The Heavy Toll of the Black Belt’s Wastewater Crisis

Many rural households in America don’t have access to safe sewage systems. In Alabama, entrenched poverty and unusual geology have created a public-health disaster.
Fence and sign by lagoon.
A sewage-treatment lagoon in Hayneville leaks waste into yards and houses.Photograph by Devin Lunsford for The New Yorker

When Pamela Rush was a young woman, in the late nineties, she moved into a trailer on an orange-dirt road in Collirene, Alabama. Rush’s home sat on half an acre of land, surrounded by lush woods, and her sister Almedia lived in another trailer on the same plot. The family had bought Rush’s trailer, a pale-blue single-wide, a few years earlier. She moved in to take care of her aging mother, and ended up staying for decades.

At forty-eight, Rush had full cheeks and a shy way of carrying herself. She looked everyone in the eye, but often had to be reminded to speak up. “Everybody in the neighborhood knows her,” her niece Veronica said. Rush’s family was one of the largest in the area, and she got together nearly every weekend with her six sisters and their children—eating, drinking, playing cards, catching up.

But Rush hesitated to invite visitors inside her trailer. It was falling apart. The walls were porous, and in hot weather the energy bill came to more than three hundred dollars a month. To save money, and to keep out rodents, she stuffed rags into holes and set traps outside the door; she kept a running tally of the opossums she caught. Trailer homes often begin losing value as soon as buyers take them off the lot. Because Rush’s mortgage had exceptionally high interest, she had paid for hers twice over already: a hundred and fourteen thousand dollars, with some fifteen thousand still to go. Her total income—including disability payments and some support from the father of her children—was less than a thousand dollars a month.

Rush’s home is in a part of Alabama known as the Black Belt, named for its rich, dark topsoil, which in the years before the Civil War made cotton the state’s main source of wealth. Now the farming that was once done by enslaved people and sharecroppers is mostly done by seasonal workers and machines. Jobs are scarce. Lowndes County, which includes Collirene, is one of the poorest counties in one of America’s poorest states.

The dirt in the region, ideal for planting cotton, isn’t good for much else. It sits in a thin layer atop impermeable clay-laden soil, which, in the early days of agriculture there, frustrated farmers trying to dig wells. Now the problem is more often with sewage. The state of Alabama mandates that anyone who is not on a municipal sewer line—which includes eighty per cent of Black Belt residents—invest in a private waste-management system. But conventional septic tanks, which store sewage until it can be filtered by the earth and consumed by microbes, are often defeated by the dense soil. For these conditions, the state recommends a “mound” system, which uses piled-up dirt to filter waste. Yet, in a region with a high water table and intense rains exacerbated by climate change, the mounds frequently erode and the tanks fail, sending sewage back through toilets, sinks, and bathtubs. In Lowndes County, at least forty per cent of households have an inadequate septic system or none at all.

In Alabama, not having a functioning septic system is a criminal misdemeanor. Residents can be fined as much as five hundred dollars per citation, evicted, and even arrested. Rush’s sister Viola was once arrested for a sewage violation. But installing a new system can cost as much as twenty thousand dollars, which is more than the average person in Lowndes County makes in a year. Instead, Rush, like her neighbors, used a pipe to empty waste into the grass outside—a practice, called straight-piping, that is not uncommon in much of rural America. (At least one in five homes in the U.S. is not on a municipal sewer line.) Floods carry sewage across people’s lawns and into their living areas, bringing with it the risk of viruses, bacteria, and parasites that thrive in feces. Studies have found E. coli and fecal coliform throughout the Black Belt, in wells and in public waters. A United Nations rapporteur on extreme poverty, visiting in 2017, said that the sewage problem was unlike anything else he had encountered in the developed world. “This is not a sight that one normally sees,” he said.

