Close quarters: Overcrowding fuels spread of COVID-19 among essential and service workers

Health experts say this creates a perfect storm for the coronavirus: People crowded together in homes at night and spending days working on the frontlines, exposed to a lot of people both at work and at home.

“Some people are affected more and it does reflect how unequal our society is,” said Justin Feldman, a social epidemiologist at the NYU School of Medicine Department of Population Health.

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Isidoro Flores Contreras hands a customer a bouquet of sunflowers. He credits Herbalife with helping him walk again, and he believes it will also keep him safe from the novel coronavirus. May 15, 2020. (Photo: Vernon McKnight / The Salinas Californian)

Hot spots for overcrowded homes are spread throughout urban and rural California, including the Salinas Valley, South Los Angeles, Oakland and desert towns near the US-Mexico border.

Monterey County, home to many farmworkers, leads the state in overcrowding with one in every seven households crowded. In Monterey and San Benito counties, nearly one in ten households, the highest rate in the state, are both overcrowded and include an essential worker.

The Alisal, a neighborhood in Salinas, is filled with farmworkers and service workers, like Flores Contreras, who live doubled or tripled up so they can afford to pay rent. During a pandemic, though, this can be deadly.

Crowded communities hit harder than others

At night, Flores Contreras beds down in the living room of a two-bedroom house in the Alisal, a Mexican and Mexican American community where 61,000 people are squeezed onto a parcel of land less than three square miles that was annexed to Salinas in 1963. 

Tens of thousands of Alisal’s residents are farmworkers, considered essential workers during stay-at-home orders. The median income in the Alisal is $49,659 and 22% live in poverty, according to Census data. 

Farmworkers are greatly overrepresented among those diagnosed with COVID-19. In Monterey County, the Alisal is the center of the coronavirus outbreak. About 31% of the patients in Monterey County diagnosed with COVID-19 live in the 93905 ZIP code, where Flores Contreras resides, even though just 14% of the county’s population lives there.

Many live doubled or tripled up, as he does, which heightens the risk of transmission. 

Flores Contreras pays $300 a month in rent — equivalent to a week of his earnings. Two couples rent the bedrooms. There’s no way they could isolate themselves at home if someone caught the virus, Flores Contreras said.

The Census Bureau defines overcrowding as a home with more people than rooms, while a home with more than 1.5 people per room is severely crowded. 

California’s overcrowded homes are due, in part, to the sky-high cost of living. Nearly a third of California renter households spend more than half their income on rent. Yet despite the recent surge in housing costs, the state’s rate of overcrowded homes has held steady since 2009, according to Census data.

COVID-19's impact, 22 miles apart

In Monterey County, the link between crowded housing and COVID-19 is clear. Comparing its eleven ZIP codes, the five areas most heavily burdened by the virus had 2.5 times the rate of crowded housing than areas with the least people diagnosed, as of June 8.

In Salinas, nestled between two mountain ranges and rooted in fertile produce fields, about 19% of homes are crowded. Narrowed to the 93905 ZIP code, where the Alisal lies, 31% of homes are crowded. An average of 4.5 people live in each household.

Drive 22 miles west, and you’ll arrive in Carmel-by-the-Sea, a wealthy live-oaked, cobblestone-paved hamlet of fewer than 4,000 people on the edge of the Pacific. The streets are narrow, the properties are worth millions of dollars and often walled off from view. 

Here, the median income is almost $91,000. Just 3.9% of homes are crowded, a stark contrast to the numbers squeezed into the Alisal. 

Fewer than five people (the county’s reporting cutoff) have been diagnosed with COVID-19 in Carmel-by-the-Sea, compared with 233 in the Alisal’s ZIP code as of June 9, according to the Monterey County Public Health Department. 

Models created at the Children’s Hospital of Philadelphia and the University of Pennsylvania evidence that overcrowding and population density are the two most important factors when it comes to the spread of the virus.

“Measured against a number of local factors, we saw that strict social distancing policies and low population density...were all important in slowing the spread of this dangerous virus,” said Dr. Gregory Tasian, faculty member at PolicyLab and an assistant professor of epidemiology who worked on the models.

In New York City, the novel coronavirus’ toll has been greater in overcrowded neighborhoods.

An April analysis of New York City emergency department data found neighborhoods with higher rates of residential overcrowding tended to have higher increases in emergency department visits for influenza-like illness in March compared with the previous four years. 

Feldman, the NYU social epidemiologist, said even though the data shows a correlation, not causation, the result makes sense.

“What we've been generally seeing is very high transmission rates within a household. Once one person gets it, it’s very easy to transmit to other people in their household. You can imagine if there's less space, if people have to share room, it's going to be really hard to isolate people,” Feldman said. 

He also observed that neighborhoods with more foreign-born residents had higher increases in visits for flu-like symptoms in March, as did higher poverty neighborhoods and neighborhoods with more Latino residents. This, too, he said is grimly logical.

“And who do we know is living in crowded housing?” asked Feldman.  “People who are lower income, they’re more likely to be immigrants, more likely to have to go to work.”

Essential workers stuffed into homes

Social distancing is especially hard for essential workers, who must leave their homes regularly to keep the rest of the U.S. fed and sheltered.

About two-thirds of Californians who live in crowded homes —about 4.1 million people — are essential workers or live with at least one essential worker. More than 158,000 people over the age of 65 live in a crowded home where at least one member is an essential worker.

