crimes or found to have committed certain acts of abuse against certain individuals; to require certain care providers to query the registry for employees and prospective employees; to require the Department of Human Resources to adopt rules; to establish criminal penalties.”

In addition to requiring the Department of Human Resources to create a database, HB105 also requires all physicians, practitioners, and caregivers to file reports when they believe that any protected person has been subjected to physical abuse, neglect, exploitation, sexual abuse, or emotional abuse. Under HB105, oral reports are to be submitted immediately to the county Department of Human Resources with a supporting written report within seven days. If the report concerns a nursing home employee, it must be submitted to the Department of Public Health. HB105 establishes criminal penalties as well: “An individual required to make a report who knowingly fails to make a report shall be guilty of a Class C misdemeanor.”


According to a study recently published by the Division of Clinical Epidemiology and Evaluative Sciences Research, financial abuse of older adults is the most common form of abuse, but is the least studied. The study found that certain older adults were more likely to be economically, medically, and sociodemographically vulnerable, such as African Americans, adults living below the federal poverty line, and adults who do not live with a partner. The study also found that adults with impaired instrumental activities of daily living (such as using the phone, managing transportation, prepping meals, housekeeping, etc.) are more likely to be victims of elder abuse. 

Forms of financial abuse can include: stolen/misappropriated money and property, forced or misled into surrendering rights or property, impersonation to obtain property or services, and lack of necessary assistance for household expenses from loved ones. 

Financial abuse is most likely to occur among family members, with the highest report being adult children and other relatives. Other common perpetrators include friends, neighbors, or paid home-care aides. 

According to the Journal of the American Society on Aging, “the lack of visibility of elder abuse as a serious national problem has been a long-standing barrier to action.” As the creator of the nation’s first statewide elder abuse registry, Alabama is taking strides to bring awareness to this problem to prevent future incidents. 

Creating and implementing a comprehensive database protects elders by lessening situations in which they might be victims of exploitation. 

Next Steps

If you suspect elder abuse and want to report it to the Alabama Department of Human Resources, use these instructions to fill out a report or email to aps@dhr.alabama.gov. You can also call the hotline at 1-800-458-7214. 

Stay Informed

Policy Review: Birmingham Bus Rapid Transit System

May 16, 2022 | Anushree Gade, LHC Intern


        Public transit has emerged as a vital public service. Metropolitan cities across the world feature a multitude of rapid transit systems (subways, trams, buses, etc.). Such systems are also present in several cities across the United States including New York, Boston, Chicago, and Atlanta. Public transit is a means by which people are given access to various other services and facilities near where they live. The availability of public transit, such as the rapid transit systems, ensures that individuals in the community have the means by which they can obtain the services and experiences they need to improve their health and health outcomes. For many, public transit ensures access to education, employment, health care, and more.1 Therefore, an affordable and cost-effective form of public transportation is crucial for cities to consider.
While extensive light rail systems like those seen in Chicago and other large cities are too expensive for smaller cities, Bus Rapid Transit (BRT) offers such cities an opportunity to provide fast and reliable public transportation to their residents. BRT systems are defined as a “high-quality bus-based system that delivers fast, comfortable, cost-effective services at metro level capacities.”2 BRT systems have lanes of their own to ensure the performance and delivery of the service. They usually also have priority at signals and their own platforms.3 These components ensure that the system is an efficient and cost-effective method of transportation.
Several cities in the U.S. have their own Bus Rapid Transit systems, with Albuquerque’s BRT, seen as the gold standard.4 Albuquerque’s system was implemented to address connectivity and traffic congestion in the city. This system involves separate lanes just for the buses, which are centered in the middle of the road and are given priority at the signals. There are stations at the platform level throughout the city. The City of Albuquerque has implemented a pilot program that started in January 2022 and lasts until December 31, 2022, in which there are no fees associated with utilizing the Albuquerque Rapid Transit (ART) and ABQ RIDE, their original bus transit system.

