Introduction

It is my first day recruiting participants in Kern County for my research on valley fever, an environmental disease caused by fungus that plagues the Central Valley of California.¹ I am at an outdoor flea market, surrounded by the loud sound of a corrido, a poetic ballad accompanied by a pronounced accordion arrangement and soloist, which is popular among the romantics in the high deserts of Northern Mexico and the old Southwest. The air hangs heavy with the spicy smell of grilled chili peppers and red meat from a taco truck nearby. In contrast to the rain showers that fell the evening before, this morning is bright, clear, and quickly warming up to 80 degrees Fahrenheit. My recruitment booth consists of a multicolored Mexican blanket laid over a table. Pieces of free candy are scattered on top next to a green box that is holding up the sign saying: “Se busca personas con fiebre del valle” (looking for people with valley fever). Two folding chairs sit neatly tucked beneath the table. I stand in the wide and busy dirt path, just in front of my display, and ask people passing by if they have had valley fever. Some shake their heads. Others shout back, “Ni lo mande dios!” “Y no la quiero!” “Gracias a dios no!” (May God not even send it! / And I don’t want it! / Thank God, no!). These are popular phrases in the Spanish language that confirm they neither had valley fever nor desired it and that, somehow, divine intervention had saved them from contagion by the deadly and painful disease.

The Centers for Disease Control and Prevention (CDC, n.d.) reports that valley fever is caused by exposure to Coccidioides immitis (cocci), a soil fungus that grows in arid lands in the Southwest of the United States and Northern Mexico. While corridos are part of the cultural environment, the cocci fungus frequently germinates in the natural environment of the Central Valley, including in the Madera, Fresno, Tulare, Kings, and Kern Counties of California. More recently, the coastal Counties of San Luis Obispo and Los Angeles have reported cases of valley fever (California Department of Public Health 2014; Johnson 2017). Cocci causes an infectious disease known as coccidioidomycosis when dirt germinating the fungus is dispersed into the air due to a strong gust of wind or excavation (C. Smith et al. 1961; Kloos 1973). Moving the dust allows the fungi spores to become airborne. Just one breath of the spores can cause the painful illness commonly referred to as valley fever.

The disease is not contagious, but it is burdensome. Forty percent of confirmed cases are thought to develop symptoms, including rashes, body aches, fatigue, fever, and chest pains that on average last for sixty days. More severe symptoms include disseminated infections in the joints, the spinal cord, and the brain, which require aggressive and timely medical interventions (CDC, n.d.). Some infections require a lifetime of treatment. Annually, an estimated twenty thousand people suffer from valley fever in the states of Utah, Nevada, New Mexico, Arizona, and California. Many more cases are undiagnosed and remain uncounted, which is likely to increase the number of related deaths (Y. Huang et al. 2012). California is responsible for approximately 30 percent of the nation’s reported cases, some six thousand diagnoses per year, and has the highest number of valley fever–related deaths. There were 3,089 deaths from the disease recorded during an eighteen-year period—an estimated 170 annual fatalities in the state (Y. Huang et al. 2012). The regional concentration of the disease is often attributed to the natural environment, its temperatures and levels of rainfall that affect the growth of the fungus, and the winds that can dangerously circulate the toxic fungus spores in the air (CDC, n.d.). While climate variation may affect the fungus growth differently, there are remarkable sociological patterns of infection: people who work outdoors, people incarcerated inside, and people with compromised immunities are among the most vulnerable populations likely to develop symptoms and die from valley fever.

