Chapter 3 Fugitive Spaces in the Carceral State

Dr. Elijah

Before prison, Elijah was a licensed medical doctor, knowledgeable about diseases and the treatments that might aid a failing bodily system. Today, Elijah is immobile and can only speak for short periods of time due to valley fever damaging his lungs and other parts of his body. He requires a nurse at his bedside for most of the day. Elijah’s son George now serves as his legal guardian and was the interlocutor during our interview over the phone.

Dr. Elijah was transferred in 2009 from a Los Angeles County jail to Taft Federal Prison (TFP), which was operated by a private contractor. In hopes of maintaining his health in good shape while incarcerated, Elijah spent as many as four hours a day walking around the track and field at the prison. He was never informed about the dangers of dust or of an outbreak of valley fever upon his arrival. Later, the warden admitted in court that there were “more cases of diagnosed valley fever at Taft than in all other federal prisons combined” (Burton 2017). At the first sign of his body’s deterioration, Elijah sought medical help from prison staff, but he was turned away. George describes his father’s initial pleading for help: “He would request medical attention several times, but it was just Tylenol or something. I think he was taking quite a bit of Tylenol. . . . His friend Rosa, who is now his caretaker, would visit him very frequently and she noticed that he wasn’t doing so well. She thought he might have liver jaundice or something like that, but we weren’t sure.” George could not estimate how long it took before his father’s health worsened; however, he points out that “it was a steady decline” and that “he developed all of the symptoms while at Taft.” George was informed that his father was suffering from valley fever after Elijah was sent and admitted to a Bakersfield hospital.

At some point he had collapsed, and I don’t know if they took him to the hospital right then and there or what exactly transpired. At some point he was taken to the local hospital, I believe it was in Bakersfield. Yeah, he was in the emergency room, and I guess he was in a state of subsist, where the infection ran all over his body and right through [inaudible]. They did a spinal tap and there was a lot of pressure built up in the cerebral fluid. When they did a spinal tap, they relieved a lot of the pressure. So, he immediately felt better. His hole was so closed that he had hydrocephalus [buildup in the brain’s ventricles]. I went to visit him in the hospital, and he was almost one hundred percent better. . . . they said he caught valley fever. They diagnosed him with Coccidioidomycosis fungus.

The prison staff prevented Elijah from entering treatment right away. Utilizing his training as a medical doctor, he made his complaints clear and concise, and they should have resulted in a logical diagnosis and treatment. Elijah’s medical expertise did not make a difference in his advocacy for adequate care.

Less than a year after contracting valley fever, Elijah was transferred to Terminal Island in Long Beach due to the poor status of his health. He spent “a lot of time in the hospital.” While at Terminal Island, George relates that his father relapsed with all the same symptoms he had endured at Taft:

So, he was scheduled for release back in 2012, I believe. But because of his health condition I think they ended up transferring him at that point to Terminal Island in Long Beach, California. He was there, and they had a lot of trouble because they didn’t transfer over his medical records or his medication. He really wasn’t doing so well over there. And they made him walk around like all over the place and he collapsed. He was having problems with memory. He had to go to the hospital numerous times, cutting what shut his brain to keep the fluids from building up, the brain tissue or the meninges. He was in the hospital here and there. He saw doctors and infectious disease specialists. . . . The staff wasn’t entirely briefed about his condition. He wasn’t given care, appropriate care. . . . They ended up keeping him an extra four months when he got released. His original sentence was four years, but I guess good time credit resulted in a total of three years. He stayed a total of three and half years. But he spent a lot of time in the hospital while incarcerated for a few months.

The failure to transfer Elijah’s medical records to Terminal Island, where he was supposed to recover from valley fever, sent Elijah’s health on a downward spiral. No one at Terminal Island knew he had contracted valley fever until he relapsed with the same symptoms. Although the prison health authorities eventually attempted to restore Elijah’s health, their belated attention and inadequate care caused irreversible injuries. Not only did Elijah complete his sentence for the crime for which he was convicted, but he was further punished with physical immobility, speech impairment, and a lifetime dependence on medication, a caretaker, and a legal guardian to make decisions for him. Elijah lost any prospect of continuing his career now that his physical health was permanently compromised. Under these disastrous social conditions, it is no wonder why new channels of communication are necessarily created by people who are incarcerated. These channels reveal a demoralizing punitive prison health system spanning across both federal and state prisons and the necessity for its victims to craft their own health strategies.

