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We visited one of America's sickest counties. We're afraid it's about to get worse.

It’s not easy to stay healthy when your home is surrounded by pools of feces. And that’s only one of Barbara Thomas’s health problems.

I meet Thomas in the Washington Heights neighborhood, a patchwork of dusty streets surrounded by farmland, less than 5 miles from Ferriday, a small town in Concordia Parish, central Louisiana.

Every day, Thomas, who is 60, wakes up fearing rain. If the skies pour down on her brown-brick bungalow, the pools of wastewater that have gathered in her backyard will swell. On hot and humid days — of which there are many in Louisiana — they release the rank scent of raw sewage.

Barbara Thomas, a resident of Concordia Parish who hasn’t had a functioning sewage system for three years.
Carlos Waters/Vox

Thomas has been living with this fetid water in her yard for three years. It’s there because the oxidation pond on her street, which is supposed to clean the neighborhood sewage, is broken and hasn’t been fixed. When I visited, the pond was completely overgrown with trees, weeds, and grass. "People are throwing dead dogs and stuff in here," a neighbor, Vernon Smith, tells me.

If Thomas flushes her toilets or runs her sinks and shower, the runoff doesn’t enter a waste treatment facility — the bedrock of modern sanitation — it just flows right onto her land, where her grandchildren play. (She has to warn the kids to stay away from the water.) The sewer on her property also backs up and overflows, putting her community at risk for a range of illnesses — diarrhea, cholera — we typically associate with extreme poverty in developing countries.

This fact was not lost on Smith, who’s been suffering with breathing problems lately. "It’s the 21st century, and we still got our sewers backing up," she says.

Life in one of America's least healthy — and most forgotten — counties

When you drive up to Concordia Parish from nearby Alexandria, you pass through miles of rolling flatland dotted with green swamps, bales of hay, and pine and pecan trees. The edges of the roads are dusted with white plumes of cotton blown in from the fields — plantations where African Americans were once forced to work.

Concordia has another unique feature: It’s one of America’s sickest counties.

Louisiana ranks 50th out of 50 states for overall health in America because of its astoundingly high rates of heart disease, smoking, obesity, drug overdose deaths, diabetes, cancer, and infant mortality. And Concordia regularly features at or near the bottom of the list of Louisiana parishes for health outcomes, according to the County Health Rankings, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

Water tower, Condcordia, Louisiana.
Store front, Concordia, Louisiana.
Local newspaper, Concordia, Louisiana.
cigarettes, Concordia, Louisiana. Carlos Waters/Vox

Concordia is a place where infants die at rates that are three times higher than in Montgomery, a high-income county in Maryland with the best health outcomes. Concordia is a place where 40 percent of the adult population is obese, nearly half of the children live in poverty, and a quarter never finish high school. Concordia’s unemployment rate stands at 8.7 percent, and the median household income, at $31,800, is about 40 percent less than the national average.

As in other rural counties in America, people in Concordia have been dying earlier in recent years — but they were already dying young compared with national life expectancy. In the Bayou State, men and women can expect to live to 76, compared with the 81 years Californians live to on average — a gap similar to the one you’d find between the United States and a developing country like Colombia. It’s no stretch to call this patch of the Deep South one of the most shocking examples of how bad health can get in the wealthiest country in the world.

I wanted to go to Concordia to understand why it was so unhealthy, and what its future might look like under Donald Trump. (Concordia’s 60 percent white majority voted for Donald Trump.) While there, I spent most of my time in Ferriday, one of Concordia’s largest hubs, which is 75 percent African American. If health outcomes are poor all over Louisiana, they are generally worse among the African-American population.

I visited clinics, homes, hospitals, restaurants, even a local funeral home. I spoke to the current and former mayor, doctors, nurses, a pastor, health activists, a hospital CEO, and patients — poor and rich, white and black. Unlike many other rural communities that are sliding backward on health these days, Concordia wasn’t ravaged by trade or technological change. It isn’t buffeted by immigration. Globalization mostly skipped right over it. Instead, this is a low-income place that seems to be locked in time and forgotten by Washington, with a state government that’s been shredding its basic safety net.

Chart showing Concordia Parish, Louisiana, consistently ranks towards the bottom in almost all health measures

Most of the people I met here don’t feel served by President Obama, nor do they think Trump will help them. But some believe the president-elect could make their lives worse. Among Concordia’s many distinctions are a history of slavery and longstanding racial tensions and disparities. And the African Americans here are terrified about living under an administration that was endorsed by the Ku Klux Klan.