Marilou was one of the few people that morning who nodded and stopped to investigate why I was asking about this disease. She knew about valley fever because her sister Beatrice suffers from it continuously. After hearing about who I am and my research interests in the disease and farmworkers, Marilou agreed to an interview. Her sister Beatrice was diagnosed with valley fever over a decade ago and was dealing with a recent reoccurring infection that made her drowsy and incapable of doing the daily routines that most people can manage before heading out to work or school. Beatrice initially developed the illness while living in the unincorporated rural community of Lamont, a small town characterized by Main Street storefronts, Latinx vendors, and Highway 184 running past the welcome sign that reads, “Growing to Feed the World.” The city population, however, has not been growing but rather declining over the past fifteen years (U.S. Census Bureau 2023). Beatrice moved closer to the city of Bakersfield after her diagnosis because she needed to take care of her father who was then ninety-eight years old. Beatrice used whatever strength she had left to ensure that her father was fed and watched over. But, beyond caring for her father’s life, she was ready for her own death. Marilou explains:

Sometimes [Beatrice] feels bad and she stops taking her medicine because she says that the medicine costs too much. And then she says, “Well if I cannot live without medicine oh well.” I tell her, “No. Do not talk like that! You know that you need your medicines. That you can do this, you can overcome this. You can do this because you do not have children to support any longer because they are working for themselves. . . . The problem is that you do not want to. Do not be a coward I tell her [original emphasis]. Order your medicines.” And she says . . . “I will do it today that I have my father to take care of because my father needs me. But the day that my father leaves us, there is a chance that I will leave behind him.”

Beatrice does not wish to follow the advice that health professionals give for a path to recovery because her obligations and disposition toward recovering contrast with the recommended treatments. The high cost of medicine and her own financial struggles make her think that it would be better for her family if she just died. When Beatrice fell sick with valley fever, she felt responsible for having acquired this disease. Seeking medical help at the onset of her symptoms resulted in a misdiagnosis. After enduring a week of continuous pain, she landed in the emergency room as someone without health insurance due to working only as seasonal labor. Without insurance, it took weeks for her to acquire the prescribed drugs. The delay contributed to the advancement and spread of the disease. Beatrice was then forced to undergo surgeries. When more invasive surgeries were recommended, she traveled to Mexico for the suggested removal of a piece of her lung at a hospital in the town where she grew up. When she reentered the United States fully recovered, Beatrice fell sick again with similar symptoms. She paid for new prescription drugs with family contributions and was told that she would need to continue taking medicine for the rest of her life. Undergoing years of constant medical observations and expensive treatments make it seem that healing might not be worth the burden that it has placed on her and her family.

Lingering in Marilou’s cry of “Do not be a coward” are resonances of the mutual support these sisters have provided for each other as they struggled to survive in the face of a seemingly unlivable destiny as young Oaxacan immigrants. They crossed dangerous international borders, raised families, endured the backbreaking conditions of agricultural labor, and made do with poverty-level wages while supporting binational families. For Marilou, the slow and highly unsuccessful recovery by Beatrice would be only the latest in a long line of staggering challenges. For Beatrice, however, whether life is worth living or not after caring for her father is an open question. In the volatile lives of farm laborers, valley fever threatens the family pledges to help and protect each other and to share the costs and burdens of immigration and low wages. Leaving it up to individuals to solve the problems caused by the large structures, systems, medical establishment, and economy combined might make dying seem like the better option for someone like Beatrice.

That same morning, Ronnie also stopped by my display table. He was wearing a wide-brimmed brown hat that made him look especially tall and confident. He was among the many Black residents shopping that day. While Ronnie did not read Spanish, the free candy caught his attention. He grabbed a fun-size Snickers chocolate bar from the table, unwrapped it, and, just before placing it in his mouth, asked me what I was selling. I explained my role as a graduate student and my goal of recruiting participants for my research study about valley fever. Ronnie was all too familiar with the dangers of this disease. He pointedly listed the symptoms as he peered over my shoulder into the dry patches of dirt surrounding us, as if to warn me that I could be the next victim. He described the rashes that manifested over the trunk of the body, the unstoppable high fevers that lasted days on end, the feeling of being worn down, and the profuse coughing. Ronnie delineated in detail how these symptoms advanced, sometimes taking over the bones and joints of people, other times claiming their lives. He stipulated that valley fever is virtually everywhere, even if we could not see it. Ronnie explained that he knew many people who had caught valley fever. He told me about the fate of one friend who was locked behind bars when he died:

I knew a buddy, he’s a buddy that died of valley fever. He was in the penitentiary. I heard him on the phone, talked with him on the phone, saying he had valley fever. . . . Well, being incarcerated you have no, no hope really because their doctors’ systems is tough. They don’t treat you as you should be treated. They treat you less than who you are. They should be giving you respect as a human being, instead they treat you like scum and they create things to happen. You know my boy, he tells the police that he was, ahh, he was feeling bad in his body and they wouldn’t see him. He died a few days later. And so, in there there’s no hope unless you have it for yourself.

