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: The Impact of Eliminating Grocery Sales Tax

February 14, 2021 | Kimberly Randall, LHC Program Coordinator Grocery Tax

Photo Courtesy of Getty Images 


For almost two decades, Alabama policymakers have debated whether or not to remove the sales tax on groceries. Currently, sales tax on groceries accounts for nearly $500 million in state revenue from a 4% sales tax, earmarked for education spending. Additionally, in many cases, local taxes are added to the state tax, making the total grocery tax as high as 11% in some areas of the state. According to Alabama Arise, Alabama is one of three states in the nation with no tax breaks on groceries, and the 4% markup accounts for as much as two weeks’ worth of food for a family.

While Mississippi currently holds the highest grocery state sales tax rate in the nation, other surrounding states such as Georgia and Florida have eliminated sales tax on most groceries. Overall, 37 states have eliminated sales tax on groceries, while ten have a reduced sales tax. In addition to the sales tax rates, food costs are increasing overall. According to a report by KPMG, average consumers are seeing increases of up to 20% on prices at the grocery store, compared to 2019. 

Proposed Legislation 

Currently, two bills are being discussed to eliminate the state sales tax on groceries. House Bill 174, proposed by Representatives Holmes, Hanes, Meadows, Wadsworth, Fincher, Mooney, Wingo, Kitchens, Howard, Warren, Drummond, Paschal, Whorton, Sorrell, Wheeler, Brown (K) and Shaver, reads: 

“Under existing law, the state imposes sales or use taxes upon certain persons, firms, or corporations. Sales of certain items are taxed at a reduced rate. Sales of other items are exempt from the taxes. This bill would exempt sales of food from the sales and use taxes beginning September 1, 2022.” 

Meanwhile, House Bill 173, proposed by Representatives Holmes, Fincher, Wingo, Meadows, Paschal, and Mooney, also eliminates the sales tax on groceries but offers an alternative funding method by way of state income tax to make up the budget deficit earmarked for education. 

“This bill would exempt sales of food from state sales and use taxes beginning January 1, 2023. Under existing law, individual income taxpayers are allowed to deduct the amount of federal income taxes paid or accrued within the year. This bill would amend Amendment 225 to the Constitution of Alabama of 1901… [to] limit the amount of federal income taxes paid or accrued an individual income taxpayer can deduct to a maximum of $4,000 for individuals filing as single, head of household, and married filing separately and $8,000 for individuals filing as married filing jointly.” 


Reducing the amount of taxes for necessary purchases, such as groceries, has been shown to significantly impact the health of households falling below the poverty line. According to Zheng et al. (2021), states which impose income tax on groceries tend to see higher levels of food insecurity, which disproportionately affects lower-income households. In states with a sales tax rate of 4%, the probability of a household experiencing food insecurity rises 3% compared to states without a tax rate. 

Additionally, sales taxes on groceries correlate to higher rates of obesity. A recent study published in the Health Economics Review found that “Counties with grocery taxes have increased prevalence of obesity and diabetes [and] estimate the economic burden of increased obesity and diabetes rates resulting from grocery taxes to be $5.9 billion.” 

The main difference between the two bills comes from funding. HB174 allows the state sales tax to expire without a plan to replace the lost revenue for the education system. However, lawmakers have stated that the Education Trust Fund has seen an increase in recent years, and the ability to cut taxes overall could be beneficial for the state as a whole. HB173 creates a limit on the amount of federal income tax that individuals can write off on their state income tax filing, ultimately only increasing taxes on individuals falling in the top 5%. 

According to an analysis from Alabama Arise, the income tax proposal would offer a tax cut to the majority of Alabamians. 

Next Steps  

The Alabama Legislative Session is currently underway and will continue for several months. Both bills are currently being discussed in committee and have 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 know more? Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty, has officially endorsed HB173 due to the impact of removing the sales tax without jeopardizing the state’s education budget. 


