The Shame of US Health Care Dysfunction: Hookworm Returns to Alabama

An article just published online(1), and reported so far in only one major media outlet (the Guardian, based in the UK) showed how hookworm, now considered a disease of poor, third world countries, has returned to the American south.  This in a country which spends more per capita on health care than any other supposedly developed country.

Background - the Supposed Eradication of Hookworm

A 2009 article in Health Affairs documented the supposed elimination of common diseases once found in US.(2)  The background of the article included:

In 1916 a new textbook appeared on the 'endemic diseases of the southern states.' With chapters on malaria, pellagra, and intestinal worms, the book’s authors identified the region as particularly, and peculiarly, diseased. Absent was the dominant southern disease of the nineteenth century: yellow fever. Although yellow fever had traveled hand in hand with the import trade of southern cities, the twentieth-century triad of pellagra, malaria, and hookworm was inextricably linked with the rural poverty engendered by cotton culture and the tenant labor system that evolved to replace slavery after the Civil War. The rural farm worker had little money or access to health care, ate a poor diet, and lived in a subtropical landscape that was host to parasitic worms and mosquitoes. In 1916 the South’s endemic diseases appeared to be thoroughly entrenched. Later, in the depths of the Great Depression, these diseases continued to plague southerners. Yet by 1950 southerners were almost free of them all.

The article noted that hookworm in particular was associated with the South:

Hookworm disease was once associated so much with the South that when a baseball commentator referred to southern players as coming from the 'Hookworm Belt' in 1947, the phrase needed no explanation. The hookworm is a tiny parasite that latches onto the wall of the small intestine, secretes an anticoagulant to promote bleeding, and feeds on the host’s blood. About 110 worms can consume a teaspoon of blood a day. A well-fed host with adequate iron intake can usually replace the lost iron and plasma proteins of a mild infection, but a malnourished person harboring sizable numbers of parasites will become anemic and protein deficient. In children the disease stunted physical and cognitive development. It made them weak, apathetic, and perpetually tired.

In the beginning of the 20th century, the Rockefeller Foundation launched a campaign that probably began the apparent eradication of hookworm.

In 1902, however, Charles Stiles, a medical zoologist, recognized in southerners the same symptoms he had seen among European hookworm victims. Once he started looking, he found a startling prevalence of the disease. He convinced representatives of the Rockefeller Foundation to take up the cause of hookworm eradication, and in 1909 the philanthropy launched an all-out assault on the disease. Their initial surveys found 43 percent of those surveyed to be infected with hookworm; in some areas the percentage rose into the 90s.

The Rockefeller campaign stressed education, treatment, and the assumption by local and state boards of health of the responsibility to carry on what the foundation had begun. With a million dollars in their coffers, the Rockefeller men spread across the South, offering lantern shows about the hookworm, testing and treating individuals, and pushing the construction of sanitary privies. Surveys of rural schools and churches found that 80 percent lacked any sort of privy; private homes were even less likely to have sanitary facilities. Children of all classes went barefoot in the summer, often not wearing shoes until they were teenagers. By 1914, when Rockefeller ended its U.S. campaign, the prevalence of infection had been cut to 39 percent, but the message of hookworm and its implications was now well known throughout the South. The campaign also energized southern public health, leaving a legacy of empowered institutions on the state and local levels.

For more on the history of the Rockefeller Foundation campaign, look here.  I hope the Foundation will not mind me using a picture of a hookworm treatment clinic from 1923.

Hookworm persisted for a surprisingly long time after these initial eradication efforts, although it seemed to be nearly gone by the 1980s.  The article noted that

Even in the 1960s there was persistent infection in coastal South Carolina (3 percent) and eastern Kentucky (14 percent). One source reported that hookworm prevalence in southern Georgia went from 60 percent in 1910 to 13 percent in 1964 and to 6 percent in 1970.

So the disease prevalence fell from over 40% in the early 20th century to a few percent by the 1980s.  One particular mechanism for the decrease was basically better plumbing.

Concerns about typhoid, which was frequently fatal, drove the cities to put in sewers and running water, and fears that the privies of the poor would infect the affluent meant that even the poorer sections of towns had sanitary waste disposal throughout much of South in the 1920s. Slowly the expectation grew that the sanitary privy was essential for adequate housing. In North Carolina in the 1940s, the state board of health required them by law.

So the problem appeared to be solved.  I learned about hookworm in a course in tropical diseases in medical school in the 1970s.  At the time, since I was not planning to go into global health, the knowledge did not seem very relevent.  I suspect that such courses were no longer very prevalent in medical school.

That was then.  This is now.

Hookworm Returns to the Impoverished US South

The new article by McKenna et al noted that hookworm is still very common globally.  In addition, it noted that the conditions are again ripe for the return of hookworm, and presumably other ailments now considered irrelevant to developed countries, to parts of the US.  In particular, the advances in plumbing so important to the eradication of hookworm are no longer so much in evidence.