Benefits and Costs of Public Transit

        With the population of cities growing, vehicle congestion and emissions are two severe consequences of personal transportation. There are increased numbers of cars on the road in metro areas, causing traffic congestion that delays travel times and greater fuel consumption as a result. These issues, in turn, contribute to the emission of greenhouse gasses into the atmosphere. With the implementation of public transit systems, either bus or rail, a decrease in congestion and improved air quality can be observed. Furthermore, public transit systems can provide disadvantaged populations such as the elderly, low-income, and disabled with a means of accessible transportation. This ensures that everyone has the opportunity to engage within the community.
Public transit provides several benefits for citizens; however, it is also important to consider the setbacks associated with it. One of the challenges that accompany the implementation of a public transit system is meeting optimal ridership. In order for public transit systems to operate effectively, there must be a sufficient reliance on them. Such systems can serve large capacities; however, the number of people that utilize the services is only a small fraction.6 As of 2018, the census indicated that only two thousand people depended on public transit in Birmingham.7 This represents about 1.0% of Birmingham’s total population. The COVID-19 pandemic has proven to be a challenge for public transit systems as well. Ridership decreased 73% across all public transit systems as a result of the pandemic.8 Public transit involves extensive human-human interactions and can contribute to the spread of infectious diseases, thus the pandemic negatively impacts ridership.

BRT in Birmingham, AL

        The city of Birmingham is one of the largest cities in the state with a population of 200,733 as of 2020.9 Birmingham spans 146.07 square miles in the center of Alabama. The Birmingham-Jefferson County Transit Authority (BJCTA) is the city’s publicly operated transit authority since 1972. The BJCTA organizes public transit services. Their main service, currently, is the MAX Transit services.
The MAX Direct is a feature of the MAX Transit services and is a micro-transit system that serves as the main form of public transportation in the city. As a micro-transit system, it is responsive to demand. The services are increased in areas with higher ridership density.10 The MAX Direct’s primary purpose is to provide transportation for commuters from the City of Mountain Brook and is an accessible transit option for people with disabilities. It travels around the city and provides transportation to the Birmingham Zoo, Bessemer, the Riverchase Galleria, and more significant Birmingham locations.11
The municipality has made plans for Birmingham’s own Bus Rapid Transit system, known as the Birmingham Xpress or BX. This new system will provide better transit options for the 25 neighborhoods along its route and replace some MAX routes between those neighborhoods. The construction for BX began in December of 2020. Similar to the Albuquerque BRT system, BX will have dedicated bus lanes and signal priority at intersections and connect citizens to several significant employers across Birmingham including the University of Alabama at Birmingham (UAB), Brookwood Princeton Medical Center, and Integrated Medical Systems. The signal priority and dedicated lane features are currently lacking in the MAX system; with BRT features in place, BX will run more efficiently than MAX, incentivizing increased ridership.12 Furthermore, Birmingham is hosting the 2022 World Games which will kick off on July 7th, 2022. This event has also seemed to have prompted the development of the BRT system.10 The construction of the BX is scheduled to be completed by July and before the World Games begin that same month.13
The existence of a transit system in Birmingham is integral to establishing and maintaining connectivity across the city and between neighborhoods. The Birmingham Xpress will enable residents to access healthcare, education, and employment. The transit system is expected to run through UAB, various health care facilities, and through the city itself where multiple large employers exist.
The Birmingham Xpress project was estimated to cost $58 million.14 The Birmingham City Council has had multiple items on its agenda relating to the BRT system. In March of 2021, the Council appropriated $9,037, 500 to the Birmingham Jefferson County Transit Authority (BJCTA) so that they can procure the buses for the BRT system.15 In August 2021, the Council provided the BJCTA with $5,000,000 for the BRT project. However, the exact reason for the funds was not mentioned.16 The Council also approved items involving the procurement of areas of land to build BRT platforms across the city.