Rush’s situation got so bad that, in 2017, her sister Barbara sent a Facebook message to an environmental activist named Catherine Coleman Flowers. For two decades, Flowers has helped people struggling with sewage problems in Alabama. (She was recently named a MacArthur Fellow.) A petite woman of sixty-two, with a gentle drawl and a no-nonsense demeanor, Flowers is a reassuring presence; she grew up in Lowndes County and is distantly related to Rush, as she is to many people in the area. Still, she was shocked when she saw the trailer. “She showed me how they were living, and I cried,” Flowers told me.

“What’s it like having a famous father?”
Cartoon by Michael Maslin

When I started visiting Flowers to report on her work, the following year, she took me to see Rush, who greeted us warmly and led us inside. The trailer was dim and claustrophobic, though Rush took care to keep it clean. Sheer pink-and-blue curtains swayed in front of a window. Rush’s nine-year-old daughter, Bianca, had a bedroom at one end of the trailer, but she spent most nights on the living-room couch, because the power was out in her room and she needed a CPAP machine to breathe while she slept. (Rush had diabetes and, like her daughter, difficulty breathing at times.) Rush’s son, Jeremiah, also lived there; he had a learning disability and, at sixteen, was still in middle school. The foul moisture in Rush’s yard seemed to penetrate the trailer, and mold bloomed on Bianca’s bedroom walls.

When Flowers first met Rush, she gave her the same talk that she gives everyone: “I can’t promise you anything, but what I will do is bring people who have the means to see the problem, and hopefully one of them will be moved enough to help you.” She began inviting influential visitors. The Reverend William J. Barber II, of the Poor People’s Campaign, came to see the place. So did Jane Fonda. Bernie Sanders made a campaign video that showed him embracing Rush and telling her that he would not forget about her.

In the summer of 2018, Flowers met Rush at the speck of an airport in Montgomery, about fifty minutes from Collirene, to see her off to Washington. Rush was due to appear in a congressional hearing on poverty, testifying before Sanders, Elijah Cummings, Elizabeth Warren, and Cory Booker. It would be her first time on a plane, but she didn’t mind; she had Bianca and Almedia with her.

The next day, she sat before the senators, wearing a patterned blouse and a necklace with a cross on it. “Hi, my name is Pamela Rush, and I’m from Lowndes County, Alabama,” she began. “I live in a mobile home with my two kids.” She started to cry, and put her hand up to shield her face. As she explained her situation, Warren nodded sympathetically. Booker appeared stricken. “I got raw sewage, and I don’t have no money,” she said, looking at the politicians as if they needed help understanding something simple. “I’m poor. I couldn’t buy my children stuff for what they need.”

Catherine Coleman Flowers grew up surrounded by activism. Montgomery is where Rosa Parks refused to surrender her bus seat in 1955. A decade later, Martin Luther King, Jr., led marchers to Montgomery from Selma, fifty-four miles away along Highway 80, to push Congress to pass the Voting Rights Act. The civil-rights leader John Lewis was born one county over, near Troy, where his parents were sharecroppers.

Flowers’s mother, Mattie, worked as a teacher’s aide and drove a school bus; her father, J.C., was a stock handler at an Air Force base in Montgomery, until he was injured on the job. Both were deeply involved in the local civil-rights movement. They opened their home to activists such as Stokely Carmichael, who helped start a Black political party called the Lowndes County Freedom Organization. J.C. was known throughout the county as fearless: he carried guns where white men could see them and helped guard a camp of Black families left homeless after their white landlords evicted them for voting. Mattie advocated for women who endured forced sterilizations at a hospital in Tuskegee; she, too, had been subjected to an involuntary tubal ligation, after the birth of her fifth child.

The county was known during the civil-rights era as Bloody Lowndes, for the campaign of murders, attacks, and evictions that whites inflicted on their Black neighbors. Today, some ten thousand people live in Lowndes, and about seven thousand are Black. Many are descendants of enslaved people who worked the plantations of the Black Belt, and owning the land where their ancestors were used as forced labor is a source of pride. But white landowners hold most of the area’s prime real estate. “The best land in Lowndes County has always been owned by white folks, from slavery through the present,” Hasan Kwame Jeffries, an associate professor of history at Ohio State University and the author of “Bloody Lowndes,” a book on power and race in the region, told me. “The wealth is tied to the land, and that land never transferred hands.”