Although the administrators of the prison never confirmed that his friend died from the complications of valley fever, for Ronnie, that correlation was possible because he knew the health care system in the prison to be inadequate and unresponsive. Ronnie believes that the lack of urgency in caring for the health of a prisoner cost him a good friend. If there were alternative treatment paths, his friend was not given those options. Without the right to medical care and the dignity of health, prison walls can weigh heavily on one’s moral capacity for self-preservation. For some prisoners, valley fever can seem to warrant an inescapable death.

Marilou’s and Ronnie’s stories are about people they love who lost hope of recovering from a disease, not just because of the illness itself but also because the available prescriptions and medical interventions were fatally inadequate or even unobtainable. Other participants, whom I interviewed in this study, also revealed that few of them depended on conventional health resources at all, neither emergency nor clinical—precisely because those that were available were also difficult to access. Red tape, differential processes for insurance, clinics that far exceed their maximum capacity of patients, and demoralizing practices, including medical racism, language discrimination, and criminalization, push farmworkers and prisoners away from preventive and immediate health care. This is a finding consistent with other studies (CURB, n.d.; Burciaga 2003; Bade 2004; Welch 2005; Van Ryn et al. 2011; Hester 2013; Holmes 2013; Ku and Jewers 2013; Horton 2016; Ansell 2017; Ferry 2021). Unfortunately, the diagnostics, medications, and development of hoped-for vaccines remain the central concerns of the biomedical and public health approaches to valley fever and command the primary attention of nurses, physicians, epidemiologists, and biotechnicians (Levine et al. 1970; McIntosh 1981). The disparate health impacts of valley fever among people like Ronnie’s friend and Marilou’s sister reveal that one root of the problem is not just health communication and health care inequality but also the knowledge regimes that focus on individual susceptibility and responses to diseases as the heart of the problem, rather than on the socioecology facing vulnerable groups.

The logic that treats people with health problems as problems was applied in 2015 when prison officials adopted a two-pronged strategy for rectifying valley fever outbreaks in prisons. The California Department of Corrections and Rehabilitation (CDCR) spent over $5 million to transfer “African-Americans, people of Filipino descent, Inuits, and persons with diabetes, HIV, or an immunocompromised state” out of endemic prisons (Plata v. Brown Jr. 2013). They did so by setting an arbitrary threshold of acceptable levels of valley fever among prisoners, one that reflected the already alarmingly high incident rates of the disease in the surrounding communities, which are both populated primarily by Latinx low-wage-earning farmworkers and replete with cumulative pollution burdens. The Department of Corrections claimed that the epidemic did not stem from the CDCR’s much criticized environmental and health practices, especially the failure to prevent exposure in a timely manner by paving dirt lots, installing air filters, and providing adequate and urgent health care. Instead, the CDCR attributed the growing incidences of valley fever to the alleged biological susceptibility of African Americans and other racialized groups with preexisting medical conditions (Moore 2013). As a result, the stereotypes that persist are of Black people, Pacific Islanders, and Indigenous people as racially homogeneous and vulnerable populations, whose health issues stem from genetic problems, or of a population of undeserving “criminals” who threaten to exhaust public resources. The case of sheriff deputies in Orange County who acted with deliberate indifference to a female prisoner’s pregnant condition by stopping at a Starbucks for coffee on the way to the hospital is a recent example of a culture of indifference to human suffering. The officers’ dalliance at Starbucks contributed to the woman’s miscarriage, which she did not provoke or desire (Saavedra 2022; Quinones v. County of Orange 2021). Biomedical regimes lead to the argument that systematic changes such as transferring the problematic individuals to other institutions will secure adequate medical care, but they rarely resolve the complex conditions that make people sick.

