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Water Qual Expo Health
DOI 10.1007/s12403-013-0088-0
O R I G I N A L PA P E R
Limited Access to Safe Drinking Water and Sanitation
in Alabama’s Black Belt: A Cross-Sectional Case Study
Jessica Cook Wedgworth ·Joe Brown
Received: 8 January 2013 / Accepted: 26 February 2013
© Springer Science+Business Media Dordrecht 2013
Abstract Anecdotal evidence from the 17-county Black
Belt region of Alabama has suggested that safe-water access
may be limited by piped water infrastructure problems and
private well contamination, possibly resulting in degradation
of water quality and therefore elevated risk of waterborne
disease. On-site sanitation access is limited as well since ex-
isting approved technology options suitable for the poorly
draining soils that predominate in this area are too costly
for many households. We conducted a cross-sectional study
of 305 households to examine (i) drinking water quality at
the household level (private wells and county public sup-
ply), (ii) possible associations between water infrastructure
characteristics and drinking water quality, (iii) availability of
on-site sanitation, and (iv) risk of Highly Credible Gastroin-
testinal Illness (HCGI). Participating households completed
one survey on water use, basic demographics, health, wa-
ter system performance, and on-site sanitation and submit-
ted one drinking water sample for analysis of fecal coliform
(FC), turbidity, pH, and total and free chlorine. Approxi-
mately 8 % of public water system samples and 20 % of pri-
vate well water samples were positive for FC, with 33 % of
The authors declare that they have no conflict of interest. All studies
have been approved by the IRB at the University of Alabama and have
therefore been performed in accordance with the ethical standards laid
down in the 1964 Declaration of Helsinki and its later amendments.
All persons gave their informed consent prior to their inclusion in the
study.
J. Cook Wedgworth (B
)·J. Brown
University of Alabama, Department of Biological Sciences,
Box 870344, Tuscaloosa, AL 35487, USA
e-mail: jjcook@crimson.ua.edu
J. Brown
Department of Disease Control, London School of Hygiene
& Tropical Medicine, London WC1E 7HT, UK
piped water supply samples lacking detectable free chlorine.
We found a significant increase (OR 4.0, 95 % CI 1.3–14) in
HCGI risk for individuals whose drinking water sample was
positive for FC. Sanitation access was not universal, with
18 % of households lacking any means of on-site wastewa-
ter disposal. Results from this study suggest that safe-water
access and on-site sanitation options may be limited in this
area. Residents may be subject to increased risk of water and
sanitation-related illness.
Keywords Drinking water quality ·Infrastructure ·
Environmental health ·Environmental justice
Abbreviations
HCGI Highly Credible Gastrointestinal Illness
FC Fecal Coliforms
Introduction
Worldwide, over 780 million people use unimproved drink-
ing water sources (WHO/UNICEF 2012), and one study has
estimated the number of people who rely on microbiologi-
cally or chemically unsafe water to be 1.8 billion, or about
28 % of the global population (Onda et al. 2012). Safe-water
access is a universal basic need and has been declared a
human right (UN 2002; Meier et al. 2013). Infectious dis-
eases caused by pathogenic bacteria, viruses, and protozoan
parasites are the most common and widespread health risks
associated with unsafe drinking water. These problems are
usually associated with lower income countries, but under-
served areas of the United States may also be at risk.
In this paper, we report on a pilot, cross-sectional study
of drinking water quality and on-site sanitation access in Al-
abama’s rural Black Belt region, which faces a number of in-
frastructure and other challenges that may limit the public’s
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J. Cook Wedgworth, J. Brown
access to safe drinking water. This study aimed to examine:
(i) drinking water quality at the household level (both private
wells and county public supply) across randomly selected
households in one rural, Black Belt county; (ii) possible as-
sociations between water infrastructure and household-level
characteristics and drinking water quality; (iii) availability
of on-site sanitation; and (iv) overall risk of Highly Credible
Gastrointestinal Illness (HCGI) in the study population. This
initial study was intended to provide baseline and hypothesis
generating data for a broader assessment of drinking water
infrastructure and risk in the region.
Study Setting
The Black Belt is a geographically distinct region that
stretches across the Southeastern United States including
parts of the Deep South (Washington 1901; Wimberley et al.
