Conclusion What Has Changed?
This project hit the ground running in the spring semester of 2015 and continued for ten consecutive months of field research. I returned to Kern County on occasion to reconnect with participants but felt that I never quite stayed long enough. During the time between analyzing the research findings and later drafting this book, I met unexpected moments to reconsider what my work proposed. For example, my daughter’s severe health crisis placed us in the hands of medical professionals including pediatric nurses, doctors, and specialists all of whom provided sincere and thorough searches for successful therapies. One year later, the COVID-19 pandemic erupted globally and revealed the socioecological determinants of health compromising people’s immunity, including a national housing crisis that saturated living quarters with infectious disease. The murders of George Floyd, Breonna Taylor, and others by police officers mobilized a global outcry against virulent policing in ways that had been unseen in my lifetime. Racial health inequalities and environmental injustice were strong sources of oppositional social movements. Coming out of the pandemic lockdowns and global civic unrest, I reembarked on the mundane routines of my research with the certainty that I was stepping into a more empathetic and brighter future. But the horrors of the Robb Elementary School shooting in Uvalde, Texas, unfolding live on national television gave me reason to pause. The school shooting of mostly brown children revealed the systemic failures of a racist institution at the U.S.-Mexican border. In one day, state actors performed suddenly the social neglect and near abandonment that racial capitalism perpetrated slowly but surely over a century. They just let people die. While part of me felt deeply that nothing had changed in the seven years that I had spent researching and writing this book, I could not resign myself to such despair. I learned from activists in Kern County that we cannot leave; we must lead. We must hang on tightly to the possibilities.
Valley fever affects people of all races, classes, ages, and gender identities. It catches everyone unexpectedly, including people who are only an arm’s length away from the best health insurance and primary care physicians. But it is also true that there are differential health pathways, outcomes, and chances of contracting and recovering from valley fever that have little to do with behavioral or biological explanations. As COVID-19 illuminated, there are underlying racial narratives and spatial legacies that both undermine the best intentions of experts and compromise patients’ immunity and subvert their chances of recovering long before they encounter toxic fungi spores. Throughout this book, my efforts have focused on hearing from community activists, abolitionists, farmworkers, and former prisoners. I amplify their broad approach to resolving valley fever precisely because they have placed their trust in our current health care system, and it is failing them.
Unlike a ravaging disease, medical experts classify valley fever as an orphan disease both because its impacts are not felt nationally enough and because proposed biomedical and pharmaceutical solutions are insufficiently lucrative (Arizona Valley Fever Center for Excellence 2024). In the political ecological sense, valley fever is a surplus disease within a specific geography and with a propensity to be exploited later. Biomedical research is cashing in on it. The University of California Research Initiatives (n.d.) were awarded $3 million for valley fever studies in 2018. The National Institutes of Health (2022) funneled $4.5 million for similar studies to three research institutions: two University of California campuses and the University of Texas, San Antonio, in 2022. While valley fever biomedical scholars look to better understand the physiological and climatic workings of valley fever, they are less inclined to examine the place-based social and environmental relationships shaping the outcomes and chances of recovery. Medical sociologists, anthropologists, and epidemiologists have shown that the strategies targeting biomedical solutions also conceal the exact social and environmental structures that generate the racial disparities in health (Roberts 1998; Briggs and Mantini-Briggs 2002; Krieger 2011). As Charles Briggs and Clara Mantini-Briggs (2002) find, treating the symptoms of a disease without addressing the social structures that cause and exacerbate it can increase the chances of recidivism and reinfection. Valley fever’s racial health outcomes expose the social and environmental fault lines that are unrepaired in endemic geographies and show how social decisions make people arbitrarily vulnerable to this disease.