Rob

Rob was chained to a bed for two months while nursed back to good health at the Coalinga community hospital. Rob was sixty years old when interviewed in 2015. He contracted valley fever less than a decade earlier at Avenal State Prison (ASP). He elaborated on the nightmare of securing proper medical care at ASP:

So, you know when I caught it, it was strange to me. . . . I went to the [prison] doctor and the doctor he’s sitting back on the door. He didn’t tell me nothing about it. He just said, “you probably have pneumonia” or something like that, and that “you’ll be okay,” right. And all the inmates kept telling me “Rob you got valley fever, man. You know that’s what’s riding this prison here. There’s a lot of people who’ve been here and gotten sick.” Some of them had valley fever to the point that they were walking like they had polio. . . . I went from 250 pounds to 190 pounds in a week and a half. . . . The next thing I know I fell out inside the doctor’s office, and they rushed me to the hospital. I stayed in the hospital for like maybe a couple of months trying to be nursed partially back to good health. . . . I was just, you know, I was stunned by how the doctor, right, he knows the symptoms of valley fever because he has dealt with so many people there, the prisoners that had caught the valley fever. So, I don’t understand still why, how come this guy, the doctor, act like he don’t know what’s going on. . . . Things never went right after that. . . . I asked them to ship me out of there because the place was destroying my health. . . . I think I was 52, 53 years old at the time. You know, I never had high blood pressure. I’ve never been diabetic. I never had anything wrong with me, period. And I went, I did that there, and I fell sick.

Rob’s temporary punishment for a crime became a lifelong sentence characterized by deteriorating health and a slow yet violent demise. He now relies on medication to keep the cocci infection under control, as well as to regulate other parts of his body affected by the disease. Within six weeks of leaving the hospital and returning to ASP, he was readmitted to the Coalinga community hospital. Rob’s severe symptoms reemerged because the prison medical staff failed to provide adequate medication. Prison health authorities changed his prescription to a less expensive formula as a cost-effective measure. Prison staff deliberately ignored the specific instructions for treatment given by the Coalinga community hospital physician. Rob wrote to several attorneys to determine whether he had a legal case against the staff who wrongfully altered his medicine. He filed a lawsuit charging the ASP authorities with negligence for deliberately ignoring the treatment plan devised by the medical experts. Rob was represented in a class action lawsuit and in an individual litigation case. He is one of the nearly one thousand inmates and former prisoners who sought legal redress due to the CDCR’s inadequate provisions against valley fever exposure, diagnosis, and treatment (personal exchange Ian Wallach 2014).

A Storm in the Dust

Court cases such as Plata v. Schwarzenegger, Coleman v. Schwarzenegger, Ashker v. Governor of California have made public that “tough on crime” policies making prison sentences longer also compromise health coverage for the incarcerated population. Judges overseeing these cases required state wardens both to reduce overcrowding, due to its hindrance to medical treatment, and to correct the inadequate provision of mental health care, such as using solitary confinement as a technique for delivering health services. Several ordered measures to reduce valley fever in state prisons were introduced as a result of these court cases. But unlike the sweeping modifications Patino boasted about in the quote at the start of this chapter, the CDCR and, to some extent, the Federal Bureau of Prisons have slowly stratified risk along race and place shifting responsibility away from poisonous places toward virtually powerless people.

The meaning of adequate health care for populations marked with criminality is deeply considered, but the problems are rarely resolved. The CDCR, for example, claims to have first become aware of the rising rates of valley fever and the associated deaths among inmates of color and those medically compromised at ASP and Pleasant Valley State Prison (PVSP) in 2005 (U.S. District Court 2013b). Yet, in the period between 2005 and 2013, the CDCR implemented few measures to protect inmates’ health. In 2006, U.S. District Judge Thelton Henderson appointed a federal medical receiver, J. Clark Kelso, to require that prison health care meet constitutional standards. Kelso directed the operations and improvements of the prison health care system. Investigating valley fever at PVSP became a primary concern for him.² Kelso’s study resulted in the posting of laminated signs about valley fever symptoms for inmates and prison staff in state prisons located in endemic zones. Authorities relocated inmates with pulmonary or heavily immunosuppressed conditions from endemic facilities using the Cocci Exclusion Policy.³ Nearly six years later, the CDCR and the receiver remodified the exclusion policy (2012) to include a more elaborate medical classification system and a “valley fever transfer list” for inmates who could obtain approval by a physician. The health hazards assessed in the facilities located in valley fever endemic zones certainly concerned the CDCR, but the solutions were advanced rather slowly, and they hardly resolved the problem. People who are incarcerated were frequently made expendable. By 2013, only three inmates were listed on the transfer list (U.S. District Court 2013b).