1997). Despite being culturally and historically rich and di-
verse, the Black Belt is also partly characterized by endemic
poverty, high rates of unemployment, and lower than aver-
age access to infrastructure and health services (Wimberley
and Morris 2002). Most Deep South Black Belt residents
are African-American. Indicators of poor health and poor
access to care such as infant mortality (ARHA and ADPH
2004; Sanspree et al. 2008; Rosenblatt et al. 2001), preva-
lence of noncommunicable diseases (Howard et al. 2007;
Voeks et al. 2008), and prevalence of HIV/AIDS (Lichten-
stein 2007) are all elevated in the region and may be locally
very high relative to the rest of the United States.
Safe-Water Access
In Alabama’s Black Belt, groundwater is the source of most
residents’ water, either from private wells or as the source
for distribution systems. According to the Alabama Depart-
ment of Public Health (ADPH), microbial contamination
of groundwater is widespread, a fact that has been linked
with failing septic systems in the area (Liu et al. 2005).
A 2003 study found that 46 % of 175 wells tested were
positive for fecal indicator microbes. The same study esti-
mated that 40 % of septic systems in Alabama had failed or
were in need of repair in 2003, and an estimated 340,000
low-income people in rural Alabama were at elevated risk
of waterborne disease due to contamination of groundwater
from failing septic systems (ADPH 2009). In 1997, ADPH
estimated that 90 % of septic systems in the Black Belt
were failing as a result of the local geology (contributing to
widespread areas of low soil permeability) and poor mainte-
nance of on-site wastewater systems.
Methods
This study was conducted over a 10 month period from Oc-
tober 2008 and ending July 2009. The study design was
cross-sectional and observational with the purpose of col-
lecting data on potential problems reported by residents and
identifying potential linkages between water quality, system
performance, and health outcomes.
Participating households were selected at random in a
geographically defined study area (one county). All house-
holds within the county were eligible for inclusion in the
study. Residents used either a public, county water supply
system (from groundwater) or an on-site well. Nine (approx-
imately 3 %) of the households we initially approached de-
clined to be included in this study. The population averaged
2.76 individuals per household, and the median age of the
residents was 40 years (U.S. Census Bureau 2010). Meth-
ods for household recruitment and informed consent were
reviewed and approved by the Institutional Review Board of
the University of Alabama.
We collected water samples from household taps for
analysis. Water quality parameters tested were fecal co-
liforms (FC), pH, free and total chlorine, and turbidity.
Testing for FC was completed in the laboratory via mem-
brane filtration followed by incubation at 44.5 °C on mem-
brane lauryl sulfate broth (MLSB) media, in accordance
with Method 9222 in Standard Methods for the Examina-
tion of Water and Wastewater (Clesceri et al. 2012). Fecal
coliforms were recognized by their ability to produce a color
change from red to yellow and concentrations were reported
as colony forming units (CFU) per 100 ml.
pH and free and total chlorine were tested at the point
of sampling using a chlorine/pH test kit and diethyl-p-
phenylene diamine 1 and 3 (DPD1 and DPD3) tablets (Tay-
lor Technologies, Sparks, MD). All participants received a
water quality report for participation in the study.
We collected individual and household-level data via a
researcher-administered survey covering household demo-
graphics, socio-economic status, drinking water source char-
acteristics and perceptions, use and handling of drinking wa-
ter, and household sanitation. Individual-level health data
were collected for all members of the household using the
previously described metric of Highly Credible Gastroin-
testinal Illness (HCGI) (Payment et al. 1991; Colford et al.
2005) with a recall period of 7 days. For the purpose of
this study, an episode of HCGI was defined as: (i) vomit-
ing, (ii) diarrhea, (iii) diarrhea and abdominal cramps, (iv) or
nausea and abdominal cramps. Surveys and water quality
data were entered regularly into a Microsoft Excel spread-
sheet or Microsoft Access database and copied into Stata
(version 8.1).