The painful stories of farmworkers and people who are incarcerated in endemic facilities are used for the promotion of scientific research grants and developments. By the same strategy, however, their voices and observations are marginalized as uncredentialed, unintelligible, and unscientific. Like the lamentable category of the “orphan disease” attached to valley fever, where vulnerable groups are “regrettably” ill but not attended to, the sufferers are forced to wait for promised interventions by experts. The ways in which vulnerable groups experience valley fever are not only disingenuous but dangerous. Waiting for an adequate diagnosis at a hospital, clinic, or prison facility leads to multiple fruitless visits and unnecessary suffering. Paying the unaffordable prices for treatments perpetuates reducing doses and scrambling for cash, while incarcerated people find prison staff arbitrarily switching prescribed drugs to save money. This is preventable. The flaws of the red tape attached to bureaucratic social insurance and the failures of promised safety nets can be fixed. The lack of transitional medical care upon release from prison requires better programming. The pressure on the lives of community caregivers who shoulder the burdens of the inadequate social conditions and medical neglect can be alleviated across the state. What I propose is to think of the stories in this book not as anecdotal accounts to legitimate research funding but, instead, more as warning signs about the need for generating collaborative community-based participatory action research and social medicine practice in the service of democratizing medical care and collective health.
The people who contract valley fever while incarcerated or while working in agriculture are generators of creative perspectives about disease and solutions for it because they have the highest stakes in their recovery. The decisions that they make have direct consequences for reducing or improving their life outcomes. As gleaned from the interviews that they shared with me, most participants understand and highlight the social and environmental dimensions of the disease. Their observations and conclusions shift the analysis away from allegations about patient noncompliance, individual depravity, dysfunctional behaviors, and genetic predispositions for disease and toward what Sze (2007) describes as the social and environmental harms affecting the broader health of the community. The participants describe how the 3p’s worsen their prospects of recovering from valley fever, echoing what Rose Braz and Craig Gilmore (2006) found in their study of the most pressing problems facing Central Valley youths. None of these are natural or inevitable. Rather, these conditions stem from farming and resource extraction methods that, to channel profits to owners and investors, deepen differential access to pathogens among the differentially situated people and places. Without addressing the socioecological conditions facing vulnerable groups, the strategies and technologies aimed at reducing valley fever can produce the very problems they purport to remedy. The proposed medical solutions rooted in the hegemony of an individualized biomedical model of health are too narrow. They do not begin to address the political dynamics that determine who is made to seem disposable, displaceable, and deportable. They fail to engage with how the violent policing of nonwhite people and nonwhite communities perpetuates the hoarding of private wealth and holds nature hostage. They maintain the structural and symbolic violence that participants describe feeling in their bones and joints when they return to work while sick with valley fever, when they are exposed to dangerous air quality, and when they sacrifice their well-being by reducing their costly antifungal prescriptions or remaining silent while facing medical neglect because of potential deportability or incarceration. People at the grass roots craft strategies for recovery against all odds. They present clear visions of what needs to be done and how experts can help find rather than dictate paths toward better health.
Community organizers address both social and environmental issues as they mobilize to promote health, safety, and self-determination. In Chapter 1, the EJ community organizers described working collaboratively and collectively across partnerships, volunteers, and sometimes regulatory agencies. They accompanied people vulnerable to the hypersurveillance of the carceral state and engaged with the environmental health burdens they faced. They generated collective strategies and tools needed for establishing healthy social ecologies.
The long history of racial capitalism in the Central Valley has entailed treating nonwhite laborers and their communities as exploitable and deportable in ways that also deprive them of health care and healthful conditions. As we saw in Chapter 5, nonwhite laborers and their communities have paid a terrible price for the racist sanitation policies and segregation practices over the years. Yet, these conditions have almost always provoked the forging of powerful cultures of opposition, resistance, solidarity, and mutuality as mechanisms for self-defense, self-definition, and self-determination. As we saw in Chapters 2, 3, and 4, community solidarities and mobilizations have interrupted the capitalist imperatives of agribusiness at times, while also challenging the inadequacy of the state’s health programs. Today, the collective degradation experienced by farmworkers and people who are incarcerated in Kern County calls for a socioecological approach that treats health care as a human right rather than as an artificially scarce commodity to be rationed out unfairly and unjustly. Generating healthier lives requires leadership and collaboration that are willing to address the combined environmental and social risks percolating in a moment of unpredictable danger.