Holes in the safety net of healthcare

June 8, 2020, by Katherine Hymel Downs, RN, MPH


Many of us were forced to delay routine healthcare in one way or another due to COVID-19, whether a dental cleaning or counseling session. In fact, according to researchers at Harvard University, visits at ambulatory health clinics dropped by 60% by late April and were finally seeing a rebound as of mid-May. Now, we are left to investigate the continuing impact. Tangible metrics include the effects of economic loss incurred by the facilities themselves, including staffing furloughs and office closures. But how do we quantify losses in health of patients—losses from delay of care? What about those patients that now find themselves on the outskirts of our healthcare system due to unemployment and loss of benefits? For patients who rely on safety net clinics (rural health clinics, federally qualified health centers, free and charitable clinics), where can they turn when those already strained facilities are forced to close?

In early April, the Health Management Association predicted that Medicaid enrollment could increase from 71 million to the upwards of 94 million due to COVID-19 and related legislation. The process of Medicaid enrollment can be done by phone, without need of internet access. However, patients often require assistance selecting a plan accepted by their healthcare provider or gathering the necessary documentation. In the wake of social distancing measures where many public libraries and even social services buildings are closed to the public, where are people to turn? How many patients even realize they are now eligible to enroll, unless they were advised by a care coordination team at the end of a hospital stay? States are no longer held to the same timeliness standards amidst the pandemic, with limited staff and modified workflows.

Part of the Families First Coronavirus Response Act (FFCRA) did address this prediction of increased enrollment from a financial standpoint. States could benefit from a 6.2% increase in federal match rate (FMAP) (an estimated $36 billion) if they met certain criteria, including the assumption of cost for testing and treatment of the virus. But how exactly does this money reach an individual clinic that serves Medicaid patients—many of whom may not be coming in the door due to COVID-19? Clinics were forced to quickly adopt telehealth services, defined by Medicaid as including both a video and audio component for reimbursement. This presents the following barriers to patients: adequate technology, internet service, and digital literacy. Hybrid clinics that serve a variety of patients—Medicare, Medicaid and uninsured—rely on reimbursements to reserve other funding sources for uninsured patients and general overhead (payroll and benefits, PPE for staff, translation services). Now they are dependent on other relief measures such as the Paycheck Protection Program and outside grants to keep doors open and meet a growing need for care.

As a healthcare provider at a rural health clinic, I admit I do not have all the answers to policy changes. However, the following action items are worth investigating:

  • Medicaid expansion for states who have not already done so
  • Modify regulations to remove barriers from the Medicaid application process
  • Consistent and clear guidelines on reimbursement for telemedicine
  • Provision of cell phones with video technology by managed care organizations (MCOs) to ensure patients have access to telemedicine

Ag-Gag: Big Agriculture fighting back

October 11, 2019 by Sara Harper, LHC Student Intern


Three years ago, I got obsessed with where meat comes from. Kip Anderson’s exposé “Cowspiracy”had come out a few years prior and, while sensationalized, it gave me a passion for something that enveloped environment, policy, and justice. Since then, I’ve written several academic pieces on the factory farming industry and adjusted my purchasing habits away from supporting industrialized farms. Do I sound like PETA yet? Throughout my research I’ve consistently addressed the issue from a human and environmental health point of view, with animal rights being a positive outcome of the latter. My reasoning for this is to steer my point away from sensationalizing the animal cruelty involved, in favor of a health-based approach to this problematic industry.

Quick background: Factory farming, or intensive livestock farming, is a sector of the Agriculture indAg-GagAcrossAmerica_ReportCover.jpgustry that relies on overcrowding animals and assembly-line style production in order to maximize meat output. These facilities have large negative impacts on the surrounding environment including: Water source contamination, greenhouse gas production, and deforestation, and so many other issues.

Okay now you’re caught up. These things are bad, right? So, who’s fighting the good fight? Well…

In the past two decades, “Big Ag” has proposed laws in states across the country that criminalize the efforts of whistleblowers in the industry. These laws have been coined “Ag-Gags” because, by nature, they silence those who intend to call out the harm done by intensive livestock farms. Alabama passed their own Ag-Gag bill in 2002, which makes it a felony offense to obtain access to a property “by false pretenses” and to possess records obtained by deception. This law was directly related to an increase in environmental advocates performing undercover investigations on factory farms under the pretense of employment.