According to the report filed by Kelso on May 1, 2013, the CDCR had long known about racial health disparities from valley fever. When compared to white male prisoners, the Black incarcerated men had a 90 percent increased risk for cocci infections at PVSP and ASP, even though they comprised approximately 24 percent of the population. Latinos comprised 42 percent of the prison population and had a 30 percent increased risk of cocci infections compared to white people. All “other” racial minorities had a 100 percent increased risk.⁴ The study concludes both that Black and racial minority inmates are disproportionately at risk and that race was a predictable criterion for identifying cases of valley fever. Almost everyone faced an elevated risk of contracting this disease, and everyone was hostage to the inadequacies of the prison health care system.

Few measures were willingly implemented to protect all prisoners. The California Department of Public Health, academic and clinical experts on valley fever, and the medical receiver Kelso convened in 2006 to examine the health crisis further. Within a year, they issued an additional report with twenty-six recommendations. The CDCR and the receiver adopted only four of their suggestions, two of which they had already implemented the previous year. By December 2008, the CDCR’s Occupational and Public Health Section requested the first formal health hazard evaluation from the National Institute for Occupational Safety and Health (NIOSH) at PVSP and ASP to “examine valley fever cases among prison employees—not inmates” (San Quentin News 2013). Six months later, in May 2009, and one week prior to the site assessment, the state of California “unilaterally cancelled the planned site visit by NIOSH” (U.S. District Court 2013b, 7). In court documents, NIOSH explains that the state’s Office of the Governor motioned to create an advisory group within the CDCR to decide “whether or not pursuing the health hazard evaluation further would be valuable to the State of California” (7). Shortly after, the CDCR disbanded the office that was responsible for overseeing occupational health issues and relocated this responsibility to another undisclosed office. NIOSH writes that “this development along with the lack of support from CDCR management precluded moving forward with the health hazard evaluation” (7). Even after contacting the union leaders of the California Correctional Peace Officers Association (CCPOA), NIOSH was forced to close out the request because neither the union nor the CDCR management supported the environmental health analysis.⁵ Analyzing and disclosing the source of health hazards for prison staff became squashed precisely because they would have revealed the environmental threats injuring workers’ and prisoners’ health. It was far safer to not evaluate the known risks facing individuals than to publicly record the failings of the state institution to workers, prisoners, and medical staff.

Studies conducted by the California Prison Health Care Services and the California Department of Public Health observed that the risks at the PVSP and ASP facilities, as well as other institutions where prisoners resided, were certainly worth evaluating. By 2011, 535 of the 640 cases (83 percent) of valley fever reported in California prison facilities occurred at two institutions: PVSP and ASP (as cited in San Quentin News 2013). PVSP had a rate fifty-two times greater and ASP had a rate nearly ten times greater than the county with the highest rate of valley fever in California between 2006 and 2010 (Pappagianis 2007). The rate of infection at PVSP in 2005 was approximately three thousand cases per one hundred thousand inmates. It was considered the most endemic state prison. Other facilities were endemic, including North Kern State Prison and Wasco State Prison. An environmental health analysis could have produced lifesaving evidence about the working and living conditions of confinement facilities, but it was delayed, devalued, and later, discarded.

The measures taken by the CDCR have long proved to be inconsistent and ineffective. By 2013, none of the eight institutions in endemic zones “showed a consistent decrease in rates” (U.S. District Court 2013b, 8). The court’s Expert Report concluded:

While CDCR transferred some medically high-risk patients, conducted soil sampling and environmental mitigation measures (in 2011 paid for by the Receiver), educated inmates and staff, distributed dust mask, [FN] installed new door sweeps and higher efficiency air filters, and created a program to measure wind speeds, these efforts have been far from timely, thorough, or effective. [FN] Prisoners were limited to one N95 mask per month. These masks are intended to be used for no more than eight hours.

The most frequent measure taken was waiting. The CDCR requested prolonging the transfer of at-risk inmates out of endemic facilities and “to do nothing about it at this time” for vulnerable groups, as well as inmates older than 55 years of age until an environmental health hazard assessment was conducted. Judge Henderson denounced the request as an insufficient response to the urgency of protecting inmates’ health (U.S. District Court 2013b, 18). Moreover, the court pointedly identified that the CDCR requested the power to retain inmates based on the need for an evaluation that would require months and that they themselves had canceled for no apparent reason five years earlier. The expert witness, Dr. John Galgiani, who was called to evaluate the measures implemented by the CDCR, similarly concluded that cocci infections were treated inadequately:

The plaintiffs’ expert, Dr. John Galgiani, an internationally known cocci expert, stated in his declaration that his review of four deaths related to cocci indicated that medical staff at prison in the cocci endemic zone are still slow to recognize the early signs of illness, particularly in African American men, and are slow to begin timely and proper treatment for the disease. We agree. We reviewed health records that raised similar concerns. (U.S. District Court 2013b, 12)

Galgiani elaborated that racialized minorities were not only among the most affected but also the least likely to be diagnosed, treated, and cared for. Although the CDCR staff may have conscientiously acted against the threat of fugitive dust, they regularly trivialized the necessary procedures to protect prisoners, especially prisoners of color. Moreover, it was unclear how the receiver determined the criteria for being racially at risk, making the rates of infection among Latino men seem less concerning for no apparent reason. The CDCR measures were slow, anemic at best, and with little consideration for the potentially lifelong consequences, including premature death for prisoners in all eight endemic facilities.

