As California struggles to contain an increasing number of H5N1 bird flu outbreaks at Central Valley dairy farms, veterinary experts and industry observers are voicing concern that the number of cattle deaths is far higher than anticipated.

Although dairy operators had been told to expect a mortality rate of less than 2%, preliminary reports suggest that between 10% and 15% of infected cattle are dying, according to veterinarians and dairy farmers.

“I was shocked the first time I encountered it in one of my herds,” said Maxwell Beal, a Central Valley-based veterinarian who has been treating infected herds in California since late August. “It was just like, wow. Production-wise, this is a lot more serious than than we had hoped. And health-wise, it’s a lot more serious than we had been led to believe.”

A total of 56 California dairy farms have reported bird flu outbreaks. At the same time, state health officials have reported two suspected cases of H5N1 infections among dairy workers in Tulare County, the largest dairy-producing county in the nation. With more than 600,000 dairy cows, the county accounts for roughly 30% of the state’s milk production.

Beal’s observations were confirmed by others during a Sept. 26 webinar for dairy farmers that was hosted by the California Dairy Quality Assurance Program — an arm of the industry-funded California Dairy Research Foundation. A summary of the findings and observations was reported in a newsletter published earlier this week by the program.

Beal, along with Murray Minnema, another Central Valley veterinarian, and Jason Lombard, a Colorado State University veterinarian, described their observations and data to dairy farmers to help them anticipate the signs of, and treatments for, the virus.

The webcast was not made available to The Times.

“The animals really don’t do well,” Beal told The Times.

He said the infected cows he has seen are not dissimilar to people who are suffering from a typical flu: “They don’t look so hot.”

He and others think the recent heat may be a factor.

Since the end of August, the Central Valley has suffered multiple heat waves, with daytime temperatures exceeding 100 degrees.

“Heat stress is always a problem in dairy cattle here in California,” he said. “So you take that, you add in this virus, which does have some affinity for the respiratory tract … we always see a little bit of snotty noses and heavy breathing in animals that are affected … and for some of them, just the stress takes them.”

Indeed, most of the deaths are not directly the result of the virus, he said, but are “virus adjacent.” For instance, he has seen a lot of bacterial pneumonia, which is likely the result of the cow’s depressed immune system, as well as bloat.

He said that when the cows aren’t feeling well, they often don’t eat.

“The digestive tract, or rumen, basically requires movement. There has to be things moving out of that rumen constantly in order for the pH balance and microbiome to stay where it should be,” he said. So, when they’re not eating, things in the digestive tract stagnate.

That, in turn, causes them to “asphyxiate because their diaphragm has too much pressure on it.”

In addition, he and others are seeing a lot of variation in the duration of illness.

While early reports had suggested the virus seemed mild and lasted only about a week or two, others are seeing it last several weeks. According to the industry newsletter, at one dairy, cows were shedding virus 14 days before they showed clinical signs of illness. It then took another three weeks for the cows to get rid of the virus.

They’re also noticing the virus is affecting larger percentages of herds — in some cases 50%-60% of the animals. This is much more than the 10% that had been previously reported.

Some say the actual rate may be even higher.

“I would speculate infection is even higher; 50-60% are showing clinical signs due to heat stress or better herd monitoring earlier in infection. Unfortunately, few or no herds have been assessed retrospectively through serology testing to determine actual infection rates,” said John Korslund, a retired U.S. Department of Agriculture veterinarian epidemiologist.

Cows are also not returning to 100% production after they’ve cleared the virus, said Beal. Instead, he and others say it’s closer to 60%-70%.

“There’s going to be some animals that are removed from the herd, because they never seem to come back,” he said.

Beal said his firsthand observations have really challenged his notions about the disease, which has so often been described as mild and insignificant.

“Once I saw it myself, I said, this is something I need to communicate with my clients about … this is not something that is just a joke at the dinner table,” he said. “I didn’t want people to not take it seriously, because I see what it is doing to the animals, and it is rough to see — as an animal caretaker, as a veterinarian like myself — it’s just not something that’s enjoyable. It’s more serious than we had been led to believe.”