Flowers attended Alabama State University, a historically Black school in Montgomery, where she helped fight to prevent a merger with two traditionally white state universities. She left school for a time and took an internship at the Martin Luther King, Jr., Center for Nonviolent Social Change, in Atlanta, then finished her undergraduate degree at Cameron University and earned a master’s at the University of Nebraska. Afterward, she taught public school in Washington, D.C., and in North Carolina; she took her classes on field trips to Selma, and filed discrimination complaints on behalf of students. In the nineties, she was briefly the director of Selma’s National Voting Rights Museum and Institute, and taught at a Detroit magnet school. But, in 2000, with her father in poor health, Flowers decided to move back home.

A distant cousin of Flowers’s was leading the Lowndes County Commission, and he helped bring her in as an adviser on economic development. To her surprise, one of the most pressing issues was sewage. Sometimes the problems were apparent from residents’ stinking yards. Other times, they surfaced in legal processes. A pastor was arrested because his church lacked a working septic tank. A husband and wife were threatened with arrest because their sewage leaked onto the road. Flowers met a family of six who had been forced from their home because the health department deemed their septic tank substandard; they had moved into tents at a campground.

In 2004, Flowers founded the Alabama Center for Rural Enterprise (ACRE), a nonprofit focussed on poverty, and started finding people to teach her the basics of soil chemistry and septic-tank design. With a grant from the Environmental Protection Agency, she launched a county-wide survey, going door-to-door and asking residents if they were having trouble with waste management. One woman had a stain running around the walls from sewage that had flooded her house; another had been forced to take out a loan to remove her carpet. “When I was growing up, we had raw sewage running back into our house, but we thought it was just a plumbing problem,” Flowers told me. “It was only after we did the house-to-house survey that we realized these were not isolated situations. One reason it’s been hidden for so long is because this is not something people just talk about. Who sits around and says, ‘Oh, the sewage ran back into my house today’?”

In 2008, Flowers also began working with the Equal Justice Initiative, a Montgomery-based organization led by the attorney and activist Bryan Stevenson. In Lowndes County, she intervened on behalf of residents who found themselves in court for sewage violations; she helped pay for septic-tank upgrades; and she persuaded donors to cover hotel rooms and storage spaces for people displaced from their homes. In Washington and in Montgomery, she advocated for more effective policies and greater awareness of the problem. “This is not what I thought I would be working on when I came back to Alabama,” she recalled, laughing. “But I knew there was not going to be any meaningful economic development if people did not have a certain quality of life in their homes. And wastewater is so basic. You can’t really attract any kind of businesses into a community if you don’t have adequate wastewater treatment.” It seemed clear to Flowers that the county was waiting for residents to fix the problem themselves. “They’re doing crisis management and hoping it will go away,” she said.

In Hayneville, the seat of Lowndes County, nearly every important building sits along Tuskeena Street. There’s the telephone company and the town hall (which shares a building with the fire department), the middle school, an auto-parts shop, a Dollar General, and the Southview Worship Center, all surrounded by sprawling parking lots. Most residents commute to work in other counties, where there are more opportunities. The ones with jobs closer to home—for local Hyundai suppliers, at the school, or in the shops—enjoy the easy trip between work and the grocery store and church.

Hayneville, once centered on cotton production, is struggling to find a new identity. One part of town—the white part—still evokes a genteel way of life. Down Tuskeena Street from the Greek Revival courthouse is a row of handsome homes with springy, neon-green lawns. But turn off onto a dead-end road called Pine Street and there is another row of homes, occupied by Black families who live next to a municipal sewage lagoon.