On June 24, 2013, Judge Henderson ordered the CDCR to grant inmates relief from valley fever at PVSP and ASP, where most cases of disease and death were recorded. The CDCR was ordered to expand their list of exclusionary factors and adopt a policy within seven days “so that no prisoners in the known at-risk groups of African-Americans, people of Filipino descent, Inuit’s, people with diabetes, HIV, or immunocompromised state,” as well as people identified at risk such as due to pregnancy, be admitted into PVSP and ASP (U.S. District Court 2013b, 1–11). Moreover, the court ordered the receiver to request that the CDC and NIOSH evaluate and determine whether any other group or criteria needs to be excluded. The order further required that within ninety days all at-risk groups be transferred out of PVSP and ASP facilities. Finally, it was ordered that all CDCR medical and nursing staff obtain additional training in “recognition, diagnosis, and treatment of cocci” (25). In Judge Henderson’s order, the primary importance was to avoid unnecessary illness and death among inmates and provide the constitutionally required level of health care for inmates immediately. The U.S. District Court order prompted the removal of approximately thirty-two hundred inmates from the PVSP and ASP facilities (St. John 2013). This would become a substantial turning point in the recent history of valley fever and mass incarceration.⁶ The CDCR long created the illusion that it meets its health care responsibilities, but, in practice, it evades them systematically.

Fugitive Ecological Relations

One of the fundamental principles of modern medicine is the saying that “prevention is the best medicine.” Yet, for almost all former prisoners in this study, it would be impossible to prevent valley fever when they were neither informed of the risk of contracting the disease prior to their detention nor fully informed of it during their hold at an endemic facility. Chiagozi landed at TFP between 2003 and 2005 in Kern County. TFP had a mean incident rate of 1,070 cases of valley fever per 100,000 population (MacLean 2015). Prior to incarceration, he spent most of his time in Southern California and first heard about valley fever when incarcerated at Taft. He relates:

I was initially in Taft when later on I discovered that people were sick, you know, people of color mostly were sick with all kinds of stuff. Then later on, I discovered what valley fever is. I don’t know what valley fever was until I got there. So initially I thought I had a bug bite in my left eye, and I was treating it, like okay it was not a big deal. . . . Then I was sweating cold at night, my body was in fever, not knowing it was valley fever. So, I was medicating myself with vitamins from the commissary and all kinds of stuff, you know. But I waited a long time to go see the doctor. I was sick. . . . I went to go see the doctor and I was treated for valley fever. . . . I waited about 2 days or 3 days then they put me on medication.

Chiagozi observed both that people of color disproportionately suffered from illnesses at Taft and that no one informed him of valley fever and its related symptoms. It was days after seeing a doctor that he became aware of the disease at the prison facility and received treatment.

Joaquin was transferred to PVSP in 1996 and was serving a sixteen-year sentence. The PVSP facility in Fresno County had a mean incident rate of 4,017 per 100,000 population; it was considered the most endemic state prison. He remembers a sign about valley fever that soon came down. Joaquin noted that “they didn’t warn us. There was something on the board of the loft. They went ahead and took it down. But a correctional staff took that down.” Joaquin describes holding a job and regularly cleaning enclosed areas outside of the cells, sometimes between walls where the piping was located. Similarly, Rob reports that he was uninformed about the risk of contracting valley fever when he was transferred to ASP in Kings County. ASP had a mean incident rate is 2,195 cases per 100,000. Rob explains:

When I first arrived in R and R [Receiving and Release], there nobody ever told us about valley fever, how you can catch it, what to do, or stuff like that. I went in and I was sitting in line waiting to be housed. And I seen the doctor, and you know, police officers and all that staff walking around. They give us a little orientation. But they never mentioned anything. . . . But the most sad part about it is that they never told us about valley fever in R and R when we first came there. If they would have, I would have taken different precautions when going outside. But since they never told me . . .

Chiagozi, Joaquin, and Rob were institutionalized at three separate highly endemic facilities. TFP is a low-security facility, and its daily operations are administered by the GEO private contractor for the Federal Bureau of Prisons. ASP is a medium-security site, and PVSP is a minimum- to maximum-security site. These last two facilities are administered by the CDCR. Despite the institutional differences, their locations, and the levels of security, Rob, Joaquin, and Chiagozi share a common experience: while imprisoned in a highly endemic facility no one with authority took the initiative or responsibility or had the decency to inform them of their elevated risk for contracting valley fever.