I left the Deep South with a worry in my gut: If the conditions these people were living in are already very bad, they are likely about to get much worse.

A problem with basic sanitation

The sanitation emergency in Washington Heights is not the only health issue Barbara Thomas is dealing with right now. As a girl, she shot herself in the foot with a gun by accident and has hobbled around ever since. (This winter, she’s finally going to have an operation to get that bullet removed.) She’s also been in and out of the hospital for her bad heart, and has already had four stents put in to improve her circulation.

"I’m not feeling good at all," she said, standing next to a small coffee table, which held a fly swatter, pill bottles, and two Bibles. For all these illnesses, she’s on disability, but sometimes, for extra cash, she picks pecans from trees in Concordia and sells them to local food stores for 80 cents a pound.

She and her neighbors have gone to the mayor of Ferriday, as well as the mayors of neighboring towns, local lawmakers, and the health department, for help getting their sewage system fixed. And they say no one will help them. They keep hearing that local officials don’t have the budgets to address the problem, that they should buy septic tanks (which Thomas and her neighbors can’t afford), and that their street is a private development and not the government’s responsibility (the owner of the development went bankrupt).

So the people of Washington Heights are left with their own feces spread around outside their homes.

sewage, Concordia, Louisiana.
One of the puddles of wastewater in Barbara Thomas’s backyard.
Carlos Waters/Vox

While extreme, this was one of the many examples of the state’s failure to provide the basics for people here.

The residents of Ferriday have long endured periods without access to clean water, relying on green water tanks shipped in by the Louisiana National Guard. They only got a functioning water treatment facility early this year, in February. This makes Ferriday a lot like other communities of color, which are more likely to be afflicted with environmental health hazards like lead poisoning, air pollution, and water contamination.

The state of Louisiana has also failed to regulate for public health in other key ways — it has some of the most permissive alcohol and tobacco laws in the country. It’s a place where you can buy booze in supermarkets, drugstores, gas stations, convenience stores, or even at drive-thrus. (Daiquiri stands selling frozen boozy confections with names like "DUI" to drivers are common throughout Louisiana.)

In my time in Louisiana, I could see no biological reasons that might explain why the people of Concordia — or Louisiana, for that matter — are sicker than in any other place in America. But I did see many clear political failures that explain how the people here wound up at the bottom of America's health rankings.

If Louisiana were a patient, "you would say the patient is dead"

If there’s one person Louisianans point to for the state’s current failures to protect the poor and public health, it’s the former governor (and onetime Republican presidential hopeful) Bobby Jindal.

The gravity of the damage Jindal wreaked on the health sector became clear when I met the medical director for central Louisiana, Dr. David Holcombe, who looks after public health for Concordia and some of the state’s other least healthy parishes.

One evening in Holcombe’s colorful home, brimming with artwork that he and his wife Nicole purchased from local artists, he pulled out a painting of his own. Holcombe had depicted Jindal as Lucifer. "I was not overly impressed by his compassion," he said. "I’m putting this delicately."

Former Gov. Bobby Jindal at a press conference in New Orleans on July 8, 2010.
Former Gov. Bobby Jindal at a press conference in New Orleans on July 8, 2010. While he was governor of Louisiana, Jindal refused to expand Medicaid and slashed other parts of the state’s safety net for the poor.
Joe Raedle/Getty

As governor, between 2008 and 2016, Jindal cut 30,000 jobs from the state’s workforce. When Holcombe took his post, in 2006, he had 121 employees for central Louisiana’s public health units, which act as safety nets for people who don’t have health insurance or money to pay for care. He’s now down to 83, after being forced to lay off nurses who cared for the poor patients.

Because Holcombe was worried about all the people who might fall through the cracks, he stepped beyond his role as medical director and started to care for patients himself. While he’s required to see three per month to keep his Medicaid affiliation, he now cares for up to 100. When I asked why a Californian son of a prominent dentist chose to practice medicine in Louisiana, he joked, "Mother Theresa only went to the Calcutta slums; she wouldn’t go to the suburbs of Washington, DC."