        Public transit is a crucial element in large metropolitan areas as it provides communities and neighborhoods with opportunities to connect with one another. Once the Birmingham Xpress starts to run, citizens will be able to easily access services. The BX will also provide more efficient transportation during the World Games. As Rio was confirmed to host the Olympics in 2016, they began work for their own Bus Rapid Transit. The public transit systems constructed in Rio served 2.2 million passengers during the Olympics alone and left a long-lasting impact on the city.17 Their public transit systems provided organized and efficient transportation that was otherwise lacking before the games. With the World Games approaching in Birmingham, the city’s public transit systems will be expected to see a marked increase in ridership.
Furthermore, the BX may also contribute to a decrease in missed medical appointments.  A study that observed the effects of a new light rail line on the number of no-show appointments revealed that there is a correlation between public transit and the number of no-show appointments. Specifically, the analysis indicated that public transit systems contribute to a decrease in the number of missed medical appointments.18 As seen in this study, it can be expected that the BX will have a similar impact as it provides a connection to several medical facilities such as UAB and Brookwood Princeton Medical Center. Overall, the BX will play a vital role in improving Birmingham’s neighborhood connectivity and contributing to the city’s economic development. 


  1. Wright L. Bus rapid transit. discovery.ucl.ac.uk. Published 2002. Accessed April 05, 2022. https://discovery.ucl.ac.uk/id/eprint/112/1/BRT_e-book.pdf. 
  2. Institute for Transportation and Development Policy. What is BRT?. itdp.org. Date unknown. Accessed April 05, 2022. https://www.itdp.org/library/standards-and-guides/the-bus-rapid-transit-standard/what-is-brt/. 
  3. Raleigh. What is bus rapid transit (BRT). Updated February 10, 2022. Accessed April 05, 2022. raleighnc.gov. https://raleighnc.gov/services/transit-streets-and-sidewalks/what-bus-rapid-transit-brt. 
  4. Institute for Transportation and Development Policy. Albuquerque, NM opens first USA gold standard BRT on historic route 66. itdp.org. Published November 27, 2017. Accessed April 6, 2022. https://www.itdp.org/2017/11/27/albuquerque-gold-standard-brt/. 
  5. City of Albuquerque. Zero fares pilot program. cabq.gov. Date Unkown. Accessed April 06, 2022. https://www.cabq.gov/transit/tickets-passes. 
  6. Gershon RRM. Public transportation: advantages and challenges. Journal of Urban Health. 2005; 82(1), 10.1093/jurban/jti003. 
  7. Liberation. Birmingham, AL: a victory for public transit. liberationnews.org. Published September 30, 2018. Accessed April 11, 2022. https://www.liberationnews.org/birmingham-al-a-victory-for-public-transit/. 
  8. Qi Y, Liu J, Tao T, Zhao Q. Impacts of COVID-19 on public transit ridership. International Journal of Transportation Science and Technology. 2021. https://doi.org/10.1016/j.ijtst.2021.11.003. Accessed April 13, 2022. 
  9. United States Census Bureau. Quick facts Birmingham city, Alabama. census.gov. Date unknown. Accessed April 14, 2022. https://www.census.gov/quickfacts/birminghamcityalabama. 
  10. Birmingham Times. MAX transit announces changes as the World Games 2022 nears. birminghamtimes.com. Published July 13, 2021. Accessed April 15, 2022. https://www.birminghamtimes.com/2021/07/max-transit-announces-changes-as-the-world-games-2022-nears/. 
  11. MAX Transit. Routes. maxtransit.org. Date unknown. Accessed April 13, 2022. https://maxtransit.org/routes/. 
  12. Birmingham City Council. Birmingham Xpress. birminghamal.gov. Date unknown. Accessed April 13, 2022. https://www.birminghamal.gov/brt. 
  13. WVTM 13. Birmingham Xpress construction almost complete. wvtm13.com. Date unknown. Accessed April 17, 2022. https://www.wvtm13.com/article/new-route-connects-five-points-west-with-woodlawn/39719728#. 
  14. Birmingham Times. MAX gets new leader as city council adds cash for bus rapid transit. Birminghamtimes.com. Published September 2, 2021. Accessed April 15, 2022. https://www.birminghamtimes.com/2021/09/max-gets-new-leader-as-city-council-adds-cash-for-bus-rapid-transit/. 
  15. Birmingham City Council. Summary of virtual pre-council meeting of the council of the city of Birmingham. Date unknown. Accessed April 6, 2022. https://docs.google.com/gview?url=https%3A%2F%2Fbhamal.granicus.com%2FDocumentViewer.php%3Ffile%3Dbhamal_32833bd813674f9eb079b619e2c6aaa4.pdf%26view%3D1&embedded=true. 
  16. Birmingham City Council. Regular meeting of the council. Date unknown. Accessed April 6, 2022. https://docs.google.com/gview?url=https%3A%2F%2Fbhamal.granicus.com%2FDocumentViewer.php%3Ffile%3Dbhamal_6d10040ec350872ae5d525f405389c3d.pdf%26view%3D1&embedded=true. 
  17. International Olympic Committee. Olympic games transport Rio to a new level. olympics.com. Published August 14, 2017. Accessed April 17, 2022. https://olympics.com/ioc/news/olympic-games-transport-rio-to-a-new-level. 
  18. Smith LB, Yang Z, Golberstein E, Huckfeldt P. The effect of a public transportation expansion on no-show appointments. Health Services Research. 2021. https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13899. Accessed April 17, 2022. 