What has changed over the years is that the institutions contributing to unequal health outcomes are now faced with new challenges. For example, the carceral conditions of endemic facilities were contested in valley fever court cases. No matter the crime, confinement should not amount to cruel and unusual punishment. Yet, during the COVID-19 pandemic, the health outcomes of prisoners depended on whether carceral staff had adequately addressed the conditions of confinement. The Marshall Project (2021) reported the weekly cases of COVID-19 infections in federal and state prisons across the country due to a decentralized government reporting system. With the help of the Associated Press, they found that California state prisons and the Federal Bureau of Prisons had a similar number of cases (49,395 vs. 49,324). However, California state prisons had twice the rate of infections between March 2020 and June 2021 compared to the federal facilities, approximately 4,199 per 10,000 prisoners compared to 2,866 per 10,000 prisoners, respectively. Nationally, at least 2,715 inmates died from COVID-19 through June 2021. California was the state with the second greatest number of reported deaths, as approximately 227 people who were incarcerated died prematurely. Drawing on letters written by prisoners, the researchers from the Prison Accountability Project (2023) in the UCLA School of Law found that people incarcerated in California faced medical abuse, unsanitary conditions, and unsafe protocols. The letters showed how prison staff, including medical personnel, did not adequately clean medical supplies and did not comply with mask mandates, recklessly endangering the housed population. Prisoners report recovering from COVID-19 amid leaking roofs, mold, and vermin in their cells. They lacked access to basic hygiene and sanitary products. Solitary confinement became a regular method for isolating the infirm prisoners. Prison staff also cut down on visitors, prosocial programming, and recreational activities, which contributed to higher reports of mental health distress and violence among the incarcerated and at the hands of correctional officers. While COVID-19 was an unprecedented global health emergency that ravaged through carceral facilities, prisoners have long reported to the courts related abuses and neglect. Valley fever court cases have highlighted the deliberate indifference imbued in carceral facilities for twenty years. Historical documents further suggest such indifference was prominent during World War II with the Japanese American detention camps. Collaborations among the most vulnerable accompanied by trained experts and community leaders have generated eye-opening reports that reveal the urgent need for new approaches.
Disasters rarely happen in isolation. While valley fever cases are rising due to droughts from climate change, prisons are also facing natural disasters from floods, heatwaves, and wildfires. The incarcerated populations have become especially vulnerable to climate change disasters. According to the CDCR, the state now has thirty-five conservation camps located across twenty-five counties designed to provide nonviolent offenders with training to fight wildfires. The inmate firefighters make up about 30 percent of the wildland fire crews and are working alongside trained CAL FIRE employees (McCann 2023). The incarcerated people fighting wildfires face great chances of sustaining physical injuries. Investigative news reporters for Time magazine filed a written request under the Freedom of Information Act and found that inmate firefighters were four times more likely to suffer injuries, including cuts, bruises, dislocations, and fractures, and eight times more likely to be injured from inhaling smoke and dangerous particulates compared to professional firefighters (Vesoulis 2018). While fighting fires can provide California prisoners with transferable skills and an expunged record, it does so with hidden costs for prisoners’ health.
The stories presented in this book are fused together not by a fungus that hurls its toxic spores at workers outside in the fields or people confined inside carceral facilities; they are joined together because of the logic and vicious structures of racial and spatial domination that are ingrained in industrial agriculture, the carceral state, and the legacies of public health and medicine inside and outside of carceral facilities. When I think about the possibilities of a better future, I am reminded of the radical health movements focused on healing the socioecology. There are powerful alternative legacies that continue to survive in the stories told about the People’s Free Medical Clinic and the Terronez Clinic. The vision to promote self-determination fifty years ago seems ever more relevant to the pursuit for health justice today.