Observational and survey data collection at household
visits were transcribed from questionnaires and double-
entered into Microsoft Excel, then copied to Stata (ver-
sion 8.1) for analysis. We calculated descriptive statistics
and examined the water quality data for associations with
measured variables. We performed logistic regression re-
porting odds ratios using presence of fecal coliform in the
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Limited Access to Safe Drinking Water and Sanitation in Alabama’s Black Belt: A Cross-Sectional Case Study
Table 1 Selected water source characteristics and calculated associations with presence of fecal coliform in household-level drinking water
samples
FC <1 cfu/100 ml FC ≥1 cfu/100 ml OR (95 % CI) p-Value
Number of households 263 42 – –
Connected to system 182 16 0.27 (0.14–0.54) <0.001
Well users 46 20 4.3 (2.16–8.50) <0.001
On-site septic tank 172 28 0.51 (0.064–4.1) 0.528
No or unknown sanitation 51 9 2.72 (0.80–9.31) 0.109
Reported “poor or very poor”
Taste 21 3 0.89 (0.25–3.10 0.851
Odor 20 1 0.30 (0.039–2.3) 0.242
Color 23 3 0.80 (0.23–2.8) 0.730
Clarity 18 1 0.33 (0.043–2.6) 0.290
Perceived safety 12 1 0.51 (0.065–4.03) 0.523
Intermittent service (piped supply only) 23 2 0.52 (0.12–2.3) 0.390
Functional problems, well 6 4 4.5 (1.2–16.7) 0.024
Free chlorine between 0.2 and 2 mg/l 146 7 0.16 (0.069–0.37) <0.001
Mean free chlorine (mg/l) 0.69 0.16 – –
household-level water sample as a binary outcome variable,
with covariates tested for independent associations with this
outcome.
Results
This study included 305 households: 462 individual partic-
ipants, 56 % female, 80 % African-American. 20 % of all
participants reported their combined household income to
be less than $20,000.
Of the 305 water samples we collected, 42 (13.8 % of all
samples) were found to contain ≥1 cfu/100 ml FC (Table 1).
Of the 42 positive samples, 27 were from county supply con-
nections and 23 were from private wells. Twenty percent
(23) of all well user water samples were positive for fecal
coliforms. Greater than 33 % of samples from the county
water supply system did not contain detectable levels of free
chlorine (<0.1 mg/l). Also, greater than 50 % of samples
from the county system had levels of free chlorine exceed-
ing 0.5 mg/l, a level which may result in strong taste. 21
(18 %) of well samples were found to have a pH under 6.5,
although 89 % of all samples were within the normal range
of pH in drinking water, 6.5–8.5.
We asked households connected to the water supply sys-
tem about their perceptions of water system performance
and aesthetic concerns. 37 % of county water customers said
that they experienced problems with their connection, most
commonly intermittent service, with 13.6 % of all county
supply participants reported service interruptions as a recur-
ring issue. 18 % of county water users rated the color of
their water poor or very poor, and 12 % rated the taste poor
or very poor.
Well users were also asked to give details about their
well. 62 % (73) of all well users had a deep well with an
average user-estimated depth of 250 feet. 68 % of well users
said that they did not experience any problems with their
well. Of the 32 % that did experience problems, odor was
the most common. Less than 1 % of well users ranked the
color of their water poor or very poor, and 8.7 % rated the
taste of their water poor or very poor.
We asked a subset of participating households about ac-
cess to sanitation (n=264). Of the county customers (n=
198), 139 (70 %) had septic tanks, and 47 (24 %) reported
that they did not have a septic tank or that they did not know
what kind of sanitation system was in place. Of the well
users (n=66), 53 (80 %) reported having septic tanks and
13 (20 %) reported that they did not have a septic tank or
they did not know what kind of sanitation system was in
place. A minority of households both county customers and
well users combined (n=13) (4 %) had access to a mu-
nicipal piped sewerage system. Households without septic
tanks or a connection to piped sewerage (18 %) discharged
untreated domestic wastewater to open ditches, pits, or other
surfaces.