When Catherine Coleman Flowers began working to help people who had sewage in their homes, she found that the issue persists in part because no one wants to talk about it. “Who sits around and says, ‘Oh, the sewage ran back into my house today’?” she said.Photograph by Devin Lunsford for The New Yorker

From above, the lagoon looks like a pair of sickly green pools, the size of several football fields, surrounded by foliage. The system was designed so that sewage from Hayneville and from truck stops on a nearby highway flows into the lagoon, where algae and bacteria break it down. But, during rainy weather, a shimmering dark lake backs into the lawns of the brick houses on Pine Street. Even on dry days, puddles of wastewater form along the roadside, drawing swarms of mosquitoes.

“I first learned about the lagoon when we were doing the house-to-house surveys,” Flowers said. “We went to visit Miss Charlie Mae.” Charlie Mae Holcombe’s house, a tidy one-level, stood just yards from the lagoon. When it rained, sewage lapped onto her property. At times, waste gathered in her bathtub, or came out of faucets in a black gush. “She was probably the only person on her street that was really complaining loudly,” Flowers said. “So I was very happy to meet her.”

When we visited, Holcombe welcomed us kindly, her graying hair in braided pigtails. She and her husband were sick of smelling raw sewage, she told us. Their house, like their neighbors’, was connected to a community septic tank that emptied into the lagoon, and she paid the town a waste-management fee. But the tank regularly malfunctioned, adding to the flooding from the lagoon. When sewage collected on their lawns, the Holcombes and their neighbors called the city, which sent workers to pump it out. (Local authorities declined to confirm facts for this article.) Holcombe had been calling the city about the lagoon for nearly three decades; she had recently taken out a loan to replace her flooring for a second time.

To some officials, sewage problems are as much a matter of personal responsibility as of public health. In 2018, Sherry Bradley, of the Alabama Department of Public Health, suggested to a reporter that people who were being flooded by the lagoon should have known better than to buy houses on Pine Street. “Well, they moved there,” she said. Bradley leads the department’s Bureau of Environmental Services, which regulates home-wastewater management throughout the state. She told the reporter, “If you’ve got sewage on the ground, it’s your fault that you’re dumping sewage on the ground.” Bradley, who is Black, added, “I was raised poor, but we were proud. We were clean.” (She maintains that she was quoted out of context.)

Flowers argues that the sanitation disaster is a product of long-standing inequities. “A reason this problem has perpetuated for so long was because they blamed it on poor ignorant Black people who don’t know how to flush a toilet or take care of a septic system,” she said. Wealthier residents have an easier solution: they pay someone to fix their septic system. Health departments in the Black Belt issue permits for septic work in predominantly white counties at more than three times the rate as in predominantly Black counties. “There have been intentional structures put in place, undergirded by racism, to keep the county poor,” Flowers said. “Not having access to decent housing creates a lot of other kinds of injustices. It creates health-care disparities. It leads to not having a decent wage.”

To Flowers, the neglect of the sanitation problem in Lowndes County is as obvious an environmental injustice as the contamination of drinking water in Flint, Michigan. “It’s these places where dirty industries want to go,” she says. According to a report by the N.A.A.C.P. and the Clean Air Task Force, Black people are seventy-five per cent more likely than the average American to live near industrial plants and service facilities, including those that handle hazardous waste. In 2005, Lowndes County residents fought off an effort by Waste Management, one of the country’s largest trash-collection firms, to build a landfill along the route of King’s march. Soon afterward, another company proposed building a landfill on the banks of the Alabama River.

For decades, the state and county governments’ disinterest in the problem transferred the burden of care to activists and local leaders. Steven L. Reed, the mayor of Montgomery, told me, “There’s a numbness to suffering and pain in communities of color. Because of the lack of diversity at the state level—we’ve not had one Black governor—that awareness is often missing.”

Flowers had brought researchers and politicians to Holcombe’s house for years, but nothing changed. “My front yard look like the whole Alabama River,” Holcombe told Flowers and me. “When you hear that gurgling sound in the toilet, you know not to use it. It will back up.” When the bathroom was unusable, she and her husband sometimes had to stay with their daughter, in Montgomery. She worried that the exposure to sewage was affecting their health. An alarming number of her friends had asthma, allergies, and heart disease. “Everyone’s got an asthma inhaler,” she said. “All of us are sick.”