Policy Watch: Alabama Establishes Grant Program for Public Schools to Provide Feminine Hygeine Products to Students

April 6, 2022 | Kimberly Randall, Lister Hill Center Staff

Female student in bathroom


The purchase of menstruation products has historically caused financial hardship to a large percentage of the population, particularly individuals and families below the poverty line. In Alabama, feminine hygiene products are not eligible to be covered under SNAP or WIC. Last year, Illinois became the first state to lift this restriction to allow the purchase of tampons and menstrual pads using SNAP benefits; however, no such legislation has been proposed in Alabama. 

Currently, only five states require or provide funds for public schools to offer menstrual products at no cost to students, while 37 states have pending legislation to do so. Legislation in Alabama was proposed in 2020 to obtain funding for period products in schools that passed the House of Representatives but stalled in the Senate. 


HB50, sponsored by Representative Rolanda Hollis (D-Birmingham), creates a grant program beginning in the 2022-23 school year for schools to apply for funding to purchase feminine hygiene products for students. Eligible schools must receive Title 1 funding and house students in grades 5-12. Funds will be reimbursed to schools that apply for the program and purchase supplies for students, who will be able to receive the products from a female counselor, teacher, or nurse in their schools. The bill has allocated $200,000 for the first year. The State Department of Education will administer the program.


According to the Alliance for Period Supplies, a non-profit started by feminine hygiene brand Kotex, 1 in 5 women and girls between the ages of 11 and 44 live below the poverty line in Alabama. Along with 29 other states, Alabama taxes period products at a sales tax rate of up to 11%. According to a study completed at St. Louis University, two-thirds of women reported an inability to afford period products in the past year. At the same time, 21% of respondents stated that they faced financial hardship concerning period products every month. 

Lack of access to period products can impact the education of students. In a national survey, 1 in 4 students reported skipping class or leaving school early due to lack of access to period products, often due to financial difficulties. Individuals often resort to paper towels, toilet paper, or rags when proper menstruation products are unavailable. According to the University of Michigan, “when menstruators resort to unhygienic alternatives, they are vulnerable to harmful physical and mental outcomes [and are at a higher risk for] urogenital infections, such as urinary tract infections and bacterial vaginosis.” Additionally, the emotional toll caused by a lack of access to proper hygiene products can lead to depression, anxiety, and overall elevated distress. Providing menstrual products would help alleviate students’ mental and financial across the state. 

