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 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 Works: US Launches At-Home Covid Testing Initiative

January 18, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator 

Photo Courtesy of Getty Images

Health policy can take many forms and impacts multiple parts of the public health sector. From housing reform to addressing nutrition in impoverished communities to climate change, legislation can have widespread impacts on the health of citizens. 

Following rising cases of the Omicron variant of the novel coronavirus, President Biden announced a series of executive actions on December 21st to assist hospitals and public health agencies. In addition to mobilizing 1,000 troops with medical experience to be dispersed to hospitals overrun with COVID-19 cases and launching distribution systems for PPE to hospitals, clinics, and the general public, the White House also announced an initiative to provide free at-home antigen testing kits to be delivered through the United States Postal Service

This initiative follows similar actions in the United Kingdom and Canada, where at-home test kits have been available to citizens free of charge for several months, either through mail delivery or at designated pharmacies. Tuesday, January 18th saw the launch of https://www.covidtests.gov/, the official website where US Citizens can request a set of four at-home test kits to be delivered via USPS. While the test kits are estimated to be delivered in late January, registration is open now. The federal government has purchased 1 billion test kits for this initiative, after doubling its original pledge of 500 million. 

In addition to the at-home delivery service, President Biden announced that private insurance companies will be required to reimburse expenses for at-home test kits purchased at local pharmacies. According to the Centers for Medicare and Medicaid Services, private insurance companies are required to reimburse over-the-counter COVID-19 tests purchased on or after January 15, 2022 at a cost of up to $12 per test. Health insurance providers must reimburse the cost of up to 8 at-home test kits per month, per person enrolled. According to Blue Cross Blue Shield Alabama, the largest health insurance provider in the state, “members who purchase a test kit should file a claim to be reimbursed. Claims can be filed electronically by logging in to your account or by submitting a Medical Expense Claim Form along with the test kit receipt.” A full list of reimbursable kits can be found on the FDA’s website. 

The Centers for Disease Control lists at-home testing as one of the key measures to reduce the spread of COVID-19. While at-home tests have a higher chance at a false-negative than a PCR test, it is suggested to utilize them prior to indoor social gatherings and other close-contact situations where the virus might be transmitted. According to the CDC, “a negative self-test result means that the test did not detect the virus and you may not have an infection, but it does not rule out infection. Repeating the test within a few days, with at least 24 hours between tests, will increase the confidence that you are not infected.” 

Want to register for your at-home test kits? It’s a simple, two-step process. 

Visit https://www.covidtests.gov


Select “Order Free At-Home Tests” which will direct you to the official page on the USPS website. 

Fill in the information as needed. Tests are estimated to ship starting in late January. 

Built Environment Symposium Re-Cap: Four Perspectives

November 21, 2019 by the LHC Team


Each Fall and Spring semester we focus in on a public health topic to encourage policy action among our stakeholders. We call this our Semester Spotlight program. This Fall was our first semester rolling out this program; we decided to start with the Built Environment. As our city continues to grow and re-develop, we hope to spark conversations about how the environment we build affects the public’s health.