Soon after Flowers met Holcombe, she got in touch with Peter J. Hotez, the dean of the National School of Tropical Medicine, at Baylor College of Medicine. As Flowers described the situation in the Black Belt, he began to suspect that residents had intestinal worms. “Most of the world’s global health threats are in the G-20 nations, paradoxically,” Hotez, who develops vaccines for neglected tropical diseases, told me. In places that think of themselves as rich, it’s easy to ignore problems of poverty, he explained. “It’s the poor living among the wealthy that now account for most of the world’s leprosy, tuberculosis, dengue—and the list goes on.”

Hotez sent Rojelio Mejia, an infectious-disease specialist who has worked in Latin America and East Africa, to start collecting soil and waste samples in Lowndes County. “I never thought that we had this degree of parasites in America,” Mejia said. In the years around the Second World War, hookworm was documented all over Alabama, but it was thought to have been eradicated by the nineteen-eighties. Hookworm enters the body through the skin, often through the hands or the soles of bare feet, and makes its way to the small intestine, where it feeds on blood. It can persist for several years, causing anemia, weight loss, fatigue, and impaired mental function, particularly in young people. Other worms found in the region’s soil can damage the lungs and may encourage asthma. “When children get infected multiple times with parasites, they suffer long term,” Mejia said. “They have decreased growth rates and decreased cognitive abilities.”

In the fall of 2017, the Baylor researchers announced that they had tested a group of Lowndes residents who lived with poor sanitation and discovered hookworm in more than a third of them, including Holcombe’s husband and son. Yet there was no meaningful intervention by the state or the federal government. “I was able to help mobilize hundreds of millions of dollars over the years from U.S.A.I.D. to address neglected tropical diseases in Africa and in poor areas of Asia,” Hotez said. “But when you talk about neglected infections of the poor in America the lights go out.”

At the Hayneville Family Health Center, a bright clinic across from the Dollar General on Tuskeena Street, George G. Thomas had seen his last patients of the morning and was getting ready for lunch when I arrived to talk with him. For most of the past thirty years, Thomas has been the only practicing doctor in Lowndes County—which, like six other counties in Alabama, doesn’t have a hospital. He and a nurse practitioner serve a population of nearly ten thousand. In the evenings, he works at another center, in Montgomery.

At least a tenth of Alabama residents are uninsured. Like many states in the Deep South, Alabama has refused to expand Medicaid under the Affordable Care Act, which would allow more than two hundred thousand Alabamians to gain health insurance. When Governor Kay Ivey was asked whether she would consider expanding Medicaid to help her constituents during the pandemic, she replied that it would be “irresponsible” to do so without considering the effect on the state budget—even though federal funds would cover most of the cost.

“We need to talk.”
Cartoon by Amy Hwang

Thomas’s clinic focusses on primary-care services; patients who require more sophisticated tests or procedures are referred to doctors in Montgomery or in Birmingham, a two-hour drive away. The county pays nineteen thousand dollars a month for an ambulance to take residents to emergency rooms in cities. But, when it is in use, patients have to make their own arrangements or stay home.

Thomas is soft-spoken, with a head of gray hair. As we talked, a blue surgical mask kept slipping down his nose. He is from North Carolina, but, during medical school at Howard University, he agreed to work for several years in a community health center in the Black Belt, in exchange for reduced tuition. (The government program that sponsored him, the National Health Service Corps, has since suffered deep cuts to its funding.) Many of his patients contend with high blood pressure and diabetes. “There is a genetic factor there,” Thomas said. “But what aggravates it is the poverty, the inability to get healthy food, the inability to get to the doctor when you need to. Sometimes, it seems like the medicine is easy—it’s just the social problems.”