17 people reported HCGI that could not be explained by
any of the pre-existing conditions we asked about. When
comparing risk of HCGI among households, we found that
those whose drinking water found to contain ≥1 cfu/100 ml
of fecal coliform (FC) were more than three times as likely
to have also reported HCGI in the previous 7 days as those
whose water sample was negative for FC (<1 cfu/100 ml)
and that this result was a statistically significant increase at
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J. Cook Wedgworth, J. Brown
Table 2 Symptom data by exposure group and logistic regression output
FC <1 cfu/100 ml FC ≥1 cfu/100 ml OR (95 % CI) p-Value
Number of people 450 57 – –
Mean age 34.7 37.1 – –
Self-reported symptoms, 7 day recall
Diarrhea 6 4 5.6 (1.5–20) 0.009
Abdominal cramps 11 2 1.5 (0.31–6.7) 0.634
Nausea 10 3 2.4 (0.65–9.2) 0.185
Vomiting 7 1 1.1 (0.14–9.4) 0.910
Fever 5 4 6.7 (1.8–26) 0.006
HCGI*8 4 4.0 (1.2–14) 0.027
*Excluding explanatory factors such as pre-existing conditions (Chrohn’s Disease, Diverticulitis, Heartburn, Irritable Bowel Syndrome, Milk
Intolerance, Stomach Ulcer, Ulcerative Colitis, Migraine)
the α=0.05 level (OR 4.1, 95 % CI 1.3–13.0). No statisti-
cally significant differences were identified when comparing
HCGI outcomes between those served by the county sup-
ply system and private wells, or when stratifying by age,
sex, race or other demographic factors. An initial analysis
of these data also indicates a possible association between
household that reported problems with the water supply
system (intermittent service, service outages, muddy water,
poor tasting or smelling water) and HCGI (OR 8.0, 95 % CI
1.0–61). Although the limited sample size does not permit
a more sophisticated analysis, these data are suggestive of a
link between water quality and water system attributes and
reported health outcomes.
Discussion
Our pilot data suggest that safe-water access may be lim-
ited in our study area: 13.8 % of all drinking water samples
were positive for fecal coliform, and one-third of samples
from the county supply system did not contain detectable
free chlorine at the time of sampling. The applicable stan-
dard for drinking water is <1 cfu total coliform in a 100 ml
sample (we used the more specific fecal coliform) and 0.3–
0.5 mg/l is the EPA-recommended range for free chlorine
residual at the household level (USEPA 2002) to protect
against recontamination. Although our data on system per-
formance are limited to subjective self-report from partici-
pating households, the relatively high prevalence of reported
issues such as intermittent service, high turbidity, and aes-
thetically displeasing water are cause for concern and fur-
ther investigation. These may be indicative of system infil-
tration or contamination between water source and point of
use.
73 people reported that they had at least one of the fol-
lowing pre-existing conditions: diverticulitis, heartburn, irri-
table bowel syndrome, milk intolerance, stomach ulcer, col-
itis, or migraine. HCGI was scored as positive for only the
participants whose symptoms had no other known origin.
When the risk of HCGI was compared among households
we found a statistically significant increase in the likelihood
of reporting HCGI if the participant’s water sample was FC
positive (OR 4.0, 95 % CI 1.2–14, Table 2).
Although small-scale, decentralized, or rural systems
may be particularly susceptible to water quality problems
(ADPH 2009) and have been linked to a disproportion-
ate number of disease outbreaks (Sobsey 2006) and health-
related violations, we cannot and do not causally attribute
the household-level water quality data we report to sys-
tem age, management, operation, or maintenance. We took
household-level water quality samples directly from taps
without sterilizing them, leaving open the possibility that
any source of detected contamination was in the domestic
environment, and not from the source or distribution system.