So why is this important? The agricultural industry in America is a high grossing source of income and production but is, by all accounts, necessary. However, powerful, money intensive industries like factory farming have little government oversight when it comes to their environmental health impacts. These production facilities are known to under-report incidents like waste spills and romanticize the idea of their farms to consumers. In this industry, whistle blowers in the media and advocacy groups are the only people holding these companies accountable for their actions. Ag-Gag bills seek to make it virtually impossible to report on factory farms in order to reduce the amount of incriminating information leaking out of their facilities.

I know what you’re thinking… “What can I do?” As consumers, it’s up to us to consume responsibly. Using your purchasing power to opt for humanely farmed meat shows that you do not condone the actions of this negligent polluting industry. All in all, the future for defeating Ag-Gags looks bright. As of June 2019, 3 states have declared Ag-Gag policies unconstitutional, ruling that the laws infringe upon freedom of speech and freedom of the press. Seventeen other states have blocked such bills from ever being passed.

Are there Dental Access Issues in Alabama?

November 4, 2019 by Conan Davis, DMD MPH


Do we have any issues to be concerned about regarding access to dental care in Alabama? Everyone has a dentist who can see them on short notice if they need, right? Wrong.

If you live in Birmingham or in one of the larger cities in Alabama, you might not have a problem being seen on short notice – particularly if you have dental insurance or out of pocket cash for treatment, but if you live in smaller towns or rural areas in our state, you might not be so lucky.


Alabama currently has only one county without a dentist: Greene County. However, about 80 percent of all the dentists practicing in Alabama practice in the 13 most urban counties. The other 20 percent practice in the 54 non-urban counties of Alabama; many of these smaller counties only have between one and three dentists. This translates to about one dentist for every 1800 people in the urban areas, versus one dentist for every 4100 people in the non-urban areas – a big difference.

This is the subject of a paper Dr. Stuart Lockwood and I are developing and hope to publish with the Lister Hill Center for al dentists.pngHealth Policy in the next few months. Dr. Lockwood and I are both former State Dental Directors with the Alabama Department of Public Health. We both have examined the teeth of thousands of children in Alabama to assess the state    of dental decay and to make referrals to local dentists. We have seen many with excellent dental care and many without any need for treatment. However, we have also seen the evidence of neglected dental needs in many children. An even larger concern we have seen is the lack of access afforded to low-income adults with no dental insurance and no public dental coverage in Alabama. We will cover that connected subject perhaps in another post.

Dr. Lockwood and I have been engaged in studying the underlying issues for our widening gap between urban and non-urban areas concerning dental care access for many years. We developed a partnership between UAB School of Dentistry and the Alabama Dental Association to develop a strategy to correct the disparities we found in the more rural areas of the state.

Through this partnership, we wrote and were awarded a grant to do several things in this area. One was to take the available data on dental practices in Alabama and with the help of the UAB School of Public Health develop a GIS map detailing where all dentists’ practices are located in Alabama. The grant also allowed for rotation experiences in rural areas for dental students as a way to allow them to see dental practice life in these areas. We also provided significant financial awards to a few graduating dentists who agreed to practice in a rural area and also agreed to see a certain percentage of Medicaid patients for a specified number of years. Graduating dental students can have very significant school debt, and this was designed to assist them with that debt and help them establish a practice. The grants were planned to help “plant” dental offices in nine rural areas needing a dentist. Nine such practices came about through this grant program and they have successfully continued in those areas to this day.

I’ve worked with Dr. Lockwood and the state dental association on language presented to the state legislature and the Governor’s office for consideration of a similar state-based financial incentive program for new dentists willing to locate in a rural area. We hoped this would also encourage young dentists to choose a smaller town or rural area in which to practice. While all our legislators were favorable to the concept, funding has not been significant just yet. We continue pursuing this possibility.

preventative-dental-care-1.jpgAnother issue regarding distribution of dentists involves the current ages of dentists in the rural areas. We will discuss these findings in some detail in our upcoming paper.

So – to answer the question, “Is it easy to find a dentist to see you on short notice anywhere in Alabama?” – no. However, many of us are engaged about this concern and working towards positive solutions for all Alabamians. We hope to be able to answer my question in the affirmative in the near future!


Conan Davis recently retired from his position as Assistant Dean for Community Collaborations and Public Health at the UAB School of Dentistry. He continues to research the inequities in access to dental care across Alabama.