The racial disparities of valley fever are sobering. Black and Latinx people comprise just 40 percent of the general population in endemic areas of California, but they account for over 60 percent of the cases reported (Hector et al. 2011). Black people and Pacific Islanders are more likely than white people to develop severe symptoms (Cox and Magee 2004; Y. Huang et al. 2012; Hector et al. 2011; Mohney 2013). Native Americans experience the greatest mortality rate, even though they represent less than 3 percent of the population (Hector et al. 2011). Of the total valley fever hospitalizations from 2000 to 2011, the government medical insurance programs covered 61 percent of cases through Medi-Cal, Medicare, and county indigent health programs, which suggests that those who have government-subsidized health care often rely more on emergency services and less on a primary care physician to identify and treat symptoms (Sondermeyer et al. 2013).

Racial health disparities reflect what the medical anthropologist Paul Farmer (2004) and physician David Ansell (2017) describe as structural violence. Historical policies and practices, such as zoning ordinances, racial covenants, blockbusting, and redlining, which segregate risks and resources along race, class, and gender, also generate differential pathways for accessing diagnostic and therapeutic tools for treatment (Lipsitz 2024). The designs of urban and rural neighborhoods, which draw from ecological resources to prioritize economic opportunities, lay the foundation for the social inequalities that produce racial disparities in health and wealth. This study on valley fever further elucidates that unequal health burdens are explainable, in part, through how public health care and medical science advances a search for the causes, consequences, and potential cures of the disease. Although access to health care is crucial for alleviating any undue burden from the ongoing policies and practices that cause racial disparities in health, the biomedical approach deliberately ignores the perspectives and opinions of members of the most vulnerable groups to contract and die from valley fever, treating their knowledge about the socioecological dimensions of the disease as ill informed, illogical, and illegitimate.

This book aims to interrupt the narrow biomedical path that remains unquestioned. I draw from medical anthropologists, sociologists, geographers, critical race scholars, and epidemiologists to begin a conversation that will illuminate how the differential rates of valley fever among farmworkers and people who are incarcerated are preventable. Claims about genetic susceptibility to disease have historically served to justify segregation and to distract the public from the unequal and discriminatory social conditions affecting people’s health (Roberts 2011). When medical experts focus exclusively on advancing biomedical research, they conceal how scientific claims about racial categories are based on societal assumptions and fictitious stories about race genetics rather than scientific evidence (Roberts 2011). They ignore how place matters in determining life expectancy and death gaps (Lipsitz 2024; Ansell 2017). This absolves corporations and state governments from the high costs they would have to incur to remediate the conditions that are injuring the health of people, especially those from racialized groups experiencing poverty, pollution, and the threat of incarceration (Roberts 2011; Briggs and Mantini-Briggs 2002). Relying on biological explanations can lead to treating the symptoms of illness without addressing the social conditions that are causing unequal health outcomes (Briggs and Mantini-Briggs 2002). The differential rates of illness, which provoke speculation about racial genetic and behavioral propensities, should also lead to an analysis of the social and environmental drivers causing disparities in health.

Understanding the social and environmental conditions of life is a central focus of the social determinants of health approach. In her timely book, The Social Determinants of Health, Kathryn S. Ratcliff (2017) employs the public health phrase of “looking upstream” to identify the drivers that are making people sick. The social determinants of health or the conditions of life can account for over 50 percent of the nation’s health profile, making social interventions one of the most important factors for lowering the rates of disease. By asking what the social causes of differential health outcomes are, Ratcliff allows for examining multiple sites of power and situated knowledge. Through a social justice and human rights perspective, Ratcliff evidences how laypeople’s experiences with illness are downplayed both by the faulty reporting systems required of federal and state governments that overlook cumulative health burdens and by the private corporations’ unwillingness to respond to affected residents’ grievances. Often, real-life scenarios are not testable in laboratories, transferable to statistical data, or even treatable. Laypeople’s knowledge, however, can encompass where social and environmental conditions are located and how these might operate in causing health disparities.