This is certainly the case also for households using on-site
wells. Our subsequent data in this study area have focused
on microbial source tracking to determine possible origins
of microbes detected in household-level drinking water sam-
ples (data not shown). These data will help identify possi-
ble transmission routes of fecal-oral pathogens and refine
options for control measures either at household or system
levels. Previous studies have identified poorly performing,
failing, or lack of on-site wastewater containment as poten-
tial sources of contamination for household drinking water,
but to our knowledge this has not been demonstrated in a
field setting in this area (He et al. 2011; Liu et al. 2005;
ADPH 2009). The dearth of on-site wastewater options for
this challenging economic and geological context has re-
sulted in a documented high percentage of failing systems
(ibid.) and alarming numbers of households with no wastew-
ater handling or containment technology in place at all. Al-
though no other systematic survey has attempted to estimate
the number of households lacking wastewater containment
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Limited Access to Safe Drinking Water and Sanitation in Alabama’s Black Belt: A Cross-Sectional Case Study
in this area, reports in the popular media of enforcement ac-
tions leading to the arrest of residents whose wastewater is
not contained (US Water News 2002) suggest that this is not
an isolated problem. Media reports describing the arrest of
indigent people from Alabama’s Black Belt for discharging
wastewater due to absent or failing septic systems were cited
in a recent report (UN 2011) by the United Nations Special
Rapporteur on the Human Right to Safe Drinking Water and
Sanitation. The same report stated that the “most common
on-site wastewater alternative ranges in price from $6,000
to as much as $30,000” in the area. Unfortunately, standard
technologies for properly handling on-site sanitation in ar-
eas with low infiltration or “perc” rates (Duran 1997) are
too expensive to be practical for many living in this region,
which is among the poorest in the USA with a high percent-
age of the population living below the federal poverty line
(Wimberley and Morris 2002). Although grants and assis-
tance may be available for some residents, options were not
widely known among residents in our survey. The practical
alternatives facing local decision makers seem to be to allow
wastewater discharges, at risk to public health and safety, or
evict people from their homes with nowhere to go. There
is a clear need in this context for innovative approaches to
low-cost on-site sanitation, policy measures that increase ac-
cess to available options for households who can least afford
them, and sensitivity among regulators and other stakehold-
ers to the real structural and environmental constraints lim-
iting sanitation access.
Wilson et al. (2008) wrote that “small southern towns
show common environmental issues that are currently either
understudied or completely neglected by researchers.” Our
decision to study safe drinking water and sanitation in this
context was initially driven wholly by community requests
due to ongoing and widespread concerns about the access to
and safety of water supplies and sanitation. An unpublished
2007–2008 survey of water access in the community by one
of our local non-profit partners revealed that 24 % of the
total population did not have domestic water service, with
unconnected households generally relying on wells not sub-
ject to water quality monitoring. At the time of the survey,
connection costs for domestic water services were $475 for
mobile homes and $425 for site-built homes, an unafford-
able fee for many households in the area. The persistent and
interconnected problems of access to water remain under-
studied, and the public health costs to communities could be
high.
This study has a number of known limitations. First, we
used household-reported system performance data, which
are highly subjective and may have been under- or over-
reported by residents. We also used self-reported symptom
data with a 7-day recall period to estimate the prevalence
of HCGI in this cohort. Self-reported health data are subject
to recall bias and therefore may be less reliable than clin-
ical or objectively verifiable measures. Second, this study
is a cross-sectional study, presenting a limited snapshot of
the area of interest. Although the geographical size of the
study area was large (one county), we cannot conclude that
these results are applicable across the region or even in ad-
jacent areas that may include similar characteristics. As a
cross-sectional study, we could not include factors that may
be changing over time. Third, as a pilot study with limited
seed funding, we were only able to include 305 households,
which limited the sophistication of our analysis for explor-
ing associations between the variables of interest. Although
we did not identify any confounders among the variables we
included in our study by using an a priori 10 % change-
in-estimate-of-effect criterion in forward addition and back-
ward elimination of covariates to the regression model, the
limited sample size precludes a more sophisticated analysis
of confounding.
Conclusion
In this pilot study, we provide initial evidence suggestive
of inadequate access to safe drinking water and sanitation
in one area of Alabama’s Black Belt, at one point in time.
Although we cannot generalize from these limited results,
the characteristics that define this area are shared across the
region. Limited access to water and sanitation may not be
unique to this study setting. More research is needed to
identify the challenges faced by local utilities, character-
ize any public health implications of inadequate water sup-
ply infrastructure and sanitation options, and develop low-
cost strategies for risk mitigation, including acceptable low-
cost options for decentralized sanitation in areas where soils
are unsuitable for traditional systems. Underserved commu-
nities may lack the resources to study and develop inno-
vative solutions for these problems without outside assis-
tance.
Acknowledgements We acknowledge financial support from the
University of Alabama Center for Community Based Partnerships and
Dr. Samory Pruitt. Many thanks also to Justinn Trott, who assisted with
field data collection.
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