The central San Joaquin Valley for years has struggled to attract medical doctors, with physician-to-resident ratios well below what medical experts say is needed for adequate healthcare.
That was before the coronavirus pandemic. Now the rapid spread of COVID-19 may well expose the Fresno area to even greater risk if the relatively few doctors in the Valley become infected, health experts told The Bee.
“I think really what this is doing is exacerbating an already stressed system,” said Fresno County Department of Public Health Director David Pomaville.
Local residents have long reported higher rates of diabetes, asthma and other lung diseases, cancer and serious heart conditions, all of which the Centers for Disease Control says put people at greater risk for severe illness from the coronavirus.
The physician shortage could become an urgent problem, especially if local doctors become sick.
In the San Joaquin Valley, there are about 45 primary care physicians for every 100,000 people, according to the California Health Care Foundation. That’s 15 to 35 fewer doctors than experts say is needed.
Five new coronavirus cases were reported in Fresno County on Tuesday evening, bringing the total number to 18. Tulare has 17 cases and Madera has five, not including a case where a patient recently recovered. Nearly 2,300 people have been infected statewide, according to a Sacramento Bee survey of numbers released by counties’ public health departments.
There are no doctors on standby
With medical doctors in short supply — and at great risk of getting sick — health experts say it’s only a matter of time before the problem escalates.
“If we get to a place where our system is stretched because of this pandemic, the concern is health care providers are going to get sick and you’re going to have a smaller and smaller healthcare workforce to provide care,” said Dr. Lori Weichenthal, assistant dean of Graduate Medical Education at UCSF Fresno. “We’re certainly anticipating there’s going to be shortages in our health care professionals as this pandemic gets worse.”
As the world grapples with the pandemic, bringing in dozens of new experienced doctors from outside the Valley isn’t possible. But a few former physicians have volunteered to help out.
“We’ve had a few retired physicians and people who are leaving other practices to volunteer, so that’s been really heartening,” said Dr. Rais Vohra, interim health officer for Fresno County’s Department of Public Health.
Doctors and nurses are also working to reduce their own risk so they can remain on the job and even continue working if they get sick.
“There will probably be a portion of health care providers that get sick but can still do their jobs,” Weichenthal said. “They can be at home doing telemedicine and helping out with a certain part of our clinical load without exposing our patients.”
Some hospitals and clinics have turned to teleconferencing where patients are examined via video chats on computers or over the telephone. UCSF Fresno has already implemented this technique with health care workers who may have been exposed to the virus from traveling to other parts of the state with more cases.
Weichenthal said those efforts should reduce exposure for doctors and patients.
More workers on the way
Even before the COVID-19 pandemic, experts were working on bolstering the Central Valley’s shrinking medical workforce, trying to stay ahead of a string of medical retirements expected in coming years.
And some younger workers are on their way.
Seventy-one medical school students will begin their residencies at UCSF Fresno in June. Two of those are coming in through the San Joaquin Valley Program in Medical Education. The tailored track allows students from the Valley to return and grow the local workforce.
As they begin, the senior class leaves, which represents about 100 health care workers. But 45 to 50% of graduating residents stay in the Valley, Weichenthal said.
She added that UCSF is already working to develop contingency programs to bring in the new students.
“People are going to be traveling from all over the country to come train here. How do we make sure they’re not infected? A lot of planning for the pandemic is thinking ahead of the curve and trying to prevent the worst possible scenarios.”
But it remains unlikely these workers will be ready to fill the void as the crest of the coronavirus wave hits the Valley, which Weichenthal said experts predict will be in two to three weeks.
Not enough doctors, not enough beds
In the case of a moderate outbreak in the Fresno area in which about 40% of the population is infected over the next year, local hospitals would need nearly five times as many beds, according to estimates released by the Harvard Global Health Institute put together by ProPublica.
Intensive care beds would be particularly strained. Without coronavirus patients, there are only 77 available beds in local intensive care units, which is almost seven times less than what is needed to care for all severe cases.
Valley hospitals are already seeing supply shortages. David Pomaville, director of the Fresno County Department of Public Health, told The Bee that shortages in masks, gowns and other equipment are expected to last a few weeks. Requests have been put in to the state for masks and gowns.
Government officials have been urging people to donate their masks to hospitals. Fresno Unified, for example, has donated to hospitals protective equipment that would have normally been used for students and staff.
Peachwood Medical Group in Clovis closed its urgent care center due to a lack of protective gear. And many of their urgent care providers were part of the aging population asked to stay home.
Federally qualified health clinics, which usually provide free care to MediCal populations, have propped up across the Valley’s rural communities in recent years. But with extra precautions to prevent the spread of the virus, even those clinics may be at risk, according to U.S. Rep. TJ Cox of Fresno.
“Right now, I’m getting calls from federally qualified health clinics about how this is putting them in dire straits. They’re our primary health care providers but with people not coming in, and they shouldn’t unless they’re showing symptoms, their revenues are dropping precipitously.”
Cox has urged Congressional leadership to consider rural communities in a COVID-19 stimulus package, as well as ensure immigrants receive equal free access to coronavirus testing.
“I just want to make sure rural communities are prioritized with funding and resources we need and haven’t gotten in the past,” he told The Bee. “Here in the Valley, our dollars go to Washington and they don’t come back. I’m simply asking for our fair share so our residents are not overlooked because they are typically older, more economically disadvantaged and a lot of times sicker than the average population.”
Doctor shortages aren’t only concern
All of this is bad news for a population that experts say is particularly vulnerable to severe illness from the coronavirus.
Experts said chronic health conditions that are prevalent in the Valley are likely to make its COVID-19 cases more severe. Asthma, diabetes and hypertension are all coronavirus risk factors and more common in the Fresno area.
“Many of the diseases our population suffers from puts people at worse risk with the virus,” Weichenthal said.
About 11.3% of Fresno County suffers from asthma, according to 2015-16 state data, compared with 8.7% of California. About a third of Valley residents are obese, compared with about a quarter of Californians.
Weichenthal said the main areas impacted by the coronavirus so far have been large population centers, as people live closer together and are less able to self-isolate. Rural communities may be less impacted because they are spread farther apart. But they’re by no means immune, and accessing care for them is harder.
“There are not a lot of hospitals in our rural communities and we have a lot that have closed in the last 10 to 15 years,” Weichenthal said. “We have one in Reedley and one in Selma. A lot of people who live in rural communities who need hospitalization or acute care have to come into Fresno or Madera to get that.”
Because they tend to live farther away from health care providers, rural communities also suffer more severe forms of chronic diseases, she said. They sometimes put off care until it’s too late.
Phoebe Seaton, co-founder and co-director of Leadership Counsel for Justice and Accountability, said rural areas house a disproportionate number of farmworkers, who can’t count on the luxury of staying home as the health crisis worsens.
“There has been no slowdown, probably an increase in shifts, and we are not getting a lot of reassurances around social distancing in those places,” Seaton said.
Those communities are also disproportionately immigrants, adding immigration enforcement to their list of worries.
“We are hearing that some people are going to be less likely to seek medical help if they are concerned about immigration enforcement,” she added. “It’s a health disadvantage now on steroids.”
Manuela Tobias is a journalist at The Fresno Bee. This article is part of The California Divide, a collaboration among newsrooms examining income inequity and economic survival in California.
The Bee’s Brianna Calix contributed to this report.