Next Steps 

HB50 passed unanimously in both the House of Representatives and the Senate on April 5, 2022, and now advances to Governor Kay Ivey’s desk to be signed into law. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

Don’t know what to say? Check out this American Civil Liberties Union guide on drafting a letter to your government officials. 

Learn More 

Want to learn more on this issue? Women in Training is a non-profit organization located in Montgomery, Alabama, dedicated to providing menstruation education and period products to underserved women, girls, and nonbinary youth in packages coined WITKITS. Started in 2019 by twin sisters Brooke and Breanna Bennett, the organization also facilitates programs to help girls break the generational cycle of poverty, including:

  • WIT Leadership Development Circle to develop a select group of high school young women into compassionate and culturally aware global leaders
  • WIT Girls STEAM Initiative to expose girls to careers in Science, Technology, Engineering, Arts, and Mathematics
  • WIT Mentor Program to match high school girls with university students or professional women to guide them through the educational and early career stages

Policy Works: State Department Announces Non-Binary Option on U.S. Passport

March 31, 2022 | Kimberly Randall, Lister Hill Center for Health Policy

abstract face
Image courtesy of Getty Images


Since their inception, United States government documents have only allowed two options for gender selection: male or female. The modern understanding of gender identity has shifted to view gender as a spectrum, rather than a dichotomy. Research has differentiated between biological sex and gender identity, which has opened up conversations regarding gender-inclusive language on a variety of platforms in recent years. 

The idea of including a third gender option on government identification has already been taken up by several state agencies. According to the National Center for Transgender Equality, 22 US states currently allow for a third gender option on a driver’s license or state-issued photo identification, while 16 states allow for the option on a birth certificate. In almost all cases, the third-gender option is marked with an X. 

In 2020, legislation was filed in the US House of Representatives calling for a third-gender option on passports, and the following year, the first passport with an X gender marker was printed. However, its recipient, Dana Zzyym, underwent extensive legal and medical scrutiny to demonstrate that they were neither male or female but intersex, and represented themselves as non-binary. The process for obtaining a third-gender passport in the US was seen as expensive and lengthy, requiring extensive documentation, prior to recent changes.

Denmark became the first nation to allow for a third-gender option on official documentation in 2014, with Malta following suit in 2016. To date, fifteen countries officially allow for third-gender options on government documents. 


Announced via Twitter on Transgender Day of Visibility, US Secretary of State Anthony Blinken stated “we recognize the achievements and resilience of transgender, nonbinary, and gender non-conforming persons worldwide. … U.S. Citizens will be able to select X as their gender marker on their U.S. passport book starting April 11.” 

The official State Department website was updated to reflect the announcement, detailing the process for how citizens can apply for or update their passport under the new guidelines: 

“You can select the gender marker you would like printed on your U.S. passport. The gender you select does not need to match the gender on your supporting documentation such as a birth certificate, previous passport, or state ID. We no longer require medical documentation to change the gender marker on your U.S. passport.

Beginning April 11, 2022, you can select male (M), female (F), or unspecified or another gender identity (X) as your gender marker if you are applying for a U.S. passport book and selecting routine service. Beginning in late 2023, you will be able to select X as a marker if you are seeking a passport card or selecting expedited service.” 

The policy with initially apply to traditional passport applications utilizing Form DS-11, however the State Department has stated that additional documents including passport cards, emergency passports printed at embassies and consulates, expedited and emergency passports issued at passport agencies, and Consular Reports of Birth Abroad will have the option by late 2023. 


Recent population studies have shown that up to 4.6% of individuals currently identify as nonbinary or gender nonconforming, while as many as two million US citizens identify as transgender. A study in the Journal of Adolescent Health found a positive correlation to overall mental wellbeing with higher rates of gender affirmation through medical care, educational experiences, and social interactions. Gender-affirming government documents are anticipated to have similar positive impacts on mental health. 