The social epidemiologist Nancy Krieger (2011) shows how a wide range of policies, practices, and processes influence people’s health. Krieger’s ecosocial theory posits that the manifestation of illness is not simply the physiological deterioration of the body but also the body’s exposure to social and ecological inequality. The body absorbs the effects from the social, political, and economic conditions in which everyday life unfolds that create disparities in “physiology, behavior, and genetic expression” (936). The reaction of the body to social inequality influences the “development, regulation, growth, and death of the biological systems, organs, and cells” (936). Racism is central to a spectrum of social processes and interactions that lead to injurious social and environmental contexts, such as residential segregation, medical racism, language discrimination, criminalization, and deportability (Lipsitz 2011). Racialized bodies undergo significant physiological deterioration, declined defenses, and elevated levels of stress, while the wealth, health, and medical knowledge of privileged groups is subsidized because of this unequal socioecology (Ansell 2017; Krieger 2011; Gee-Payne and Sturges 2004).

Policing and the threat of incarceration or deportation are extensions of the environmental racism that gives shape to the conditions of life. Hazardous labor and unsafe housing, combined with poverty, make life and health precarious. Valley fever is not an amalgam of individual and isolated choices that happen to unfold in the Central Valley but rather evidence of a linked fate among people living in racialized places. It is part of a broader story of intergenerational inequality and the cumulative consequences of environmental injustice. The term “cumulative vulnerabilities,” used in this book, emerges out of the search for an intersectional humanities and social science lens for perceiving what shapes, and how one is contracting and recovering from valley fever. The term draws attention to the combined environmental, social, and health threats facing farmworkers and incarcerated people over the life course of individuals and generations. Just as the health of individuals is shaped by their medical histories, the collective vulnerabilities of racialized groups stem from their long history of displacement and dispossession, housing insecurity and inadequate health care, and exposure to incarceration in prisons and to sources of pollution.

Drawing on ecosocial approach, which illuminates the policies, practices, and processes shaping the conditions of life in a valley fever endemic county, this book turns to the testimonies of valley fever patients, their families and friends, and community activists and organizers. It builds a conversation with the vulnerable groups and their relations who share a search for answers to ongoing environmental health problems. Immigration policies, exploitative farming and labor practices, red tape in the public health care system, and the excessive siting of waste facilities in rural Latinx communities along with prison infrastructures replete with racial segregation all make lives vulnerable. The accumulation of social and political problems produces differential paths to illness, health care, and healing (Krieger 2002).

The concept of cumulative vulnerabilities differs from the public health term “cumulative disadvantages,” which focuses both on how people’s social and class status interact with their specific physical and biological characteristics over their life course and on how this nexus might lead to differential health outcomes along race, gender, and age (Shuey and Wilson 2008; McDonough et al. 2015). Criminologists have similarly applied cumulative disadvantages to account for people’s experiences with the criminal justice system from policing and prosecution to the courts (Kurlychek and Johnson 2019). The cumulative vulnerabilities lens that I employ, in contrast, shifts the focus away from individuals and toward the social and environmental conditions giving and taking life. The term aligns more closely with research by scholars who spatialize health risks by investigating the cumulative social, environmental, and health vulnerabilities. Ganlin Huang and Jonathan London (2012) map various pollution sites, multiple social vulnerabilities, such as social economic status and age, as well as different indicators of life loss, such as low-weight births and asthma rates, to explain the greater concentration of risks to human life in racialized communities. The cumulative environmental, social, and health vulnerability indicators identify the census boundaries or zip codes with the greatest need for social and environmental interventions. The conditions of life that are shaping health risks, however, are only part of the story. As Ratcliff’s (2017) work reveals, the past and present social relationships give shape to the conditions that make health precarious.