For Sabrina Hester, COVID-19 started in mid-March with a runny nose and a tickle in the back of her throat.
She thought it was allergies.
“It took about two days, then it just hit me like a truck,” Sabrina said.
In those early days of the pandemic, advice was sparse and often unclear. When Sabrina went to an urgent care with symptoms, staff didn’t even wear personal protective equipment until she asked for a COVID-19 test.
When that test came back positive, though, Sabrina and her husband, Akili, made new house rules.
“The law was no common area, no living room, no kitchen. You get your food, you go back upstairs,” Akili said.
The quarantine applied to three other people living in the house, including their two children and Akili’s sister, Zuri.
They were lucky. Their house was big enough for them to each be able to isolate in their own bedrooms.
Others haven’t been so fortunate. Some homes aren’t big enough to sufficiently quarantine, a phenomenon some believe could be linked with higher COVID-19 infection rates in areas where crowded homes are more common.
In communities across North Carolina, families often live in homes that are too small. Doors are opened for displaced kin, and generations often shelter together. This has made combating COVID-19 a challenge for some.
“It’s really a recipe, I think, for disaster, a recipe for spreading the virus if you live in an overcrowded household,” said Bill Rohe, the former director of UNC-Chapel Hill’s Center for Urban and Regional Studies.
“Overcrowding” is widely accepted as having more than one person living in a house per room. About 2.3% of households in North Carolina are defined as overcrowded, according to five-year estimates from the U.S. Census Bureau’s 2018 American Community Survey.
A North Carolina News Collaborative analysis found that the COVID-19 infection rate is higher in the ZIP codes with the most crowding. The rate of crowded homes was higher in the ZIP codes that had the highest infection rates, the analysis also found.
The collaborative compared infection rate data from the N.C. Department of Health and Human Services with five-year overcrowding estimates compiled with the assistance of Carolina Demography.
The phenomenon is no surprise to those who have studied crowding. This summer, the U.S. Census Bureau identified 11 factors that would make communities vulnerable to COVID-19. Among the flags: overcrowded housing.
OVERCROWDING AND THE VIRUS
Congregate living conditions like farmworker housing, jails and nursing homes have accounted for about 31,600 COVID-19 cases and nearly 2,400 deaths in North Carolina — roughly half of all coronavirus-linked deaths in the state.
But individual homes can be cramped, as well. And the situation has long been worsening in North Carolina.
Rohe co-authored a 2017 report called “Extreme Housing Conditions in North Carolina,” concluding that the number of overcrowded rental units in the state rose 45.5% from 2008 to 2013.
There is “every reason,” Rohe said, to believe that overcrowding has risen even more during the COVID-19 pandemic. Rohe pointed to COVID-19’s impact on jobs — September’s statewide unemployment rate was 7.3%, according to the N.C. Department of Commerce, more than double February’s 3.6%.
“Where are those unemployed people going? Probably going back to live with relatives, maybe going to double up with other families,” Rohe said.
Crowded homes can make following precautions against virus spreading nearly impossible, Rohe said. In addition to making it difficult to isolate someone with the virus, it can be hard to find space to socially distance. Already, research has shown that air-borne diseases like the flu spread more easily in crowded homes.
“That has been going on even without the pandemic so with the pandemic the health impact of overcrowding is much, much worse,” Rohe said.
The overlap between crowded conditions and COVID-19 can be seen across North Carolina.
In Richmond County’s ZIP code 28347, both crowding and COVID-19 rates are well above state averages — 20.5% and 777.7 per 10,000, respectively.
And in the Triangle, ZIP code 27701 has been hit hard.
Akili Hester has had a front row seat. He owns and operates Black Wall Street Barbershop in a busy strip mall along Fayetteville Street, a main artery through the community. His sister, Zuri, runs Nzinga’s Kitchen nearby.
The community is known as Southside, a rapidly gentrifying area that includes part of downtown Durham and a small pocket just south of Highway 147 on Fayetteville Street.
This Durham ZIP code has a COVID-19 rate of 301.26 per 10,000 people and a crowding rate of 5.34%, both above state averages.
On a sunny fall afternoon, people could be seen sitting on the porches of some nearby homes while construction was underway on others.
CARING FOR SOMEONE WITH COVID-19
When Sabrina’s test came back positive, Akili immediately shut the doors to the shop, focusing only on caring for Sabrina. Less than two weeks later, the governor’s lockdown order would have forced his hand.
At home, Akili tried to keep the virus from spreading.
The Hesters’ children, Joe Gibbs Jr. and Jakayla Gibbs, were ordered to their rooms except for bathroom trips and kitchen runs for food.
Jakayla Gibbs went from spending every day with her friends to sitting alone in her room, hearing her mom cough through the walls.