Many prisoners who develop active symptoms obtain clearer information from the networks around them than from prison medical personnel. For example, Rob describes how he was able to secure a proper diagnosis following his cellmates’ recommendations: “So, like I said my friends and associates there they were getting on me about it. . . . And they said, ‘man, come on. Go in there, man, like you know what you’re talking about. That’s bull. That’s bull crap. You go and take your butt up in there and don’t come out of there.’ So that’s what I did.” It was after being instructed on what to say that Rob was able to get diagnosed.

After being turned away, Joaquin, now in his midfifties, describes that his supervisor secured a proper diagnosis. “I thought my body was fighting something, but I didn’t know what. . . . As a matter of fact, the day before I went to see the doctor, the day before I actually had signed up to go see a doctor, and I saw a nurse. And, the nurse that was there, examined me and said nothing was wrong with me. So, I left back to my cell.” When he returned to work, his boss witnessed Joaquin’s deteriorating health and intervened. The boss demanded that a doctor see Joaquin immediately because he was not his usual self.

Similarly, Ronnie, who appeared in the Introduction, knew friends in a penitentiary who contracted valley fever and tells the story about how his friend likely died of valley fever. Ronnie further describes that communication about the disease among prison authorities is intentionally limited. When I asked him if prison staff share information about valley fever, he recalled, “Not with the proper people. But, you know, they send [information] to certain channels. They go to the doctors’ office and when they get to the doctors’ office it’s hard to see the doctor because the nurses, they are there more than they should be, and they speak with you with a bad tone of voice.” Ronnie explains that the prison authorities channel information about the disease through a chain of command of “experts.” These accounts suggest that nurses, physicians, and other prison health authorities act as gatekeepers depriving patients of medical knowledge.

When prisoners report a grievance about their health, the prison health authorities can generally discredit a complaint as nagging, whining, and weakness, saying the complainer is not tough enough to handle common germs and viruses that can cause a cold. Thus, people who are incarcerated find it necessary to set up a parallel communication network to convey information about the disease. Fugitive strategies of communication aid in explaining the stakes of an active case of valley fever. Cellmates become diagnosticians and custodians of health. They mobilize valley fever sufferers to shield themselves from the punitive rather than the palliative medical environment. While prisons promote and prolong the suffering of illness in silence and alone, the prisoners encourage conversations and discussions among themselves about symptoms, contagions, and strategies to communicate with health care personnel more effectively. They share stories about how valley fever has claimed the lives of other prisoners. They critique the inadequate prison health care model together as they witness the patterns of ineptitude that characterize it.

When nurses and doctors turn away inmates who have visible symptoms of valley fever, it falls to the seasoned prisoners to become the interlocutors of medical knowledge. The participants described sharing stories about their experiences with inmates, about the disease’s common symptoms, and about the prison staff who contracted and died from valley fever. They manage alternative communication channels to advocate for a proper diagnosis by performing the “right” language. Ronnie describes that information was kept from the prisoners and phone callers, but, nonetheless, he was able to conclude that his friend likely died of valley fever. Rob’s cellmates urged him to speak to the health staff as if he already knew he had the disease. His cellmates reminded him that prisoners have died because of the punitive model of health care.

When physical contact with other inmates is allowed, some participants described receiving help from cellmates who nursed them back to health. For example, when Joaquin was incarcerated between 1996 and 1998, all inmates taking medication were required to stand in line during the morning to receive their dose. They obtained only a single dose, which had to be consumed at the distribution site. Any break with this regimen was punished with solitary confinement. The prison staff forced him to stand in the distribution line to obtain his antifungal medicine despite his feeling extremely weak. Joaquin recalls that his fellow inmates provided support with their shoulders, holding him up in the line. Without the assistance of his cellmates during this critical time, Joaquin might have experienced a drastically different life outcome.

Further, the participants related that cellmates helped them obtain more nutritious food than the health staff enabled. Chiagozi explains that valley fever limited his mobility to attend the scheduled meal hours at the commissary at TFP: “Sometimes, it affected my walk, and I was tired. Sometimes, I couldn’t go eat. So, I had to send people to the commissary to buy me food.” Rosemary, an elderly woman, reports her son Jon’s experience in a maximum security prison. She learned that the prison staff offered Jon only a cold sandwich to eat when he was too sickly from the infection to get out of bed. She sent extra money to Jon so that his cellmates could buy him additional food. Rosemary emphasized the importance of good nutrition for a proper recovery, but this was not a priority for the CDCR.

