Barragan’s extensive exposure to the soil as a farmworker puts him at a higher risk of developing valley fever, but Ramos says they had never heard of the disease before.
“If we knew more about it, he probably would have been more careful,” Ramos says, translating for Barragan, who only speaks Spanish. “I hear ‘valley fever’ and all I think is ‘fever.’ So I’m thinking a cold. He probably had symptoms before and we didn’t know.” Barragan still works as a farm laborer, but his health scare was enough to convince him to start considering other work. “He’s learning English,” Ramos says. “He’s going to get a high school diploma, because he doesn’t want to be out in the fields anymore.”
While hospitalized, Barragan underwent a strict regimen of the antifungal fluconazole, delivered intravenously three days a week for three months. The medicine gave him seizures, and caused him to shed weight, about 50 pounds over the course of his stay. Because antifungals are rarely administered directly to the infection site—with the exception of shunts that convey them directly into the brain to combat meningitis—the hope is that enough can be pumped throughout the body to target wherever the fungus has spread. Sustained use of antifungals, whether orally or intravenously, can cause permanent kidney damage, however. “With the oral medications, why it gets scary is that they see how much the patient can tolerate,” Emery says. “It’s not like with other drugs when they say, ‘OK, we know this body weight and we give them this specific amount of medication.’”
Barragan’s symptoms eventually cleared, but he is still supposed to take up to 10 pills of fluconazole daily for the next three years. He’s wary of experiencing any more side effects, like the fatigue that put him out of work for four months, but he considers himself fortunate—of the 10 other patients also in treatment for valley fever during his stay in the hospital, four of them died from “disseminated” disease, he says.
Disseminated valley fever might be one of the greatest conundrums surrounding the disease. It only occurs in 1 percent or less of infections, but if a patient is black or Filipino, the risk of developing valley fever is much higher. Its damage to the skeletal system, joints, lungs or meninges—the delicate membranes that enclose the brain and spinal cord—is vicious, as the fungus can decompose the vertebrae, skull, long bones, like the femur and tibia, or the joints of the knees, wrists, ankles, and elbows. Meningitis, the most serious manifestation of disseminated cocci, happens if the fungus manages reach the protective membranes of the brain and spinal cord. To keep a patient alive, treatment must last a lifetime.
“The fact of the matter is that [getting infected] is a game changer,” Emery says. “Your life has to revolve around getting these drugs or you die. No one will take their patients off of medication believing that they’ll survive. We’ve tried. Everything looks healthy, everything looks normal, and then we try taking them off the medication and they go back to disease state.”
* * *
Kern County’s first great epidemic of valley fever began in 1991 and lasted for three years, the result of a particularly rainy spring following a five-year drought. In just one year—from 1991 to 1992—cases jumped from 959 to more than 3,000. Counting asymptomatic patients, however, some doctors think up to 8,000 people may have been infected.
The surge was alarming, but Emery says interest and funding for the disease disappeared completely two years after the epidemic ended. “We put fire stations everywhere to protect you, but when it comes down to public health, you’re fighting for everything. What we do doesn’t necessarily get seen until something bad happens, like a big outbreak of cocci, H1N1, or bioterrorism,” he says. “When something like that happens, all of a sudden we get funding, but it just seems like we continuously chase our tails.”
A second valley fever epidemic hit Kern County in 2001 and remains ongoing. It led to the deaths of more than three dozen inmates since 2006 at two nearby state prisons, Avenal and Pleasant Valley, before Kern County’s epidemic received the national attention Emery had been waiting for. Because the prisons house high concentrations of black and Filipino inmates, valley fever infection rates are astronomical there compared to the state average: 1,000 times higher at Pleasant Valley, where more than 1,000 inmates have contracted valley fever over the past five years, and 189 times higher at Avenal. Following a federal mandate to transfer more than 2,500 at-risk inmates out of Kern County in 2013, the National Institutes of Health and the Centers for Disease Control and Prevention announced plans to start a clinical trial in Bakersfield, in hopes of understanding how early diagnosis affects the course of treatment, and developing a vaccine. In June, the FDA also announced plans to include cocci on its Generating Antibiotic Incentives Now (GAIN) program, a federal system intended to encourage the development of new antibacterial or antifungal drugs to treat what the government deems serious or life-threatening infections. Adding cocci to the list extends the period that valley fever antibiotics or vaccines can be sold without any generic-brand competition on the market by five years—a much-needed incentive for a pharmaceutical company to jump on board and manufacture a vaccine.
Even now, although it's been decades since research took off in the 1930s and 40s, and the first patient was diagnosed in 1892, the prospect for a vaccine still remains uncertain. Developing a vaccine would mean creating a financial incentive lucrative enough to draw Big Pharma into producing a product that only a relatively small portion of the entire country would ever use. There are only a handful of researchers nationwide working toward a vaccine, primarily in California, Texas, and Arizona, and Emery believes the effort needs another big infusion of money to push it over the top. It could be decades more before one is perfected in the lab.
Yet the question remains whether valley fever would still be as mysterious or overlooked if it didn’t affect some of California’s poorest residents. Kern County, the state’s disease epicenter, is a hub for farm laborers, not investment bankers or tech entrepreneurs. Agriculture in Kern might be a $6 billion enterprise, but the reality is that more than 22 percent of the county’s population lives below the poverty line, compared to the national average of 15 percent.
“Most of the other vaccines that we’re dealing with now were sort of a big full court press government thing,” Rutherford says. “If you look at the AIDS vaccine efforts, you know, [their budgets] are astronomical. The amounts of money spent, and properly so, are very high. I can guarantee that this is true, that if this disease were happening in Washington, DC, the conversation would be [different].”
Emery, who will retire within the next decade, says he’s “scared to death” that when he leaves the Kern County’s public health department, so too will local pressure to confront valley fever.
“It’s my disease. It’s Kern County’s disease,” he says, adding that his work will probably never be done in his lifetime. “This disease needs a voice. If I die tomorrow on my motorcycle, I’ll die with a smile. I got involved and I made a difference.”