The addition of a third-gender option enables individuals to feel gender congruence, or “the feeling of harmony with one’s gender.” Being noted as a gender nonconforming person could help aid in how individuals are seen and recognized in an official capacity. Increased gender congruency has been shown to increase positive outlook regarding one’s identity and overall life satisfaction. In addition, gender-affirming recognition and language are linked to lower rates of anxiety, depression, and suicide in non-binary persons. According to the ILGA, “​​the X marker could provide relief to non-binary person, persons not identifying with any gender at all and persons currently transitioning.”

While activists have advocated for a third-gender option on official documentation as early as 2000, there are some fears that it could increase discrimination for visa applications and border crossings. Australia, an X-gender issuing nation, has warned that travelers utilizing the third-gender option could face difficulties when entering certain countries. Additionally, logistical issues such as checking in for an airline flight where there is no third gender option may impact travelers as well. It is expected that following the updated passport policy, federal regulations regarding this will change in the coming months. 

Next Steps: 

The policy for U.S. passports will go into effect on April 11th and the move has received support from President Biden. However, legislation has been passed in the Alabama Senate and is now in debate in the House of Representatives that would restrict access to gender-affirming medical care for citizens under the age of 18. SB184 would prohibit medical procedures or prescriptions intended to alter the physical appearance or hormonal balance of individuals undergoing transition. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

Don’t know what to say? Check out this guide from the American Civil Liberties Union on drafting a letter to your government officials. 

Learn More: 

Want to learn more about LGBTQ+ policy initiatives? Check out these resources. 

International Lesbian, Gay, Bisexual, Trans, and Intersex Association 

Magic City Acceptance Center

Movement Advancement Project 

The Knights and Orchids Society Inc

The Trevor Project

Policy Watch: The Establishment of the Alabama Voluntary Firearm Do-Not-Sell Database

March 22, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator



Currently, in the state of Alabama, the ability to buy a firearm is available to most adults over the age of 18, with certain weapons restricted to citizens over the age of 21. Individuals who have been convicted of certain violent or alcohol-related crimes are not able to legally purchase a firearm. Alabama follows federal regulations regarding background checks, where licensed gun dealers must process a potential buyer’s information through the National Instant Criminal Background Check System database, facilitated by the Federal Bureau of Investigation. 

Alabama is one of the most lenient states in the country regarding gun laws. No additional background checks, evaluations, waiting periods, or training are required to purchase a firearm. While there are stricter measures for individuals applying for a concealed carry permit, where applicants may be denied a permit if they are a registered sex offender or have previously been declared mentally unstable in a court of law, these restrictions are generally at the discretion of the issuing county. 

Recent legislation (HB272) that was signed into law last month lifted additional restrictions for owning and carrying a firearm. Under the new legislation, a gun owner is able to have a weapon in a vehicle without a permit, and the bill revised the legal presumption that carrying a firearm is “prima facie” evidence or the intention to commit a crime of violence.

Voluntary Do-Not-Sell lists have been proposed in several states since 2019. Sometimes called “Donna’s Law,” the legislation was first initiated after Donna Nathan admitted herself to a psychiatric facility and later took her own life by firearm upon release. 


HB462, sponsored by Reps. Rafferty (D-Birmingham) and Farley (R-McCalla) is a bipartisan bill calling for the establishment of a database operated by the Alabama Department of Mental Health for individuals to volunteer their own names onto a Do-Not-Sell list. This would restrict an individual’s ability to purchase or possess a firearm once their name was added to the list and creates criminal penalties for violations. The bill also provides a pathway for individuals to remove their name once it has been added. The purpose of this list is to restrict access to firearms to individuals “when there is a fear that he or she may become a risk to himself or herself or others.”

With a start date of June 1, 2023, the ADMH is tasked with developing the searchable database, along with creating and distributing a registration form for applicants. Individuals wishing to add their names to their name to the Do-Not-Sell List may do so in the following ways: 

  1. Submitted in person at a circuit clerk’s office with government-issued photo identification. A county clerk shall immediately transmit any received registration form to the department.
  2. Mailed to the department with a copy of the registering individual’s government-issued photo identification.
  3. Submitted electronically to the department by short message service or multimedia messaging service along with a copy of government-issued photo identification and a photographic portrait of the individual that contains exchangeable image file format data proving that the photographic portrait was taken within one hour prior to transmission to the department.