Flowers had told me about meeting people who took medications every other day, to delay the expense of a refill. Thomas said that his prescriptions sometimes weren’t filled at all—and that patients who didn’t have the money to keep up appointments often just disappeared. “If your rent’s due, even if your high blood pressure could be doing damage to your kidneys and to your eyes, right now you have to survive,” he went on. “The emergency of life takes precedence over the slow erosion of chronic disease.”

In September, 2018, Earthjustice, a nonprofit that specializes in environmental law, filed a federal Civil Rights Act complaint against the Alabama Department of Public Health and the Lowndes County Health Department. The complaint alleges that the agencies’ failure to improve wastewater treatment has had a “disproportionate and adverse effect” on the Black community. Anna Sewell, a staff attorney with Earthjustice, told me, “It’s the long-standing ignoring of the problem that led us to file the complaint. The primarily Black residents of Lowndes County continue to suffer the effects of the health departments’ failure.” Sewell first visited Lowndes with the U.N. special rapporteur. “I remember being struck by seeing children’s toys near raw sewage on the ground,” she said. “It was just appalling.” Two years later, federal authorities were still conducting an initial review—an “unconscionable delay,” Sewell said.

When the Baylor researchers released their findings, Alabama’s department of health posted a notice online, denying that hookworm was present in Lowndes County. “The health department said, They don’t know what they’re talking about,” Rojelio Mejia, the researcher, told me.

Alabama’s state health officer, Scott Harris, noted that the Baylor study was based on just sixty-seven people, and that the researchers had used a newer, more sensitive test, which Harris said could produce false positives. So far, he added, state reviews had not shown that children in Lowndes County suffered gastrointestinal ailments at a significantly higher rate than those in the rest of the state. He acknowledged that the county, like others in the Black Belt, has “a long history of problems with water.” (In the nineteen-twenties, the state health department created a waste-management division specifically to address widespread hookworm infections.) But, he went on, “the issue is not hookworm as much as it is continuing poverty that just hasn’t been addressed for generations. There are very clear examples of structural racism that have made it difficult to make progress, and our state is not invested in a consistent, sustained way in trying to fix those problems.”

The University of Alabama at Birmingham School of Medicine recently began researching parasites in the Black Belt. Claudette Poole, a specialist in pediatric infectious disease who is the study’s principal investigator, credited Flowers with helping to provide funding: in 2018, after Baylor released its study, the Centers for Disease Control and Prevention awarded Poole $1.2 million to investigate soil-transmitted parasites in children in Alabama.

Poole told me, “Our data gathering on hookworm specifically is too early to say anything definitive.” But, she added, “poor sanitation is a proxy for poverty, and poverty itself is linked to a whole host of poor health outcomes.” At the very least, the presence of raw sewage would contribute to infections from pathogens linked to vomiting, diarrhea, and potentially fatal sepsis. “Ultimately, the issue is about sanitation,” Poole said. “Whether the hookworm is there or not doesn’t change that.” So far, the researchers have tested two hundred and eighty-three children, of whom twenty per cent said their homes use straight-piping. Only twelve per cent live in homes connected to municipal sewers. “The sanitation is really dire,” Poole said.

There has been some progress. Senator Doug Jones and Representative Terri Sewell, both of Alabama, have sponsored grants to assist residents in connecting to the sewer grid or installing septic tanks. Jones told me that Flowers had given him a tour soon after he took office. “I was just stunned,” he said. “The abject poverty in these areas is really something you can’t get your arms around unless you see it.” He began working with Sewell, Booker, and others to “at least get some federal monies down there to help.”

The Lowndes County government has been slow to make improvements, though. Jacquelyn Thomas, the county administrator, told me that a sewer line was being installed in the town of White Hall. The work, funded in part by the United States Department of Agriculture, has taken more than five years and has cost more than a million dollars—for a line that will serve seventy residents, in a town of roughly a thousand. For a county with a low tax base, Thomas suggested, installing sewers that reached more households would be prohibitively expensive.