Community Reintegration

In Arizona, whenever there is a dust storm forecast, the state emergency information network sends an alert. People are forewarned of the powerful winds carrying dust that can, at times, blind one’s visibility in seconds, cause collisions, and even knock down entire walls. People should seek immediate shelter and drivers should pull aside to stay alive. When prisoners return home, settling down and finding a safe place to access and continue valley fever treatment can feel like a dust storm without a warning.

The following section explores how people who contracted valley fever while incarcerated managed their health upon their release. In the United States, approximately 93 percent of prisoners will return home (Petersilia 2003). Six million former prisoners will reintegrate into free communities annually (Hammett, Roberts, and Kennedy 2001). Until recently, most returning citizens entered the public without a medical discharge plan (Shavit 2016). An update to California Assembly Bill 960, Section 3, 1172.2, revised the rules and granted advance release for prisoners with serious medical ailments or who are permanently unable to carry out basic activities due to an end-of-life condition. Upon approval from a judge, qualified prisoners would receive a postrelease plan and medical records. For most returning citizens, however, state-sponsored health insurance coverage often lapses when they are held for over twelve months. Even if they contracted valley fever and need continuing care, they are unlikely to have health insurance upon release. Not surprisingly, the participants in this study describe their release without any formal reentry plan, such as health insurance or a follow-up appointment with a physician. Given that inmates are more likely to acquire illnesses while in prison than in the public and more likely to suffer from undiagnosed medical and mental health problems (Petersilia 2003), depriving returning citizens of a discharge medical plan threatens their integration into communities (see also Visher et al. 2011; Woods et al. 2013). Criminal records follow every step of their reintegration process, but a medical record at hand is nearly impossible to obtain.

In the best-case scenario, people released from prison were handed an amber plastic vial with a thirty-day supply of medication. They alone were then responsible for securing their treatment during their transition to parole. This California Correctional Health Care Services policy changed in 2023 when the courts required the CCHCS to close the medication gap for people with disabilities transitioning into parole. The series of measures, outlined in Armstrong v Newsom (2023), now requires a sixty-day supply of prescription medication, a practice that benefits people released with valley fever.

The lingering side effects of valley fever can further complicate reentry. Joaquin was released from PVSP with apparent physical strength, no respiratory problems, and no sign of his former condition of valley fever. Yet, the damage that the disease caused to his body materialized days after securing a job in an outdoor setting. Joaquin explains:

So, they started me a treatment, which was that fluconazole. . . . And I was like six months, eight months to a year of just taking that. It was two [pills] in the morning, two in the day, and I had two and two. . . . My level is down. And it’s there now. [After release] I was working in a farm and all that medication, the long-term use of it messed up my stomach. Smells, stuff like that, odors, my stomach gets so sensitive. I feel like dry heaving in my chest. I’m going to throw up. And then my head, dizzy. I mean, things weren’t working, so I did something else.

Although prison staff declared Joaquin healed from the disease, he struggled with acute dizziness and nausea while working. Valley fever destabilized his prospects for securing employment.

Nicholas, who was sentenced to fourteen months at TFP explains how working was not a realistic outcome after release. He developed lifelong secondary symptoms that caused a physical disability. Nicholas was granted temporary Social Security Disability Insurance benefits. But unlike a permanent job, this benefit makes it impossible to subsist. “Now I got to do something because you can’t be on disability forever. The thing is that they kill you with your record and now even your disease. You have to fight two things at the same time. It’s hard to get a job. It’s too much liability for your employer.” The severe damage to his lungs from the disease makes it challenging to move for long periods of time. Employers are more likely to discriminate against people with a criminal record (Pager 2003). Having a physical disability can further compromise securing a job.

When Rob returned from completing his sentence at ASP, the disease rendered him incapacitated. Rob shared that his new life depended on securing both the medication to fight off a reinfection of valley fever and other medicines to help his body function regularly. Rob explains:

You know, I’m still on the medication for the rest of my life. I can’t have a bowel movement by myself. I have a medication that I have to take in order to loosen up my bowels so that I can use the restroom because the side effects of the medication of the valley fever, it dries you up on the inside. And they don’t let me have a regular bowel movement like you or what else might go to the restroom. So, I have to take this medication to clean myself out sometimes. And the doctor told me “Rob you might as well get use to this because you are going to be on this stuff for the rest of your life. There is no cure for valley fever. There’s no cure for it.” Some people get it worse than me. Some people just get a little something. And I think that I am one of the ones that got it really really bad because, like I said, I spent in the hospital for like 2 months. Things never went right after that there.