According to the Alabama Center for Rural Enterprise (ACRE), an organization that addresses poverty and economic development in one of the poorest areas of the nation, there continues to be residences without adequate sanitation systems, increasing exposure to open sewage near dwellings. The “Black-Belt” soil native to this area is composed of a firm sedimentary limestone bed overlain with a layer of dark, rich soils, which requires expensive septic systems for proper waste disposal. In Lowndes County, Alabama, where the per capita income is $18,046, and 31.4% of the population lives below the poverty line, sanitation systems are unaffordable. For rural, impoverished individuals, the main form of waste removal involves use of 'straight piping,' a method involving a series of ditches or crudely constructed piping systems to guide human waste away from the residence. Most pipes never reach more than 10 meters in length, and during rainstorms or flooding, the residents report visible stool entering their homes (reported by ACRE, unpublished data).

The investigators therefore performed an epidemiological study in Lowndes County.  There sample size was small.  However, their findings were striking.  More than one-third (34.%) of subjects tested positive for necator americanus, the American hookworm.  This is close to the prevalence reported back in the early twentieth century.

The Guardian article provided vivid anecdotal evidence about the state of public health in rural Alabama that likely contributed to this result.  The reporter's tour of Lowndes county revealed vividly inadequate sewage systems.  He documented that in Alabama, "public health" was ostensibly insured by making it a criminal offense for people to have inadequate sewage systems.

people were afraid to report the problems, given the spate of criminal prosecutions that were launched by Alabama state between 2002 and 2008 against residents who were open-piping sewage from their homes, unable to afford proper treatment systems. One grandmother was jailed over a weekend for failing to buy a septic tank that cost more than her entire annual income.

'People are scared. They don’t like to speak out as they’re worried the health department will come round and cause trouble,' [community activist Aaron] Thigpen said.

Apparently the state government does not see that it has any resonsibility to provide adequate sewer systems, or provide any help to people to improve sanitation, even those clearly unable to affort it on their own.  Consider, for example, the plight of Ruby Rudolf

Rudolph, now 66, does have her own septic tank at the back of her house, which she shows us in the sweltering 41C (105F) heat. But it doesn’t function properly and when it rains the tank spills over, spreading raw waste all over the yard. 'That’s better than when it flushes back into the house, and I’ve had that too,' she said.

She’s been told a replacement system would cost her at least $12,000, which is beyond her means. She runs through her finances: she gets up at 4am every day to do an early shift at a Mapco convenience store, which brings in less than $1,200 a month. From that amount she has to pay $611 for her mortgage and there’s the electricity bill that can be more than $300 a month when it’s hot and the air conditioning is busy. There’s not a lot left to put toward a new tank.

Left entirely unsaid in the scholarly article or the Guardian story is the likelihood that any residents of these rural Alabama counties have access to any other ways to mitigate the hookworm problem.  Left also unsaid is whether they have access to health care professionals who could test them or treat them for hookworm.

Conclusions

As we have noted endlessly, the US spends more per capita on health care than any other developed country.  US politicians used to make the claim that the country has the best health care system in the world, often to ward off any attempts at true health care reform.  However, US rankings on various measures - some of which may be disputed - of health care processes and outcomes have been decidedly mediocre.  (See for example the latest Commonwealth Fund study here.)

The new study of hookworm prevalence was not based on a big, systematic, or geographically diverse sample.  However it is striking, and dismaying that a disease once thought to be eradicated is again alive and well in the poorer parts of a very rich country. 

Note that while the eradication of hookworm was partially attributed to the energizing of public health in the south, currently public health officials seem to think their job is to arrest poor people who cannot afford adequate sanitation.  The government does not seem to think it has a responsibility to assure working sewers or other forms of basic sanitation.  There also seems to be a governmental abandonment of public health focused on reaching individuals who might most be at risk of disease.

Meanwhile, the country, as we have said before, has seen the diversion of tremendous amounts of health care and public health dollars into the pockets of health care managers, their cronies, health care management and administration in general, and in some cases investors.  This appears in turn to be a consequence of deregulating the system, allowing concentration of power,  allowing the commercialization of various kinds of health care organizations (insurance, hospitals, medical practices, etc), and of turning health care leadership over to managers trained in business schools (managerialism) with no appreciation of health care professionals' values, and with perverse incentives focused on increasing their organizations' revenue and hence their personal enrichment.  We can spend untold sums on new treatments with dubious margins of benefits vs harms, but not on basic public health or access to primary care. 

And hookworm is back. 

Shame on us. 

References

1.  McKenna ML, McAtee S, Bryan PE et al.  Human intestinal parasite burden and poor sanitation in rural Alabama.  Am J Trop Med Hygeine 2017; https://doi.org/10.4269/ajtmh.17-0396

2.  Humphreys M. How four once common diseases were eliminated from the American south.  Health Aff 2009; 28: 1734-1744.  Link here.