Recently, the state health department stepped in to address the problem in Lowndes—an unusual move for a regulatory agency. It launched a pilot program, funded by a $2.3-million matching grant from the U.S.D.A., that is intended to provide septic systems for a hundred homes. Sherry Bradley, who is administering the program, told me that residents will pay an affordable monthly fee for systems that are better engineered for the local soil.

Flowers, too, thinks that places like Lowndes County need a different solution. “Alabama needs to deal with the fact that the technology doesn’t work,” she said. She plans to use some of the money from her MacArthur award—six hundred and twenty-five thousand dollars, over five years—to investigate alternatives. She is helping lead a Columbia University initiative to develop sewage-treatment methods that don’t rely on a public line. Her co-director, an environmental engineer named Kartik Chandran, told me that he is working on household treatment systems that can be monitored and repaired remotely, and others that encourage feces to break down more easily. “With any utility infrastructure—communications, water, sewer—we talk about trillions of dollars in spending, but all of that is devoted to people who are on the networks,” Chandran said. “What happens to the twenty per cent of this country’s population who are not on a network? It’s like they don’t exist.”

The problem is not just in Alabama, Flowers points out. In some parts of rural Alaska, where installing a single septic system can cost more than a hundred thousand dollars, people rely on outhouses and “honey buckets”—pails lined with garbage bags. In Centreville, Illinois, where the city has done little to repair worn-out sewage infrastructure, untreated waste accumulates on neighborhood streets. In Florida’s Miami-Dade County, according to a recent study, rising sea levels may threaten two-thirds of residential septic systems by 2040. As Flowers became involved in the sanitation crisis beyond Alabama, ACRE evolved into the Center for Rural Enterprise and Environmental Justice, which works to influence policy in neglected communities. “If it weren’t for the people in Lowndes County, we would not be talking about this as a national issue,” she said. “But we need to find a solution that’s going to benefit everybody.”

A United Nations rapporteur on extreme poverty, visiting the Black Belt in 2017, said that the sanitation problem was unlike anything else he had encountered in the developed world: “This is not a sight that one normally sees.”Photograph by Devin Lunsford for The New Yorker

Last fall, Flowers called Pamela Rush, to say that their prayers had been answered. Flowers’s organization had secured a donation from Kat Taylor, the wife of the billionaire former Democratic Presidential candidate Tom Steyer. The money would allow them to buy Rush and her kids a new trailer—an energy-efficient double-wide with a working septic tank. “Thank you, Jesus!” Rush shouted. The women cried together.

During the past several years, Flowers told me, she and her staff have helped a dozen families move into safer homes. But finding a spokesperson for the issue was tricky. Most people with sewage problems were understandably wary of letting strangers and cameras into their homes. Rush, however, spoke willingly to the media and to politicians. She began consulting for Flowers’s center, sharing her story and conducting surveys in the community.

Rush’s car was unreliable, so Flowers’s colleague Stephanie N. Wallace sometimes drove her and her daughter to doctors’ appointments in Birmingham. On the way, Rush talked about how her activism had changed her life. “As she began to speak about her living conditions, she began to evolve into a totally different person,” Wallace recalled. “She’d be, like, ‘There’re a lot of folks who told me I shouldn’t talk about what I’m going through. But I did it to help my kids.’ ” During a recent ride, Rush told Wallace how excited she was about her new home, and how grateful she felt to get donations from people who didn’t even know her. She asked if they could stop by the mobile-home lot. Wallace said to wait; she and Flowers wanted it to be a surprise.

One weekend in June, Rush came down with what felt like a sinus infection. She developed a cough, lost her appetite, and had trouble seeing. On Sunday, her niece Veronica dropped off baked chicken and collard greens at her doorstep. On Tuesday, she took Rush to a clinic in Selma, thinking that maybe her blood-sugar level was too high. It was—but she also had pneumonia. When Rush tested positive for COVID-19, too, she was sent on to the University of Alabama hospital in Birmingham.