Now released from prison, Rob explains, “I still go to the doctor every two weeks to three weeks. I see the doctor because they have to constantly be drawing blood from me to find out the level of the cocci, of the valley fever.” Driving to a private doctor who can establish long-term care might require not only taking time off from work, at least two times a month, but also the medical insurance to pay for the lab work and the medication. The threat of the infection reoccurring will require substantial and long-term support for hundreds of former prisoners who contract valley fever.

Valley fever alone can complicate every step toward reintegration. At the same time, returning home might also include facing unstable housing arrangements and overcrowded community clinics. The prospect of securing a job might further be hampered by high unemployment rates and the mark of a criminal record. Environmental racism in the form of pollution, poverty and policing can additionally contribute to physiological distress (Ansell 2017; Bender, Cobbina, and McGarrell 2016; Lipsitz 2012; Phillips 2012; Clear, Rose, and Ryder 2001). These combined socioecological conditions can make establishing care feel like being trapped in an unexpected dust storm, but these challenges are rooted in systems meant to fail. More possibilities to secure health care, housing, and employment are needed for returning citizens, but especially for the formerly incarcerated people who contracted valley fever and other life-altering diseases.

When the Dust Settles

Although long overdue and unquestionably important, the strategies mentioned in Patino’s discourse and those demanded by the federal court accomplished important milestones. In a report by Kimberley Lucas (2022), the combined rate of valley fever cases at ASP and PVSP changed from 5,306 to 2,401 per 100,000 CDCR residents between 2011 and 2016. The number of valley fever cases among the incarcerated Black population fell from 246 to 45 and for the white population, 138 to 61 cases, in this same time period. For the Latino incarcerated population, however, the number of infections slid only slightly from 273 to 161 cases (2011–2016), in part, because they were deprioritized for exclusion unless qualified under another risk category. While calculated strategies saved numerous lives at PVSP and ASP, other endemic facilities saw rising valley fever cases. The combined infections at all endemic facilities increased from 283 to 291 cases per 100,000 CDCR residents from 2011 to 2016. Additionally, two years after celebrating noticeable reductions at PVSP and ASP, the rate of infection grew for all prisoners. Latinos faced the highest risks, rising to an approximate 500 cases per 100,000 CDCR prisoners in 2018, a rate that outpaced all other mentioned racialized groups.

The CDCR reduced valley fever infections and deaths among prisoners by prohibiting some people from entering endemic facilities. The strategies implemented, however, are highly problematic. For example, as a response to the rising rates, the CDCR implemented a soil sealant only at PVSP and ASP in 2011 and again in 2018. Installing ground cover to reduce dust around the prison properties was allegedly not feasible due to an initial cost that “could potentially exceed $750,000 in addition to ongoing maintenance costs” (U.S. District Court 2013b, 5). Yet, soil sealants were proved to reduce infections at military bases in the same endemic region. The line of protection for racial groups was drawn at a risk of 50 percent or more, allowing preventable cases to linger among groups who are qualified to transfer into endemic facilities. In this way, the CDCR leaned into the environmental racism and health injustices endured by the surrounding communities. The expected rate of infections at endemic facilities was set to mirror the rate in their neighboring communities, or what they considered appropriate and acceptable levels. In doing so, they neutralized the artificial ways in which rural populations bear higher risks of valley fever that are associated with inaccessible medical care, environmental racism, poverty, and policing. The CDCR’s combined strategies accomplish an added burden of proof for future court litigators.

Since the strategies were implemented, a string of current and former California prisoners have tested their Eighth Amendment rights against cruel and unusual punishment. They argue that they were unknowingly exposed to a heightened risk of contracting valley fever and that prison officials were deliberately indifferent to their substantial risk of harm. In four cases presented in the Ninth Circuit Court—Smith v. Schwarzenegger, Gregge v. Kate, Jackson v. Brown, and Hines v. Youseff—Judge Andrew Jay Kleinfeld ruled to dismiss all claims without an appeal. In Kleinfeld’s opinion, the evidence was “largely identical” and could not establish that prison officials had violated the Eighth Amendment. Additionally, Kleinfeld holds that the defendants were not personally involved in any alleged violations. Plaintiffs had the burden of proof that the mentioned officials clearly “personally played a role in violating the Constitution” and any culpable action or inaction “was directly attributed to them” (Klein 2019). Without any subjective or objective evidence, the defendants had earned qualified immunity. All cases were dismissed, some without a hearing. Most telling is Kleinfeld’s opinion that each injury was not “so grave that it violates contemporary standards of decency to expose anyone unwilling to such a risk,” meaning that the risk is not one that society would refuse to tolerate (Hines v. Youseff). In his understanding of society and who is doing the tolerating, Kleinfeld opines that “even though valley fever is more common in prisons, it is important to remember that it is not unique to prisons. More than a million people freely live in the Central Valley, and many of them contract valley fever each year” (Hines v. Youseff; see also Marks 2019). In a sweeping motion, Kleinfeld rejects any role that the CDCR prison officials might have played. At the same time, he inadvertently suggests that the free population in the Central Valley is equally susceptible to illness without redress, ignoring how low-income and communities of color disproportionately shoulder the burdens of valley fever. Since the judge dismissed these cases, the U.S. Supreme Court has also denied a hearing. A San Diego attorney is submitting a claim to the United Nations court arguing that prisoners’ human rights were violated. Protecting prisoners against valley fever was a standard leveraged during World War II for German and Italian prisoners of war that resulted in evacuation, but that principle is not being upheld to protect contemporary prisoners, many of whom come from aggrieved racialized groups.