FLUKER,LA - MAY 5: Mary Alice Solomon (L), who is unemployed and illiterate, sits in her trailer as niece Shakira McKnight (R) sleeps May 5, 2009 in Fluker, Louisiana. Solomon's family couldn't afford to buy her glasses when she was a child and she never
Mary Alice Solomon (L) in her trailer in Fluker, Louisiana, in Tangipahoa Parish as niece Shakira McKnight (R) sleeps in 2009. Many unemployed Louisiana residents like Solomon were affected when former Gov. Bobby Jindal rejected $98.4 million of the federal government stimulus funds for the unemployment reform package.
Mario Tama/Getty

Jindal did other things to tear up Louisiana’s health safety net. He closed down the state-run hospital system for the poor, and replaced it with public-private partnerships, which have increased hospital costs for Louisiana. Since 2008, he nearly halved the staff of the Department of Children and Family Services and slashed funding for higher education by 44 percent.

An outspoken critic of Obamacare, Jindal refused funding to expand Medicaid in his state. (Medicaid and Medicare are the government’s safety net health insurance programs that provide care to the poor and the elderly. The Affordable Care Act broadened Medicaid eligibility to cover millions more low-income Americans, and offered states federal money to recoup the costs.) Jindal also declined nearly $100 million in federal government stimulus spending for the state’s unemployed residents.

At the same time, he introduced tax cuts for the rich and financial incentives to lure oil companies to Louisiana. Tax revenue from oil companies fell from $703 million in 2008 to $290 million in 2012. And, contrary to his bet on the industry, oil prices collapsed. So instead of attracting business and raising money for Louisiana, his scheme helped carve a massive dent in one of the state’s main sources of income, resulting in a budget deficit that reaches $2 billion.

"This was years of mismanagement by a governor who was more concerned about satisfying a national audience in a presidential race," Jay Dardenne, the lieutenant governor under Jindal, told the Washington Post in March.

By the time Jindal’s successor, Democrat John Bel Edwards, came to power in 2016, the state was facing a "historic fiscal crisis." On his second day on the job in January, Edwards introduced Medicaid expansion through an executive order, and more than 336,000 of Louisiana’s poor finally got health insurance.

The forthcoming Trump administration poses a threat to these people, too. Like Jindal, the president-elect is no fan of the Affordable Care Act. He’s run on a platform that promises to repeal and replace Obamacare, and he’s chosen as head of the Department of Health and Human Services Tom Price, who’s intent on carrying out that promise. (As Vox’s Sarah Kliff wrote, Price has a robust plan for how to repeal Medicaid expansion and replace it with nothing.) Trump has also endorsed Paul Ryan's plan to gut Medicaid.

The impact of the years of Jindal’s cuts will take some time to show up in the health statistics, but I could already see early signs of trouble. Emerson Slain, one of the men I met in Ferriday, was going blind in one eye from Type 2 diabetes. He had private insurance switched to Medicaid during Louisiana’s expansion earlier this year. Finding a doctor who would accept his new health plan delayed the eye surgery he needed by five months. Trump and Price’s stated plans put Slain, and the hundreds of thousands of people who recently got Medicaid in Louisiana, in limbo again.

Holcombe in his office.
David Holcombe is the regional medical director for central Louisiana, which includes some of the poorest and least healthy counties in the US.
Carlos Waters/Vox

Jindal’s Louisiana may be a preview of what’s coming to other vulnerable communities across the United States under the Trump administration, said Arlie Hochschild, author of a new book on Louisiana politics, Strangers in their Own Land. "Jindal bet on industry and didn’t protect the people at all. Just give them their tax money back. And never mind schools. And never mind hospitals. That is the dark bargain of Tea Party politics." She estimates that he cut $1.6 billion from hospitals and education.

"This is an example we should study up close now that Donald Trump will be our president," said Hochschild.

Holcombe, the regional medical director, is also bracing himself. "So much funding for public health comes from federal sources," he said. "If there’s really a change in direction ... it’ll affect maternal child care, nutrition, STDs, tuberculosis."

This in a state that’s long been stagnating. "When you look at the state health rankings — they were started in 1990 — they were like this for Louisiana," Holcombe said, holding his hand out in a horizontal wave. "If you were in the ICU, you would say it’s a flat line. You would say the patient is dead."

The past is the present on the Mississippi

Louisiana’s political climate has certainly exacerbated the poor health here. But if you really want to understand why Concordia is so sick, you have to look at its history of racial inequality. It’s woven into a map of the state’s health statistics today.

The four sickest parishes, including Concordia, are all clustered together, along the Mississippi River in the central and northeastern edge of Louisiana’s L-shape. "That area was just about as classic a Southern cotton plantation as you can find," Louisiana historian John Rodrigue told me. The Mississippi Delta was home to some of the largest slave holdings in the US — the quintessential model of a small white minority ruling over a large black, impoverished majority.