The bill also lays out additional actions to implement an online portal in 2024, with particular consideration to protecting the identity of applicants and preventing program misuse through fraudulent applications. 

Individuals who request to be added to the Do-Not-Sell List must wait 21 days before requesting their names to be removed. Their application for removal will be administered by the district court, where the individual must provide evidence stating that they are not a harm to themselves or others. 


Self-harm is the 10th leading cause of death in adults in the United States and has been declared a public health crisis. Recently, Virginia and Washington have enacted legislation establishing voluntary Do-Not-Sell Lists for firearms to restrict access to individuals experiencing a mental health crisis. According to the Centers for Disease Control and Prevention, half of all suicides are caused by a firearm and are, by far, the deadliest method with the highest chance of mortality per attempt. Delaying firearm purchases has been found to reduce the number of suicides without increasing the number of suicides by other means, showing that suicide attempts by different methods “is unlikely to undermine the lifesaving potential of these laws.”

There is empirical data to support the creation of a Do-Not-Sell list. A survey conducted in Alabama distributed to 200 patients receiving psychiatric care found that 46% of responses indicated they would register for such a database. Broader internet surveys found up to ⅓ of all participants would add their name to a Do-Not-Sell List. According to the New England Journal of Medicine, the vast majority of individuals experiencing suicidal ideation or thoughts will see a clinician within a year of their death, putting medical practitioners in a position to screen their patients for suicidal tendencies: 

“​​Clinicians routinely assess their patients’ risk of suicide, yet they are limited in terms of the practical interventions they can use for patients who are not actively suicidal but who fear they may become so. … [Voluntary Do-Not-Sell Lists] reduce suicide risk consensually and indefinitely in advance of a crisis. The majority of people who die by suicide see a primarycare provider in the year before their death.” 

As a part of standard medical practice, clinicians can regularly encourage the use of advance directives such as determining a medical proxy, so this form of legislation offers patients an opportunity to create such a directive in reference to firearm-related decisions. Unlike other mental health interventions, voluntary registries develop opportunities to enhance patient autonomy and preserve their role in their healthcare decision-making processes. 

Next Steps 

Downtown Birmingham Want to know how gun violence is impacting Birmingham? Katie White, a former Lister Hill Center Intern, compiled research on the history, policy, and impact of firearms in the city.                                                                                                                   Read her full report here

HB462 is currently in discussion in the Alabama House of Representatives, having been read on the floor and placed on the calendar for formal debate. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

DDon’tknow what to say? Check out this guide from the American Civil Liberties Union on drafting a letter to your government officials. 

Learn More 

Want to know more about firearm legislation and how gun violence impacts mental health? Take a look at these resources: 

Gifford Law Center to Prevent Gun Violence 

APHA Gun Violence Fact Sheet 

EFSGV Public Health Approach to Gun Violence 


Policy Watch: Alabama Lawmakers Propose Mandated Mental Health Professionals in K-12 Schools

March 17, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator 

Cutout of a head with puzzle pieces in brain

Image Courtesy of Getty Images


In 2009, the Institute of Medicine compiled a report that recommended local and state governments develop a system to increase access to resources for students for the prevention and treatment of mental, emotional, and behavioral disorders. A year later, the state of Alabama created the School-Based Mental Health Coalition, a subsidiary of the Alabama Department of Mental Health. The agency’s goal was to bridge the various government offices such as the Department of Education and Department of Public Health to ensure that students enrolled in public K-12 schooling had adequate access to adequate mental health intervention, treatment, and prevention services. 

Currently, there are 80 school systems statewide collaborating with just over a dozen mental health agencies to refer students for professional services. The program was expected to increase attendance, reduce the frequency of administrative corrections like suspensions, and integrate mental health practitioners into students’ lives. 