“Imagine all of a sudden you can’t see your mom and she’s sick, like that’s weird. And then it’s almost like you just have to hear about how she’s doing to a certain extent. I can only imagine the level of stress that that was,” Akili said, glancing at Jakayla.
“Especially when you hear her in her room sounding like she’s gonna die,” Jakayla replied.
Akili’s sister, Zuri, who lives with them, also hunkered down. When Sabrina’s positive test came back, Zuri was preparing to open her restaurant for the day. She immediately switched gears, sending her staff home and advising them to get tested.
Akili, Jakayla, Sabrina and Zuri recounted their experience on a recent Friday night at the Black Wall Street Barbershop. The family sat grouped in front of a painting depicting Durham’s mascot, a bull, wearing a mask. As they spoke, a barber wrapped up his final haircut of the day nearby while another customer sat under a dryer.
Months since their scare, memories are still sharp.
At one point, Zuri heard Sabrina let out a cough unlike any she had ever heard before. She asked Akili if they should consider taking Sabrina to the hospital.
“We didn’t even know what coronavirus really was,” Zuri said.
Inside her bedroom, Sabrina tried to sleep, easing her body aches.
“If I was asleep, I wasn’t hurting,” Sabrina said.
Akili and Sabrina were in daily contact with the Durham County Health Department, where officials wanted to monitor Sabrina’s fever. When she was too weak to stand one day, Akili pressed them, asking if this was a sign he should take her to the emergency room.
Sabrina didn’t really have an appetite for the month she was sick, subsisting mostly on chicken broth and the daily wheatgrass drinks Akili brought her to boost her immune system.
Every time Akili left the room, he covered his face and tried to wipe down every surface he touched.
Akili and Sabrina quietly shared fears that he would get sick while caring for her.
“In the back of my mind, I was terrified,” Akili said. “Because I’m scared for her, I’m scared for myself, I’m scared for my household. Because if I’m the one taking care of her — I honestly thought as soon as she got well, I was going to get sick.”
Akili didn’t fall ill. Neither did the kids.
Deirdre Smith, a Wake County public health nurse, knows the fear families face when one person in the household gets sick. She supervises contact tracing efforts in the county.
She said it is not uncommon to investigate the COVID-19 case of one family member only to find out another became symptomatic a short time later. In Wake, contact tracing efforts typically include four or five people in a household.
Proximity and time spent with the person who contracted the virus play a part, Smith said. So does a home’s air circulation.
Like Rohe, Smith said COVID-related job struggles have put more people at risk from the virus.
“We have a lot of people (where) economics has forced them to change their living situation, and there are a lot more people residing together and having alternative living arrangements,” Smith said.
LINGERING IMPACTS OF COVID-19
For the Hesters, life remained in a holding pattern until the beginning of July. Until then, Sabrina’s shortness of breath lingered and she tired easily.
Akili finally had permission from the state to reopen his barbershop. Zuri partially reopened the restaurant.
Like so many others, the virus has changed the Hesters.
Akili removed the waiting area from the barbershop and now wears a mask when he cuts hair.
Half of his customers haven’t returned, and a federal Paycheck Protection Program grant wasn’t enough to fully restore the revenue he lost while the shop was closed.
To claw back some of that money, Akili launched a t-shirt line representing his city and this moment. On brightly colored backgrounds, the shirts depict the same bull that is now painted on the shop’s wall.
The Hesters can, however, see how they were fortunate in their battle with COVID-19.
Their house was large enough to offer each a haven from the disease.
Without it, Sabrina said she would have gone to the hospital, an expense and a discomfort.
“I would have removed myself from the home, especially once I finally knew that it was the coronavirus,” Sabrina said. “Luckily everybody has their own space and we were able to keep our distance.”
Adam Wagner is a reporter at The News & Observer and a Report for America corps member. He can be reached at firstname.lastname@example.org or 919-829-4669.
The collaborative's analysis relied on infection rate data from N.C. DHHS, which is available at the ZIP code level. Those rates were paired with crowding data from the U.S. Census Bureau's American Community Survey, which is available at the ZIP Code Tabulation Area level, a census estimate of the areas inside a ZIP code.
The analysis found that the quarter of ZIP codes with the most crowding averaged COVID-19 infection rates of 308.4 cases per 10,000 people. In the quarter of ZIP codes with the least crowding, the COVID-19 rate averaged 236.2 cases per 10,000 people.
It also found that in the quarter of ZIP codes with the highest COVID-19 infection rates, crowding averaged 3.66%. In the quarter of ZIP codes with the lowest COVID-19 infection rates, crowding averaged 2.53%.
Statewide, the ZIP code-level average for COVID-19 infection rates was 251.5 cases per 10,000 residents. The ZIP code-level average for crowding was 2.86%.