Map showing the health of counties in Louisiana. Some of the unhealthiest counties are located along the Mississippi River

The legacy carried into sharecropping (black people rented plots of land from white people in return for part of their crop), Jim Crow laws (which enforced racial segregation until the 1960s), and long-lasting gaps in educational and employment opportunities — as well as health outcomes — between black and white people.

When I went to meet another resident of Washington Heights, Robert Lewis Jr., who was in Ferriday’s hospital, he described a Concordia that’s been frozen in time. That day, he was getting treatment for a pressure ulcer on his feet, which were hanging from his wheelchair, wrapped in white gauze, and looking bluish.

Antibellum home, Concordia, Louisiana. Carlos Waters/Vox
Carlos Waters/Vox
A former plantation home in Natchez, Mississippi — one of the many grand houses that overlook the river and Concordia on the other side for a study in contrasts.

Lewis, who is 79, started his career as a water boy on a plantation run by white people; his mom and older sister worked in the "big house" as cooks for the plantation owners. Lewis has had a series of different jobs over his life, including working as a safety engineer on an oil rig, which landed him in hospital and on disability. (He slipped on a wet platform and broke his neck and back.)

"You cannot talk about the conditions in Ferriday [or] in Washington Heights," he said, "without talking about race, because race is a major problem." And he worried that the kind of treatment black people in the South get — as well as any fragile gains in basic civil rights — were about to slide back under Trump.

"It looks like at this point in time, [Trump] won’t be better for the country because the country is divided. ... It’s only going to make those racist skinheads, the KKK come out," Lewis said. "The racists feel like they have a man in office who is supporting 'em, backing 'em up."

Devils Walking, a book about murders by Klansmen on the Mississippi in the 1960s, was spread open on his hospital table that day. Lewis and his family were nearly counted among the casualties. A civil rights campaigner, Lewis was thrown in jail and charged with aggravated battery — after Klan members bombed his house in November 1965. The cops justified the prison sentence because he was holding a gun when they showed up, according to the record in the book.

Concordia, Louisiana
A Trump sign just after the election in Concordia, Louisiana.
Carlos Waters/Vox

His past grounds the present in Louisiana. A steady stream of boys and men, most of them black, help keep Louisiana’s prison industry thriving. Louisiana has been dubbed "the world’s prison capital" with the highest per capita incarceration rate, nearly five times Iran’s incarceration rate, 13 times China’s, and 20 times Germany’s, according to a Times-Picayune investigation.

Louisiana also has the longest prison sentences in America: It’s a place where a two-time car burglar can face 20 years in jail without parole. It’s home to Angola, the largest maximum-security prison in the US, located 70 miles south of Ferriday. Like the hospitals here, prisons have been increasingly privatized over the past 20 years. So there are economic incentives to keep people in jail for as long as possible.

Mass incarceration breaks up families and makes communities sicker, Duke researcher Susan Reif told me, contributing to the racial health disparities. Consider HIV. "Incarceration is a significant driver of HIV and STDs," and when you have people coming in and out of jail, it disrupts sexual networks, she explained. Prisons have higher rates of STDs, and when prisoners return to the community, they can bring with them any diseases they may have picked up while incarcerated.

Seventy percent of those diagnosed with HIV in Louisiana are black, and the state has the highest rate of HIV in the US. In Concordia, black people have about four times the number of chlamydia and gonorrhea infections as white people.

Earlier in the week, Louisiana’s racial history came up in a meeting at Holcombe’s central Louisiana health unit in Alexandria, an hour and a half drive from Concordia. Holcombe and his colleagues gathered around a plastic table in a beige meeting room, and talked about how Louisiana has the lowest rate of breastfeeding in the country (only 57 percent of mothers have ever breastfed, as opposed to 80 percent in the US overall). Among African Americans, only 30 percent breastfeed their babies.

"I ask every woman — did you breastfeed?" Holcombe explained. The women tell him they don’t want to. The reason: the memory of black nannies breastfeeding white children, an institution of the antebellum South. "People are very much aware of that [history]," he said. "It’s still in that community consciousness."

Infant mortality is twice as high among black people as it is among white people, all over Louisiana. Black people in Louisiana are nearly three times as likely as whites to be poor. Nearly 30 percent report being in fair or poor health compared with 19 percent of whites. Of all the states, black people in Louisiana have the highest mortality rate — 1,017 deaths per 100,000 population — which is double the death rate for black people in Idaho or Hawaii. So Louisiana, with its rock-bottom health outcomes, is also an extreme example of the black-white health gap.