He said he is working hard with Central Valley farmers to treat the animals — largely by making sure the cattle are adequately hydrated. He also treats sick cows with a medication similar to aspirin, to reduce fever, pain and discomfort.

He said the treatment is pretty effective, and seems to be helping.

Others are not surprised H5N1 is becoming more severe in cows.

“As I’ve said since we first learned of the outbreak in dairy cows, nothing we’ve learned about this virus is new or unexpected,” said Rick Bright, a virologist and former head of the U.S. Biomedical Advanced Research and Development Authority. “It’s behaving exactly as we’ve come to know of this virus over the past 25 years. It’s spreading very efficiently now among mammals, and it’s mutating and adapting to mammals as it does.”

He credited state health officials and veterinarian for “being more forthcoming and transparent with their data” than other states, and said this may be the reason the virus seems to be hitting California cows so hard.

“This virus is out of control. It is time for urgent and serious leadership and action to halt further transmission and mutation,” Bright said. “The concept of letting it burn out through food animals, with unmonitored voluntary testing, has failed. There are pandemic playbooks that we need to dust off and begin to implement.”

In the meantime, officials continue to reassure the public about the safety of the nation’s dairy supply. They say pasteurization inactivates the virus. They also warn people to stay away from raw milk.

Beal noted one of the sentinel signs that a farm has been infected is dead barn cats that have drunk the infected, raw milk.

“It’s weird, actually, how consistently that seems to be happening everywhere,” he said. “It’s pretty sad and shocking. But that’s one of the first things that people see sometimes.”

There is also some suggestion that some cows that have recovered from the virus have been reinfected, although this has not been confirmed.

“We don’t have any data to support this yet, but there have been anecdotal reports of reinfections in herds,” said Kay Russo, a dairy-poultry vet with RSM Consulting, an international consulting firm.

She said it could just be a persistent infection that is being observed, but also speculated that the virus could be mutating rapidly — and evolving “enough to reinfect an animal.”

And Jason Lombard, one of the speakers at the dairy webinar, said in an email that he had been told by veterinarians that they are observing clinical signs of disease in animals that had been infected, “but I don’t believe any of them have been confirmed via testing.”

As of Oct. 4, California officials have reported 56 infected herds. Although state officials will not disclose the location of these herds, the Valley Veterinarians Inc. website — a veterinary clinic run by large-animal vets in the Central Valley — said the infections are in Tulare and Fresno counties.

Steve Lyle, a California Department of Food and Agriculture spokesman, would not confirm the counties.

There are more than 200 herds in Tulare County and more than 100 in Fresno County. The state’s largest raw milk dairy is also in Fresno County.

Requests by The Times to observe infected farms or speak with the owners of infected dairies went unanswered by the state and declined by industry insiders.

“We are not recommending farmers engage on this due to farm security issues we’ve had,” said Anja Raudabaugh, chief executive officer of Western United Dairies, an industry trade group for California dairy farmers. “It is very unwise to consider viewing a dairy under quarantine … this is just not the time.”

She said her organization doesn’t want anyone “doxing” farmers or increasing traffic at or near a farm, “both of which have happened.”

In the last week, the H5N1 virus has been detected in wastewater samples collected in Turlock, San Francisco, Sunnyvale and Palo Alto.

State epidemiologist Erica Pan said it was hard to know where the virus is coming from. While Turlock is a dairy center, the hits in the Bay Area cities could potentially be from wild birds, she said, but the source is not known.

“When will I see the doctor?” Most female doctors have been asked this question many times. It feels like a slight — a failure to recognize the struggle it took to get to where they are, a fight that is far from over once a woman has her medical degree.

Women now make up more than half of medical students but only about 37% of practicing doctors. That is partly because the makeup of the medical workforce lags that of the student body. But it’s also because persistent sexism drives higher attrition among women in medicine.

Even in households headed by a mother and father who both work, the woman is frequently expected to be the primary caretaker. As a result, female physicians often feel forced to work part time, choose lower-paying specialties such as pediatrics or leave the profession altogether.