However, the program is not currently statewide, only accounting for 57% of school districts. While the state does offer some funding available for schools to partake in the program, often, the local districts are responsible for a portion of the cost, limiting the ability for poorer districts to join. 

Proposed Legislation 

Senate Bill 306, proposed by Sen. Rodger Smitherman (D-Birmingham), works to establish a minimum set of requirements for a certified mental health services coordinator and mandate that at least one position be required in all school districts within the state. The bill would go into effect with the 2023-2024 academic year. 

The coordinator must have one or more of the following qualifications: 

(1) Have a bachelor’s degree in social work. 

(2) Satisfy State Department of Education qualifications for a school counselor. 

(3) Satisfy State Department of Education qualifications for a school nurse. 

(4) Have professional mental health experience, or have been licensed in a mental health occupation including, but not limited to, licensure as a licensed professional counselor or marriage and family therapist.

(5) Other qualifications as determined by the Alabama Department of Mental Health and the State Department of Education.

Additionally, employees have one year after being hired to complete a certification program developed and implemented by the Alabama Department of Mental Health. 

The legislation also outlines an implementation plan to enact the bill, requiring each local board of education to complete a needs assessment report and a resource map for all public schools in their jurisdiction. These documents are intended to document the status of mental health for the entire school system and create a baseline on which to improve once the program is implemented. 

While the bill does not specify that school districts must join the School-Based Mental Health Coalition, there is substantial overlap between the legislation and the purpose of the SBMHC. 


According to the World Health Organization, mental-health-related disabilities are a leading cause of mental health issues worldwide, with over ⅔ of patients receiving no or inadequate treatment for those conditions. Rates of depression have risen almost 50% in the last ten years, but access to mental health services has remained stagnant. Weare and Nind (2011) state that “childhood and adolescence provide key opportunities to develop the foundations for mental health and prevent mental health problems, and the school is a unique resource to help achieve this.” School-based services such as counselors and caseworkers have been shown to positively impact mental health prognosis in children and teens.

Multi-tiered systems of support (MTSS) are integral to providing proper support to students utilizing a school counselor, social worker, or psychologist. MTTS methods often utilize universal intervention as the primary mechanism for identifying at-risk students, primarily through widespread behavioral testing across the student body. A second tier, narrowed intervention, focuses on a select, smaller unit of students who may be at risk or suspected of behavioral disorders and includes increased monitoring and small-group counseling sessions. Lastly, the final stage of MTSS is an individualized plan of action which may consist of

“(a) conducting a functional behavior assessment and developing an individualized behavior plan; (b) direct student-level mental health services provided by a counselor, school psychologist, or school social worker; (c) additional coordinated mental health services with community agencies; or (d) possible identification for special education.” 

However, there can be a substantial delay in getting students access to necessary psychiatric and behavioral resources, negatively impacting mental health outcomes. A study completed by Guerra et al. (2019) found that the presence of a mental health services coordinator was vital to creating an environment that supports mental student health and learning. While there is no accessible data in the state of Alabama correlating improved health outcomes with mental health service coordinators, broad-scale investigations have shown a substantial impact on overall mental health outcomes across districts. The legislation would ensure that coordinators employed in every school district help streamline the processes to get students the help they need. 

Next Steps 

The Alabama Legislative Session is currently underway and will continue for several months. SB306 is presently being discussed in committee and has not yet gone to a vote. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

Don’t know what to say? Check out this guide from the American Civil Liberties Union on drafting a letter to your government officials. 

Stay Informed 

Want to learn more? Several state agencies are dedicated to mental health resources in the state, such as the Alabama Department of Mental Health and its subsidiaries, the National Alliance on Mental Health, and the Youth Services Institute

Additionally, check out these previous publications that the Lister Hill Center has released about mental health services in Alabama: 

Policy Review: Analyzing Alabama’s Efforts to Improve Mental Health

Policy Review: Medicaid Expansion’s Impact on Mental Health

Policy Review: Student Mental Health at UAB