Five years after his diagnosis, Richard Nuwintore suffers severe stomach pain and fatigue from the antifungal pills he takes twice every day. (Kerry Klein/Valley Public Radio)
When the wind kicks up in the town of Coalinga, dust devils whirl over almond orchards and pumpjacks. You can even see the narrow brown funnels from the grounds of Pleasant Valley State Prison, on the outskirts of town.
But at the prison itself, there’s hardly any dust. That's evidence of years of work by the California Department of Corrections and Rehabilitation to reduce and control the San Joaquin Valley's ubiquitous wind-borne dust. The dust carries the spores of the debilitating fungal disease known as coccidioidomycosis, or "valley fever."
“As you can see, it’s a slight breeze but there’s nothing blowing around,” says prison spokesman Matt Martin, gesturing toward dirt-packed exercise yards and the unpaved shoulders of nearby roads. "It’s a dirt spray, it’ll keep the dust down.”
Inhaling the dust can be deadly. Spores of the dangerous fungus lurk inside the dust, and if prisoners inhale those spores, they can get sick.
By 2011, hundreds of state prisoners were falling ill with the disease every year. Annual prisoner deaths from the disease ranged between six to nine. Pleasant Valley had the most cases; in 2011, the prison's diagnosis rate was more than 600 times the general California rate.
Prisoners are especially vulnerable to valley fever. They can’t install new air filters or double-paned windows. And they obviously can’t leave.
“Preventing this disease is challenging because we all breathe, and many of us live in areas where this fungus is found,” says Dr. Tom Chiller, chief of the mycotic diseases branch of the Centers for Disease Control and Prevention.
But in the last few years, California’s state prisons have made progress. They’ve worked to screen out the prisoners most vulnerable to the disease and have taken measures to lower the risk to inmates incarcerated there. Between 2011 and 2015, while background valley fever rates in the southwest dropped by 30 to 50 percent, rates in state prisons fell close to 90 percent overall. Those improvements did not happen quickly or easily, and some required intervention by outsiders.
Some prisoners more vulnerable than others
Richard Nuwintore was barely three weeks into his sentence at Taft Correctional Institution when he began to cough and experience chest pain. Within a few days, it was obvious something was wrong.
“I could touch my skin and I was really hot,” Nuwintore recalls. “I had the coughing, the night sweats. My appetite was gone. I couldn't eat. I couldn't swallow, and I was losing weight really, really fast.”
Valley fever is endemic to dusty areas of the southwestern United States. Most who inhale the spores overcome the disease without ever knowing it. Some develop symptoms resembling pneumonia or bronchitis. In a small minority, the disease causes severe lung infection or disseminates throughout the body, requiring lifelong treatment. In the worst cases, the infection leads to fatal meningitis.
The disease draws its name from the San Joaquin Valley, the agricultural belt in the center of the state where the disease is concentrated. Kern County — where Nuwintore was incarcerated at Taft — has the highest valley fever incidence of any California county.
Originally a refugee from the east African country of Burundi, Nuwintore had never heard of the disease before arriving at Taft.
“Other inmates were telling me about valley fever, and I was like, ‘What is it? What is it?’ ” he says. “It was something scary, you know?”
Nuwintore was a victim of confinement in an endemic area, but weather and genetics also played a role. In 2011, when he was diagnosed, valley fever rates in Arizona and California were skyrocketing — a peak experts largely attribute toweather cycles of rain and drought. And research shows that individuals of African-American or African descent, like Nuwintore, are especially prone to the disease.
Taft is a federal prison and its health data have not been made available. But in state prisons all around Taft, the disease simmered. Between 2007 and 2015, almost 3,500 state prisoners in California were diagnosed with valley fever — many of whom, like Nuwintore, still struggle to manage the disease.
Prisons take steps to reduce risk
The California Department of Corrections and Rehabilitation began taking steps to prevent valley fever long before the alarming 2011 spike in cases.
Beginning in 2006, prison officials began excluding inmates with weakened immune systems — due to factors such as HIV or chemotherapy — from all eight prisons in the Central Valley. But valley fever rates still rose among prisoners.
More sweeping interventions arrived in 2013, at the behest of federal officials who by that time had taken over the administration of prison health care in California.
The federal oversight officials added a new rule specifically for prisoners who are African-American or Filipino, another group that is especially susceptible to the disease. The rule held that inmates from those two ethnic groups could not be sent to the two most affected prisons, Pleasant Valley and nearby Avenal State Prison.
At those two prisons, officials have distributed dust masks that inmates can wear outside. Prisoners also have the option to stay indoors when wind speeds are high.
“I think [valley fever] is one of the biggest issues that we've had in this system,” says Janet Mohle-Boetani, a health administrator with the California Department of Corrections and Rehabilitation. “We're taking precautions for every prison in the Central Valley, and we're taking extra special precautions for the two prisons that have the very high rates of valley fever.”
The most significant change, perhaps, arrived in 2015 on the recommendation of the Centers for Disease Control and Prevention. It’sa skin test called Spherusol that can detect valley fever immunity, and it’s offered to every inmate entering the state prison system. An individual who tests positive has already been exposed to the fungus and fought it off successfully, and is henceforth immune. Inmates who test negative are still at risk.
“If they inhale the dust with the fungus in it and they've tested negative, they're much more likely to get the disease than someone who has a positive test,” says Mohle-Boetani. “So if someone comes into the reception center and then they test negative, we put a medical restriction on those patients so they are not sent to live in Avenal or Pleasant Valley State Prison.”
People gain immunity after successfully fighting off the disease. In a mass screening in early 2015, around 35,000 inmates in the California prison system took the test and roughly 9 percent were shown to be immune.
The CDC recommended Spherusol to the state prison system shortly after the test became commercially available in 2014. The FDA has not actually approved Spherusol for this purpose, but like other medical products, it is being used off-label to sort the prisoners by risk.
“Given the fact that they were having such high rates of cocci, we knew that we needed to do whatever we could to try to help them lower the risk,” says the CDC’s Tom Chiller, referring to valley fever by its scientific nickname, cocci. “We immediately thought 'Maybe this could be used to understand which prisoners could exist in an area with the fungal spores but not get infected, or at least have an extremely low risk of getting infected.'”
John Galgiani, director of the University of Arizona’s Valley Fever Center for Excellence, is optimistic about the decline in valley fever reported in California’s prisons, but he says it’s too early to determine the exact reasons.
“I think they should be given credit for the drop to some extent,” Galgiani says, “but it'll take time to see if it stays low, to see if it's because of the policies that are now put in place.”
Health impacts linger after prison sentence
Today, Richard Nuwintore lives on a suburban cul-de-sac outside Sacramento with his mother and girlfriend.
He may be free from prison, but he’s not free of the disease. He’s too sick to work, and he’ll probably be on antifungal medications for the rest of his life. The fat pink and blue pills keep him alive, but their side effects are almost as bad as the disease itself.
“You wake up, you have a little bit of energy, but as the day goes by you start to just feel pain in the joints,” he says. “Of course, your stomach is still on fire because the medicine is kind of powerful. And [there's] fatigue, and sometimes you get dizzy.”
Last year, Nuwintore and another inmate won a landmark case that established the right of prisoners to sue the federal government for damages related to the disease, even though Taft is managed by a private contractor. They’ve now filed a second lawsuit to recoup their medical costs and lost earnings — a sum that could reach millions.