That’s unfortunate not just for doctors but also for patients. On the whole, female doctors are more empathetic, detail-oriented and likely to follow through than their male counterparts. In other words, they are better doctors.

Admittedly, that is a generalization, but it’s one worth making. I experienced it firsthand working with female colleagues, and I’m informed by that experience in addressing my own medical needs. I prefer to see female doctors.

It wasn’t always that way. But after seeing a series of male doctors who were not listening to me, in a hurry to get out of the exam room or appearing only mildly interested in figuring out the cause of my problem, I made the switch — and I’m not going back. While I found that male doctors typically decided what my diagnosis was and how to treat it before entering the exam room, female doctors tended to be open-minded about what my medical issues were and — gasp! — listen to my answers to their questions.

But don’t take my word for it. Look at the data.

One recent study found that both female and male patients had lower mortality rates when they were treated by female physicians. Perhaps not surprisingly, the benefits of getting care from women were greater for women than for men.

“What our findings indicate is that female and male physicians practice medicine differently, and these differences have a meaningful impact on patients’ health outcomes,” said Yusuke Tsugawa, a senior author of the study.

Female doctors seem more likely to discover the root cause of a medical problem, as we are taught to do in medical school, rather than merely treat the symptoms.

“Female physicians spend more time with patients and spend more time engaging in shared medical decision-making,” Dr. Lisa Rotenstein, a co-author of the study, told Medical News Today. “Evidence from the outpatient setting demonstrates that female physicians spend more time on the electronic health record than male counterparts and deliver higher-quality care. In the surgical realm, female physicians spend longer on a surgical procedure and have lower rates of postoperative readmissions. We need to be asking ourselves how to provide the training and incentives so that all doctors can emulate the care provided by female physicians.”

One reason for the discrepancy might be male doctors’ propensity to be more ego-driven. They may revert to “mansplaining” to patients instead of engaging in an equal, cooperative patient-physician relationship. I’ve been guilty of that myself, so I know it when I see it.

What’s blocking women’s advancement in medicine? Old-fashioned sexism in the workplace is the most obvious answer. Female doctors are paid 25% less than their male counterparts on average, according to the 2019 Medscape Physician Compensation Report, earning an estimated $2 million less over a 40-year career.

There is also a power imbalance. Men are more likely to be full professors at medical schools and presidents of professional medical associations. A 2019 survey found that women oncologists were less likely than their male counterparts to attend scientific meetings because of child care and other demands. And anyone in medicine will attest that these conferences provide opportunities to angle for leadership positions.

Excluding women from leadership deprives young female doctors of role models. While I haven’t seen female doctors being asked to get coffee for their male colleagues (though I have seen women nurses asked to do so, even recently), the unequal distribution of responsibilities is undeniable. Female physicians are often overburdened with menial, uncompensated assignments, secretarial tasks and committee service that does not necessarily lead to promotions, taking precious time away from activities that would be more likely to advance their careers.

These and other factors lead to higher burnout rates among women physicians. A 2022 American Medical Assn. survey found that 57% of female physicians reported suffering at least one symptom of burnout, compared with 47% of men.

“Women physicians are paid less than men, work harder, have less resources, are less likely to be promoted and receive less respect in the workplace,” Roberta Gebhard, a former president of the American Medical Women’s Association, told the Hill. “With all of these barriers to success in the workplace … it’s no wonder that women physicians are more likely to stop practicing than men.”

The patriarchal system is alive and well in medicine, and it isn’t helping our patients. We must address this antiquated disparity. It is incumbent on medical institutions to champion female physicians, not only as rank-and-file doctors but also as leaders of the profession and its organizations. Patients should also examine their own assumptions and challenge the notion that seeing a male doctor will yield better results.

It’s time for doctors to live up to one of the highest ideals of medicine: that all people should be treated equally. That includes female physicians.

David Weill is a physician, a former director of Stanford’s Center for Advanced Lung Disease, the principal of the Weill Consulting Group and the author, most recently, of “All That Really Matters.”

