Abstract.Hookworm infection affects 430 million people worldwide, causing iron deficiency, impaired cognitive development, and stunting in children. Because of the environmental conditions needed for the hookworm life-cycle, this parasite is endemic to resource-limited countries. Necator americanus was endemic in the southern United States before improvement of sewage disposal systems and eradication programs. With continued poverty, poor sanitation, and an environment suitable for the hookworm life-cycle in some regions of the southern United States, a current prevalence study using modern molecular diagnostics is warranted. Lowndes County, Alabama, was chosen as the study site given previous high hookworm burdens, degree of poverty, and use of open-sewage systems. Participants were interviewed, and stool, serum, and soil samples were tested for nine intestinal parasites using a multiparallel quantitative real-time PCR (qPCR) and enzyme-linked immunosorbent assays. We found that, among 24 households, 42.4% reported exposure to raw sewage within their home, and from 55 stool samples, 19 (34.5%) tested positive for N. americanus, four (7.3%) for Strongyloides stercoralis, and one (1.8%) for Entamoeba histolytica. Stool tested positive for N. americanus contained low levels of parasite DNA (geometric mean 0.0302 fg/μL). Soil studies detected one (2.9%) Cryptosporidium species, and Toxocara serology assay detected one (5.2%) positive in this population. Individuals living in this high-risk environment within the United States continue to have stool samples positive for N. americanus. Gastrointestinal parasites known to be endemic to developing countries are identifiable in American poverty regions, and areas with lower disease burden are more likely to be identified by using qPCR.

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A majority of Lowndes County, Alabama, residents live without properly functioning, legal, basic sanitation infrastructure. We describe the contemporary racialization of sanitation inequality in the county. We trace structural dimensions of race in land tenure through the heir property system, housing availability, and public health enforcement. Our analysis shows how cumulative effects of colorblind policies overlain on explicitly racist foundations operate to establish public health sanitation law as a persistent mechanism of producing racial stratification.

For more than seventeen years, I have fought to address the root causes of poverty in poor rural communities. It became obvious during my work that a prevalent problem in this nation is the neglect of infrastructure needs in such communities. A basic need of all communities is water and sanitation. Without water, people cannot live, and its lack diminishes life significantly. Without sanitation and treatment of wastewater, health issues can arise that could end one's life. Flint, Michigan was the canary in the mine that caused alarm about water issues and the inequality associated with access. It was a stark form of environmental injustice. Yet in rural communities throughout the United States, far from major media, this problem of inequality of access to water and sanitation is more common than not. It is rarely talked about. Lowndes County is a poor rural county that has led the way many times in pursuit of social justice, despite its history of suffering injustice; it is now leading the charge for poor communities long deprived of wastewater infrastructure. It is revealing America's dirty shame, people living amid raw sewage.Lowndes County is in central Alabama, to the west of Montgomery, the state capital, bordered by Dallas County, whose county seat is Selma. Most of the Selma to Montgomery March Trail goes through Lowndes County. The 2010 population was 11,299, and is estimated to have since decreased to 10,857: 73.4 percent of the county's population is African American, and 25.4 percent is white. The county seat is Hayneville, which is over 85 percent African American. Fort Deposit is the largest town in the county, with a population that is about 68 percent African American. The southwestern third of the county comprises the most concentrated area of rural, poor African

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