During the summer, the people of Lowndes County began to realize how widely the coronavirus had spread around them. Flowers lost two cousins, a father and his daughter. At a Montgomery City Council meeting in June, William Saliski, a pulmonologist at Jackson Hospital, said that the wards were full of COVID patients. Half of them were on ventilators, he said—a group that was as much as ninety per cent Black. Another doctor described bodies being carried out every half hour. But, as the council deliberated over a citywide mask-wearing rule, the meeting turned contentious. A local man named William Boyd told the members that he had lost six relatives to COVID. “The question on the table is whether Black lives matter,” he said. Still, the council voted down the policy; it approved a similar rule only after Montgomery’s mayor, Steven Reed, issued an executive order mandating masks in public. Governor Ivey was also reluctant: she instituted a mask rule in mid-July, after three months in which the rate of new cases in the state increased nearly six hundred per cent.

In Alabama, as in the country at large, Black people are about twice as likely as their white neighbors to die from COVID-19. Lowndes County has the state’s highest per-capita death rate. Though there is no link between hookworm and COVID, the same people are being afflicted by both. “What I saw in Lowndes County, with the sanitation being such a poor system, it really makes sense why that area is so hard hit with COVID,” Mejia said. “Even though it’s rural, and it’s not high-density like it is in the city, you have extreme poverty and multiple generations living in the same trailer. So, when you have crowding, the virus can spread.” Residents’ underlying health conditions—diabetes (often unchecked because sufferers can’t see a doctor regularly), high blood pressure, and breathing problems—make them more vulnerable to the virus. “These things don’t increase your risk of getting it,” Mejia said. “But they definitely increase your chance of a bad outcome.”

At the clinic in Hayneville, Dr. Thomas told me that one of his patients had lost both his mother and his grandmother. As Thomas saw it, the only way to control the virus was to address the poverty that had allowed it to spread. Even patients who had tested positive resisted staying at home if they felt able to get to their jobs. “Day to day, people decide they have to work, or they do what they have to do to survive,” Thomas said. Most businesses required employees who had caught the virus to show negative results before returning to work, but some people told me that their employers would settle for a doctor’s note affirming their lack of symptoms. “It seems like Lowndes County isn’t a priority,” Thomas went on. “If it was a priority, then these things shouldn’t happen.”

Two of Rush’s sisters also came down with COVID. Barbara contracted the virus at her factory job and recovered; Almedia got it and was sent to a hospital in Selma. Rush tried to stay optimistic. From her bed, she sent a message to Veronica, asking for eyeliner; Veronica laughed and said that she had no business looking for a boyfriend in the hospital. Her family told her not to be afraid, and she promised that she wasn’t. Over the next week, though, her organs began to shut down, and she was put on a ventilator, which left her unable to communicate. On the day before the Fourth of July, Almedia was feeling well enough to go home. That afternoon, Pamela Rush died.

A few weeks later, as a heat wave settled over the Deep South, scores of relatives and loved ones gathered for a graveside service at a church just past the town of White Hall. Two small tents provided relief from the sun; men in face masks carried the coffin. Rush’s son, in a crisp white shirt and a red tie, wept inconsolably, and others fanned themselves as they wiped away tears. Her family remembered Rush as the quiet girl in high school, who loved to dance and cook and listen to the blues, and who was generous. “If she could help anybody, she would,” Veronica recalled. About a week before Rush got sick, she had whipped up turkey wings and potatoes for Veronica; they sat outside in the yard, the way they always did. “She was so excited about that house,” Veronica said. “She was telling me, ‘When I get that new house, you can come and spend the night.’ ”

The tragedies that ran alongside the pleasures in Rush’s life—the trailer, the sewage, her children’s health problems, and, eventually, COVID—came one after another, making a poor woman’s life devastatingly expensive. “Every time a door opened, another door was in its place,” Flowers said. “But she opened her private world to the public to expose what poverty really looks like. Now they have a face—they’ve seen it. It’s not something you can get out of your mind.” ♦