When Nora Bruhn bought admission to the Lightning in a Bottle arts and music festival on the shores of Kern County’s Buena Vista Lake earlier this spring, her ticket never mentioned she might end up with a fungus growing in her lungs.

After weeks of night sweats, “heaviness and a heat” in her left lung, a cough that wouldn’t quit and a painful rash on her legs, her physician brother said she might have valley fever, a potentially deadly disease caused by a dust-loving fungus that lives in the soils of the San Joaquin Valley.

Bruhn said she hadn’t been warned beforehand that Kern County and Buena Vista Lake are endemic for coccidioides — the fungus that causes the disease.

“If there had been a warning that there’s a potentially lethal fungal entity in the soil, there’s no way I would have gone,” said the San Francisco-based artist. “Honestly, I would have just been paranoid to breathe the whole entire time I was there.”

The incidence and range of valley fever has grown dramatically over the last two decades, and some experts warn that the fungus is growing increasingly resistant to drugs — a phenomenon they say is due to the spraying of antifungal agents on area crops.

As annual cases continue to rise, local health officers have sought to increase awareness of the disease and its symptoms, which are often misdiagnosed. This messaging however focuses only on Kern County and other Central Valley locations and rarely reaches those who live outside Kern County, or other high-risk areas.

In the case of the Lightning in a Bottle festival, Bruhn said she wasn’t provided with any information about the risk on her ticket, or in materials provided to her by the event organizers. As far as she can recall, there were no signs or warnings at the site where she ate, slept, danced and inhaled dust for six straight days.

And she wasn’t the only one infected. According to state health officials, 19 others were diagnosed with coccidioidomycosis in the weeks and months following the event. Five were hospitalized.

According to a statement provided by the California Department of Public Health, officials have been in communication with organizers and “encouraged” them to notify “attendees about valley fever and providing attendees with recommendations to follow up with healthcare providers if they develop illness.”

Do LaB, the company that stages the festival, said through a spokesperson that it adheres to the health and safety guidance provided by federal, state and local authorities. “Health and safety is always the primary concern,” they said.

The company’s website warns festivalgoers about the prevalence of dust — but doesn’t mention the fungus or the disease.

“Some campgrounds and stage areas will be on dusty terrain,” the website says. “We strongly recommend that everyone bring a scarf, bandana, or dust mask in case the wind kicks up! We also recommend goggles and sunglasses.”

Bruhn said that’s not enough.

“I think it’s really irresponsible to have a festival in a place where breathing is possibly a life-threatening act,” she said.

Kern County’s health department is also in discussions with the production company.

In California, the number of valley fever cases has risen more than 600% since 2000. In 2001, fewer than 1,500 Californians were diagnosed. Last year, that number was more than 9,000.

Most people who are infected will not experience symptoms, and their bodies will fight off the infection naturally. Those who do suffer symptoms however are often hard-pressed to recognize them, as they resemble the onset of COVID or the flu. This further complicates efforts to address the disease.

Take for example the case of Brynn Carrigan, Kern County’s director of public health.

In April, Carrigan began getting a lot of headaches. Not really a “headache person,” she chalked them up to stress: Managing a high-profile public health job while also parenting two teenagers. But as the days and weeks went by, the headaches became more frequent, longer in duration and increasingly painful. She also developed an agonizing sensitivity to light.

“I’ve never experienced sensitivity to light like that … all the curtains in my house had to be closed. I was wearing sunglasses inside — because even the clock on my microwave and my oven, and the cable box … oh, my God, it caused excruciating pain,” she said. In order to leave the house, she had to put a blanket over her head because the pain caused by sunlight was unbearable.

She also developed nausea and began vomiting, which led to significant weight loss. Soon she became so exhausted she couldn’t shower without needing to lie down and sleep afterward.

Her doctors ordered blood work and a CT scan. They told her to get a massage, suggesting her symptoms were the result of tension. Another surmised her symptoms were the result of dehydration.

Eventually, it got so bad she was hospitalized.

