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Dr Rais Vohra is an interim health worker in Fresno County, one of California’s persistent Covid-19 hotspots, as well as an emergency physician at the Fresno Regional Community Medical Center. “At this point, if you’re still working every day, despite your exhaustion, it’s because you really like the team you’re working with,” Vohra explains.

Dr Rais Vohra has impeccable timing. He took over as acting Fresno County health worker just months before the onset of the covid-19 pandemic. Almost immediately, he found himself navigating the treacherous tensions between public health messages and a skeptical population in an industrial agriculture hub that’s also one of California’s most politically conservative regions.

These are first of all the anti-mask demonstrations, amplified by the wishes of the county sheriff that its deputies would refuse to apply the state’s mask mandate. Then there was the vocal resentment of the covid-related trade restrictions. End this with growing mistrust of new covid vaccines and a large population of migrant farm workers facing long-standing challenges in accessing healthcare. Small surprise therefore, that from December 3, about 55% of Fresno County residents have been fully immunized, nearly 10 percentage points below the state average. In some rural pockets of the county, less than 40% of residents are fully vaccinated.

For nearly two years, Vohra and the rest of the county’s healthcare system struggled to keep up with what appeared to be a relentless spate of covid surges. The current wave has hospitals in the overwhelmed area, with emergency rooms so crowded that ambulances line up for hours to unload patients. Almost 160,000 cases of covid have been registered, and more than 2,200 residents have died.

Fresno County covers 6,000 square miles and includes the city of Fresno – the urban core of the Central Valley – as well as large tracts of farmland. The county is home to around 1 million people, just over half of whom are Latinos.

Vohra, who is also professor of clinical emergency medicine at UCSF-Fresno, spoke with Jenny Gold of KHN about the “why” behind the persistent flare-ups and the toll in Fresno’s healthcare system. The conversation has been edited for length and clarity.

Q: Fresno County covid hospitalization rate is four times what Los Angeles County sees and eight times the rate of San Francisco. Why?

The whole state experienced a surge in the fall. And when the outbreak resolved in the rest of the state, unfortunately, our numbers did not go down. We have capped. We may have a new wave this winter, so not being able to recoup our resources and give people time to debrief and think about how to prepare for the next one is obviously of great concern.

Our immunization rates are not where we need them. The amount of masking we have is significantly less and we were unable to secure a mask warrant. We also have a lot of essential workers. A remote worker who can “Zoom in” is very different from someone who works at Foster Farms, who has to show up and has no free time left. Every little thing is connected to every other little thing.

Q: Why does the county’s vaccination rate continue to be lower than rates in much of the state?

There are people who still have access issues, and we are absolutely trying to fix it. Then there are other people who just don’t accept the science, and I don’t know how to get these people to buy in. I think the emotion comes first and the reasoning comes later.

Is it disappointing? Yeah, that’s it. Are we trying to do the right thing and improve that rate? Of course we are.

But when you look at all the things we’ve heard, sometimes I’m pleasantly surprised. One million doses of vaccine have been administered. If you had told me a year ago that we were going to do it in less than a year, I wouldn’t have believed it.

Q: The Fresno hospital system is struggling to absorb the burden of covid patients and has begged other counties to take patients. Are you getting help?

We only have seven acute care hospitals here in Fresno County. We probably need twice as much to serve the population. They always operate at a very high capacity, sometimes over 100% of what they are licensed for. And so this wave of covid was really, really difficult.

You would think that with all of our computer technology, we would have a way to share the burden and transfer people. But that’s not how the system is designed. We had a great conversation with our state partners and all the other hospitals to talk about it, and hopefully something will come to pass. But these are not easy questions to answer.

In addition to the logistical issues of finding an open bed and an EMS [emergency medical services] transport vehicle with the right people capable of handling a critically ill patient for hundreds of kilometers, you must also have patient consent. And, it turns out that patients and their families really resist if you tell them, “Your family member is going to get great care, but it will be 100 or 200 miles away.

Q: When you said Fresno needed twice as many hospitals, did you mean in times of covid or in normal times?

Non-covid time. We have such a shortage of clinicians and we have such a shortage of nurses that it is really difficult to meet the needs of patients. The population has grown much faster than the hospitals.

Rural hospitals are actually limiting their services, not adding new ones, and this is just part of a much larger and more tragic story about the healthcare landscape.

Q: As a health worker in Fresno County, you operate at a point of natural tension amid anti-mask and anti-vaccination feelings. How did you navigate there?

It was very interesting, very humbling and also very informative. It actually forces us to be very sure what recommendations we make, because we know they’re going to be looked at closely.

Sometimes we are disappointed. For example, we really went to great lengths to get a mask warrant when we saw the fall surge was just around the corner. And, unfortunately, our riding just didn’t want to embrace that. People were just ready to finish, and bringing him back wasn’t even an option.

Q: I imagine the public health staff and health care providers are exhausted. What do you see?

There is an element of exhaustion and fatigue that I had never seen in my colleagues before the arrival of the pandemic. At first we were all talking about health heroes, and although it was scary and surreal, we had a lot of adrenaline. But it ran out a long time ago. Now people are doing the best they can.

In hospitals, a lot of people are really fed up with this anti-vaccination sentiment. Because they are the ones who take care of people who get sick. It is very sad to see and to experience. What it does, however, is bind people together in a way that only severe trauma can. At this point, if you’re still going to work every day, despite your exhaustion, it’s because you really love the team you’re working with. I certainly see it in our Department of Health.

Q: Your wife, Dr Stacy Sawtelle Vohra, is an emergency physician at the Fresno Regional Community Medical Center, so also on the front line of Covid. What was your family’s record?

Whenever there is high transmission in our community, it also affects us personally, and people have to take time off work to care for loved ones or to be screened. We had our kids tested because they came down with the sniffles. And you have to prevent a child from going to school when he takes his exam. Living this, you understand that if I couldn’t do my meetings from home, it would just become an impossibility. We haven’t created good solutions for our communities, especially for parents who have to work and don’t have good child care options.

We are both blessed with understanding and flexible employers. We have two young children aged 4 and 7 and their top priority was to make sure the Elf on the shelf introduced himself today. For better or for worse, we are good compartmentalizers, and we leave it all to the office or to the ER. And when we’re home, we’re family. We just hope to give them as normal a childhood as possible during this really difficult time.