"You have an African-American population that was subservient during the times of slavery. It was subservient during the time of Jim Crow," Holcombe said. "These were sharecroppers who worked on other people’s land. Now we’re in a new era — but there’s still a large disenfranchised population living in these areas that track right up the Mississippi River."

Things are going to get worse — and not just for Concordia

When I asked Vernon Smith, a resident of Washington Heights, why she believes the sewage system in her neighborhood has gone unfixed all these years, she put it plainly: "It’s majority black and low-income."

"I know because another neighborhood — called Panola Woods — that’s mostly white, they have a sewer system, and they don’t live too far from me," she added.

Smith doesn’t think the government is going to answer the calls of her neighbors in Washington Heights anytime soon. So she’s turning to her faith. "I think God is going to send someone to help us."

Smith has good reason to feel unheard. Much has been made of the plight of the white working class in America’s Rust Belt who are grappling with economic troubles wrought by globalization, and changes in trade, and technology. But not a shred of attention during the election went to people like her: the poor black working class of the South who, arguably, have always been left behind.

Chart showing the widening gap in years of life lost in rural and urban America

Concordia, and in particular the African Americans here, has been on the losing end of the American dream for — forever. And no one is talking about how to make life better for them. Echoing Smith, Holcombe said, "We have been living with bad outcome statistics and horrible disparities in Louisiana for decades. The amount of attention paid to a problem is generally proportional to the population's economic impact and educational levels." He added: "When blacks die at the same rate as whites, we know we will have made some real progress."

The gap between black and white mortality seems to be closing in recent years, but in absolute terms, African Americans, particularly in Louisiana, still have worse health outcomes overall compared with whites. They are more likely to die young. They are more likely to experience chronic disease. They are more likely to lack health insurance. They are dealing with infinitely complicated, pervasive, and longstanding problems, yet they've gotten lost in the conversations about struggling white communities in Pennsylvania and Ohio.

"I’m not that pleased with President Obama," Gene Allen, the African-American two-time former mayor of Ferriday, told me, "because this is one of the poorest regions in the nation. President Obama, [he’s] never been in this area."

Former Mayor of Ferriday, Gene Allen.
Former Ferriday Mayor Gene Allen. "I’m not that pleased with President Obama because this is one of the poorest regions in the nation. President Obama, [he’s] never been in this area."
Carlos Waters/Vox

Allen was tired when I met him, and had a gray pallor. He was still recovering from a quintuple bypass surgery on his heart. But he wasn’t thinking about his health that day. He wanted to talk about being left behind. "Trump said something that was very important: We never got nothing from the Democratic Party either," Allen told me.

Allen’s major concerns were the poor economic prospects for his community and what he called the "plantation mentality," which he believes stops African Americans in Concordia from expecting much for themselves. The fixes for Concordia’s stagnation, in his view, would be a strengthening of the social compact between Concordia and the government. "We need education here in these rural communities," he said. "Our school systems are poor."

What Allen didn’t acknowledge is the difficulty of implementing social policies — more funding for early childhood education, a stronger social safety net, job retraining — in states with Republican governors who, like Jindal, believe in minimal government intervention.

He also didn’t acknowledge that we’re entering a period when the federal government is poised to further weaken the basic safety net.

"People [who voted for Trump] don’t want [a strong safety net]," said Princeton economist Angus Deaton. "The safety net makes them really angry. And that’s one of the things that makes the whole thing so hard to deal with."

Dilapidated house, Concordia, Louisiana.
A home in Concordia, Louisiana. The median household income in the parish is $31,800, which is about 40 percent less than the national average. Nearly half the children in the parish live in poverty.
Carlos Waters/Vox

The majority of Louisianans, and the majority of Southerners, voted for Trump, and Trump has made no secret of his belief in privatizing public goods, including prisons and health care. He has said he thinks privately-owned prisons "work a lot better" than public ones, and he’s expected to expand them during his tenure. His pledge to gut Obamacare would take health insurance away from millions of Americans.

It would require a herculean effort — and real political will — to turn things around for Concordia. But it won’t take much to ratchet up the suffering. Cutting Medicaid, inflaming longstanding racial tensions, throwing more young black men in prison — this would hurt people here. And if Trump runs the country in the manner many anticipate, the people in Concordia will be among his first victims.

Editor: Eliza Barclay
Photographer: Carlos Waters
Photo editor: Kainaz Amaria
Graphics: Sarah Frostenson