According to an analysis by the Public Policy Institute of California (PPIC), essential workers are more likely than nonessential workers to live in overcrowded housing—16% versus 12%. More than a third of California’s labor force works in essential jobs that mean they must be physically present, such as farming, fishing or forestry. And almost a third of farmworkers and people who work in restaurants live in overcrowded homes. 

“Compared to non-essential workers, they are at higher risk of infection because they continue to circulate among others despite the shutdown,” wrote PPIC researchers Marisol Cuellar Mejia and Paulette Cha.

Crowded housing also puts Latinos at higher risk. Latino households are nearly eight times as likely as white households to be crowded. 

More than three out of every four Monterey County residents who have been diagnosed with COVID-19 are Hispanic or Latino, a much bigger percentage compared with the county's Hispanic or Latino population (59%), according to the Census Bureau's American Community Surveys data. About 40% of people diagnosed work in agriculture. 

Oakland is another place with wide disparities in infections and housing conditions. In the ZIP code that contains the affluent Montclair neighborhood and Piedmont city, just 1% of homes are overcrowded. Fewer than one in every 1,000 residents tested positive for the coronavirus there. But across town, in majority Latino neighborhoods like Fruitvale, the infection rate is six times higher and 21% of homes are overcrowded.

The same pattern shows up in Fresno County. Mendota has the county’s highest infection rate and its most overcrowding. On the other end of the spectrum is Clovis, which has 21 times more white people than Mendota and just a quarter of its poverty rate. It has both the lowest rate of residential crowding and the lowest burden of disease.

Isolating in L.A. 

At the low-income health clinic where Dr. Efrain Talamantes works in Los Angeles, most patients arriving with coronavirus symptoms are Latino, low-income and live in crowded housing. Many are house cleaners, construction workers, grocery store workers and caretakers of the elderly.

Talamantes is the medical director of the Institute for Health Equity at AltaMed Health Services, a health clinic with 35 sites throughout Los Angeles and Orange counties that serves more than 300,000 people.

He said he prefers not to tell his patients who live with a lot of other people to isolate themselves.

“Patients who live in places where there's no privacy… when you tell someone to get in a room and stay away from their loved ones, it's almost nonsense to them,” said Talamantes.

He recounted the story of a grocery store worker with concerning symptoms. She needed to go back to work because her partner had been let go. He told her she had to stay home, and asked if it was possible for her to isolate from her partner and three-year-old child, who loves to climb all over her. 

The answer was no. 

In their small apartment, there was nowhere to isolate. She had no family who could take her in and no money to rent a hotel room.

In cases like that, Talamantes tries to emphasize hand hygiene and wearing a mask. 

He said that patients are often just as worried about staying housed as they are about the virus, and fear being evicted if their landlord finds out they’ve contracted COVID-19.

He frequently finds himself pairing medical advice with information about renters’ rights, including the statewide moratorium on evictions for people affected by the virus.

“What we’re most concerned about is how this virus is going to exacerbate inequalities in communities where we've made so much progress since the last recession. It really takes a toll on the communities they’re in,” Talamantes said. 

In Los Angeles, as many as two in every five households are overcrowded in some neighborhoods. The areas most heavily burdened by COVID-19 had twice the rate of crowded housing as the areas least hard hit.

Ricardo Hernandez and his family of five live in West Adams, a neighborhood in South Los Angeles where 83% of residents are Latino or black, in a two-bedroom, one-bathroom home that his parents purchased years ago. 

In West Adams, about 17% of households are overcrowded, and there were about seven coronavirus cases for every 1,000 residents in late May, almost three times the statewide rate of 2.6 per 1,000.

For months, Hernandez, his wife and two sons shared one bedroom, while his mother, a diabetic, and his brother, a kidney transplant survivor, shared the other. Because of their health problems, they are both highly vulnerable to severe effects if they are infected with the virus.

“We remove our shoes before entering the house, we disinfect door knobs often and we wash our hands as much as we can,” said Hernandez. 

Only Hernandez was working, but during the stay-at-home orders, his earnings as a marketing manager were “enough to pay our bills, credit cards, groceries and other basic necessities.”

Should one of them get the coronavirus, the family plans to isolate the infected person in one of the bedrooms, and disinfect the bathroom every time it is used. 

Although it was hard, Hernandez said it had been beneficial to stay at home together during the pandemic. 

“I feel this is a mental, moral cure and a peace of mind, because we know how we are doing when we see each other,” he said.  

‘I have to just follow the rules like everybody else’

For California’s farmworkers, crowded housing is the norm, whether it’s a rental unit, a farmworker shelter, or employer-provided barracks-style housing.

On the northern edge of the Salton Sea in Riverside County, Gloria Gomez runs the Galilee Center, a boarding house for farmworkers who stay in Mecca for just months at a time, a pit stop on their journey around the state to pick fresh produce year-round. 

“‘La corrida,’ they call it,” said Gomez. (In English, “the circuit.”) 

Gomez, who worked as a farmworker as a child, started Galilee Center ten years ago because farm workers were sleeping in cars or in parks.

The pandemic, however, has completely changed their operations.

The center expanded its hours to 24 hours a day, provides three full meals a day instead of two and stopped charging farmworkers the usual $7 a day for room and board. Staff moved the beds six feet apart, reduced the number of residents and cleans the dorms every two hours to prevent the spread of the virus. 

“I said to (the farmworkers) ‘We’re here to save your lives,’” said Gomez. “‘Please save our lives by staying in our place when you are not working,.’”

Applicants for financial assistance there have exploded; The center is spending $20,000 a month when it used to spend $2,000. And nearly 700 families showed up to the center’s food bank, more than three times the number before January. Galilee Center is struggling trying to find enough donations,