Shortened Life Expectancies

The underlying assumption of the problem of valley fever in prisons today is that the differences in rates of illness have more to do with individual biology and behavior than with racist punitive institutions. Even when extensive evidence demonstrates the CDCR’s slow response to protect prisoners from exposure to dust, the problem of valley fever is stubbornly portrayed as a problem caused by the prisoners. Unless people who are incarcerated have medical eligibility that bars them from placement in endemic prison facilities, they are destined to serve their sentence in a place with limited environmental health assessment, with poor structural conditions, and lacking health professionals who can identify, diagnose, and treat valley fever correctly.

The various experiences shared by former prisoners with valley fever and their kin suggest that the prison health care model is restrictive and punitive rather than restorative and palliative. Prisoners need to convince medical experts that they contracted the disease. Achieving a diagnosis might require dangerous waiting in the form of repetitive and fruitless visits to the prison clinics and a lack of privacy or confidentiality. It also requires that the provision of care be given handcuffed behind bars, in isolation cages, or even through lengthy bureaucratic processes.

Returning home with valley fever destabilizes community integration. The returning citizens must obtain medical records, secure a new physician, and manage finances to pay for medical treatments and transportation as well as reduce the time gap between release and obtaining treatment. Even when prison physicians have declared people “recovered” and ready for release, the lasting and hidden effects of valley fever can limit job opportunities or lead to relinquishing jobs. Long-term valley fever can shorten the benefits that go with stable employment.

The prison medical system reveals the logic of social redemption that is achieved through a shortened life expectancy or premature death. For example, the life expectancy of male prisoners in California is nineteen years less than the average freely roaming male (Imai 2017). For female prisoners, life expectancy is twenty-seven years shorter than free women. None of these practices that shorten life would be considered decent, let alone desirable by the broader public. They are cruel conditions that threaten the health and safety of all people who are affected by incarceration, that congest community health services after release, and that reinforce an illogical correctional system. It is yet to be resolved what are the definitive standards of constitutional levels of health care. That premature death is tolerated seems counterintuitive.

The participants in this study and court records bear witness to a string of violations of prisoners’ dignity and humanity. Because of the unforeseeable injuries experienced with valley fever, prisoners are forced to become active guardians against the neglectful social and environmental conditions. While the court mandates that the CDCR implement steps to protect prisoners from valley fever, such interventions cannot meaningfully protect all prisoners’ health in facilities and in the public. How will a renewed prison health care system measure up against exposure to a potentially incurable, unpredictable, and fatal disease?

1. 2. After medical care in California’s adult prisons was found to be unconstitutional (see Brown, et al. v. Plata, et al., 563 U.S. 493 [2011]). A three court judge put the prison system into receivership in 2006 after the state failed to make court-ordered corrections.
2. 3. The CDC identified eight valley fever endemic CDCR facilities: Avenal State Prison, Pleasant Valley State Prison, California Correctional Institution in Tehachapi, Corcoran State Prison, Kern Valley State Prison and North Kern State Prison in Delano, Wasco State Prison, and the Substance Abuse Treatment Facility in Corcoran (see U.S. District Court 2013b; Plata v. Brown Jr.).
3. 4. Inmates older than 56 years of age had a 60 percent increased risk when compared to those 17–35 years of age, and so age was also seen as a reliable criterion to use in reducing incidences of valley fever among inmates. However, age was also not utilized in this way until 2015. Inmates who were 36–55 years of age comprised nearly 50 percent of the prison population at both PVSP and ASP and had an increased rate of 40 percent. See U.S. District Court 2013a.
4. 5. This study was revisited in 2014 and completed in 2015. It is now publicly available on the Center for Disease Control and Prevention stacks (Burr, De Perio, and Galloway 2016).
5. 6. Nearly seventy years after invoking the Geneva conventions during the holding of Italian prisoners of war at Camp Florence in Pinal County, Arizona, health officials were required to mobilize the exclusion of selected domestic populations from endemic facilities.