America's Sanitation Gap: The Rural Sewage Crisis Hiding in Plain Sight

Catherine Coleman Flowers has spent decades pointing at something most Americans would rather not think about. Sewage. Specifically, the absence of any reliable, affordable way to deal with it for a surprising number of people living in rural communities across the United States. She calls it America's dirty secret, and the label is apt in more ways than one.

For the vast majority of Americans, sanitation is invisible infrastructure. You flush, and the problem disappears into a network of pipes, treatment plants, and regulatory frameworks that hum along without much public attention. But that invisibility is itself a product of geography and wealth. In rural areas, particularly across the Black Belt of Alabama, Appalachia, and tribal lands in the Southwest, the infrastructure simply does not exist, and the cost of building or maintaining it falls on households that can least afford it.

Flowers, a MacArthur Fellow and founder of the Center for Rural Enterprise and Environmental Justice, has documented communities where raw sewage surfaces in yards, where children play near open drainage ditches, and where hookworm, a parasitic infection once thought eradicated in the United States, has quietly returned. Her work in Lowndes County, Alabama became a touchstone for understanding how sanitation inequality operates not as an accident but as a consequence of compounding neglect.

The United States has an enormous and well-documented infrastructure funding gap, but the conversation tends to center on bridges, roads, and broadband. Wastewater infrastructure in rural communities rarely makes the shortlist, even though the consequences of its absence are immediate and biological. The Environmental Protection Agency has estimated that the U.S. needs to invest hundreds of billions of dollars in water and wastewater infrastructure over the next two decades, yet rural sanitation consistently loses out to urban systems that serve more voters and attract more political attention.

Part of the problem is structural. Municipal sewer systems benefit from economies of scale. The more households connected to a system, the lower the per-household cost of treatment. In sparsely populated rural areas, those economics invert. Running sewer lines across miles of terrain to serve a few dozen homes is prohibitively expensive, which is why many rural residents rely on septic systems. But septic systems require suitable soil conditions, regular maintenance, and upfront installation costs that can run into the tens of thousands of dollars. For low-income households, that cost is simply out of reach.

When septic systems fail or were never installed in the first place, the waste has to go somewhere. It goes into yards, ditches, and eventually waterways. The public health consequences are not abstract. Exposure to untreated sewage is linked to gastrointestinal illness, skin infections, and the resurgence of parasitic diseases. A 2017 study published in the American Journal of Tropical Medicine and Hygiene found evidence of hookworm transmission in Lowndes County, a finding that drew international attention precisely because hookworm had been considered a disease of the distant past in wealthy nations.

The systems dynamics at work here are worth examining carefully. Rural communities with poor sanitation infrastructure tend to have lower property values, which reduces the local tax base, which limits the public funds available for infrastructure investment, which keeps property values low. It is a feedback loop that self-reinforces over generations, and it is compounded by the political economy of infrastructure spending, where federal and state dollars tend to follow population density and lobbying capacity rather than need.

There is also a second-order consequence that rarely surfaces in policy discussions. Poor sanitation infrastructure is a significant barrier to economic development. Businesses require reliable wastewater disposal. Without it, new employers do not locate in a community, which means the population that might generate the tax revenue to fund infrastructure improvements never arrives. The sanitation gap and the economic development gap are not separate problems. They are the same problem viewed from different angles.

Flowers and others have argued that framing rural sanitation as a civil rights issue rather than merely a technical one is essential to breaking this cycle. The communities most affected are disproportionately Black, Indigenous, and low-income, a pattern that reflects historical decisions about where infrastructure was built and for whom. The passage of the Infrastructure Investment and Jobs Act in 2021 included funding for wastewater systems, but advocates have noted that accessing those funds requires grant-writing capacity and administrative infrastructure that many small rural communities do not have.

The dirty secret, in the end, is not just about sewage. It is about which communities the country has decided are worth connecting to the systems that make modern life possible, and which ones it has quietly decided to leave behind. Whether the current wave of infrastructure investment actually reaches the places that need it most will depend on whether policymakers are willing to look at what has been ignored for so long.