When test results came in, her doctors told Carrigan she had a case of disseminated valley fever, a rare but very serious form of the disease that affects the brain and spine rather than the lungs. In retrospect, she said she probably had the disease for months.

Valley fever, a fungal infection, spreads through dust.

(Jason Armond/Los Angeles Times)

And yet, here she was, arguably the most high-profile public health official in a county recognized as a hot spot for the fungus and the disease, misdiagnosed by herself and other health professionals repeatedly before someone finally decided to test her for the fungus.

Now she’ll have to take expensive antifungal medications for the rest of her life — medication that has resulted in her losing her hair, including her eyelashes, as well as making her skin and mouth constantly dry.

As a result of Carrigan’s experience, her agency is running public service announcements on TV, radio and in movie theaters. She does news conferences, talks to reporters and runs presentations for outdoor workforces — solar farms, agriculture and construction — to educate those “individuals that have no choice but to be outside and really disturbing the soil.” She’s also hoping to get in schools.

But she realizes her influence is geographically constrained. She can really only speak to the people who live there.

For people who come to Kern County for a visit — like Bruhn and the 20,000 other concertgoers who attended Lightning in a Bottle this year — once they leave, they’re on their own.

A truck raises dust on a dirt road in Bakersfield in March 2022.

(Jason Armond/Los Angeles Times)

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Outside of California, valley fever is also prevalent in Arizona and some areas of Nevada, New Mexico, Utah and Texas, as well as parts of Mexico and Central and South America

Experts worry that as the range of valley fever spreads — whether by a changing climate, shifting demographics, or increased construction in areas once left to coyotes, desert rodents and cacti — more and more severe cases will appear.

They’re also concerned that the fungus is building resistance to the medicines used to fight it.

Antje Lauer, a professor of microbiology at Cal State Bakersfield and a “cocci” fungus expert, said she and her students have found growing pharmaceutical resistance in the fungus, the result of the use of agricultural fungicides on crops.

She said the drug fluconazole — the fungicide doctors prescribe off-label to treat the disease — is nearly identical in molecular structure to the antifungal agents “being sprayed against plant pathogens. … So when a pathogen gets exposed via those pesticides, the valley fever fungus is also in those soils. It gets exposed and is building an immunity.”

It’s the kind of thing that really concerns G.R. Thompson, a professor of medicine at UC Davis and an expert in the treatment of valley fever and other fungal diseases.

“If you ask me, what keeps you up at night about valley fever or fungal infections?, it’s what we do to the environment” he said. “We learned that giving chickens and livestock antibiotics was bad, because even though they grew faster, it led to antibiotic resistance. Right now, we’re kind of having our own reckoning with fungal infections in the environment. We’re putting down antifungals on our crops, and now our fungi are become resistant before our patients have ever even been treated.”

He said he and other health and environment professionals are working with various local, state and federal agencies “to make sure that everybody’s talking to each other. You know that what we’re putting down on our crops is not going to cause problems in our hospitals.”

Because at the same time, he said, there’s a growing concern that the fungus has become more severe in terms of clinical outcomes.

“We’re seeing more patients in the hospital this year than ever before, which has us wondering … has the fungus changed?” he said, quickly adding that health experts are actively investigating this question and don’t have an answer.

John Galgiani, who runs the Valley Fever Center for Excellence out of the University of Arizona in Tucson, is hopeful that a vaccine may be forthcoming.

He said a Long Beach-based medical startup called Anivive got a contract to take a vaccine that’s being developed for dogs — outdoor-loving creatures with noses to the ground and a penchant for digging, and therefore susceptible to the disease — and reformulate it to make it suitable for human clinical trials.

He said prison populations, construction workers, farmworkers, firefighters, archaeologists — anyone who digs in the soil, breaths it in or spends time outdoors in these areas — would be suitable populations for such inoculations.

But he, like everyone else The Times spoke with, believes education and outreach are the most important tools in the fight against the disease.

As there is with any other risky activity, he said, if people are aware, such knowledge empowers them with choice — and in this case, the tools they need to help themselves should they fall ill.