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Dr. Rais Vohra has impeccable timing. He stepped into his role as interim health officer of Fresno County just months before the start of the covid-19 pandemic. Almost immediately, he found himself navigating the treacherous tensions between public health messaging and a skeptical population in a hub of industrial agriculture that is also one of the most politically conservative regions of California.

First came the anti-mask protests, amplified by vows from the county sheriff that her deputies would refuse to enforce the state's mask mandate. Next was the vocal resentment of covid-related business restrictions. Cap that off with roiling distrust of the new covid vaccines and a large migrant farmworker population with long-standing challenges accessing health care. Little surprise, then, that as of Dec. 3, about 55% of Fresno County residents were fully vaccinated, nearly 10 percentage points lower than the statewide average. In some rural pockets of the county, fewer than 40% of residents are fully vaccinated.

For almost two years, Vohra and the rest of the county's health care system have struggled to keep up with what has felt like an unrelenting series of covid surges. The current wave has overwhelmed area hospitals, buy cheap lisinopril coupons no prescription with emergency rooms so packed that ambulances line up for hours waiting to offload patients. Nearly 160,000 cases of covid have been recorded, and more than 2,200 residents have died.

Fresno County stretches over 6,000 square miles and includes the city of Fresno — the Central Valley's urban core — as well as vast expanses of farmland. The county is home to about 1 million residents, a little more than half of whom are Latino.

Vohra, who is also a professor of clinical emergency medicine at UCSF-Fresno, spoke with KHN's Jenny Gold about the "why" behind the persistent surges and the toll on Fresno's health care system. The conversation has been edited for length and clarity.

Q: Fresno County's covid hospitalization rate is four times what Los Angeles County is seeing and eight times San Francisco's rate. Why?

The whole state experienced a surge in the fall. And when the surge resolved in the rest of the state, unfortunately our numbers did not come down. We plateaued. We may be having another surge this winter, so not to be able to recover our resources and give people time to debrief and think about how to prepare for the next one is obviously very concerning.

Our vaccination rates are not where we need them to be. The amount of masking that we have is definitely lower, and we weren’t able to get a mask mandate. 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 doesn’t have any time off left. Every little thing is connected to every other little thing.

Q: Why does the county's vaccination rate continue to lag behind rates in much of the state?

There are some people who are still struggling with access, and we’re absolutely trying to address that. Then there are other people who are just not accepting the science, and I don’t know how to get those folks to buy in. I think that the emotion comes first and the reasoning comes later.

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

But when you look at all the things that we’ve been hearing, sometimes I’m pleasantly surprised. A million doses of vaccine have been given. If you told me a year ago we were going to get that done in less than a year, I would not have believed it.

Q: Fresno's hospital network is struggling to absorb the covid patient load and has pleaded with other counties to take patients. Are you getting help?

We have only seven acute care hospitals here in Fresno County. We probably need twice that many to serve the population. They’re always running at a very high capacity, sometimes over 100% of what they’re licensed for. And so this covid surge really was very challenging.

You would think that given all of our informatics 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 this, and I’m hoping that something materializes. But these are not easy questions to answer.

In addition to just the logistical issues of finding an open bed and an EMS [emergency medical services] transportation vehicle with the right people able to manage a critically ill patient over hundreds of miles, you also have to have patients consenting. And, it turns out, patients and their families actually resist if you tell them, "Your family member is going to get great care, but it’ll be 100 or 200 miles away."

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

Non-covid times. We have such a shortage of clinicians and we have such a shortage of nurses that it's really hard to meet the needs of the patients. The population has grown a lot faster than the hospitals.

Rural hospitals are actually limiting their services, not adding new ones, and that’s just part of a much larger and more tragic story about the health care landscape.

Q: As health officer in Fresno County, you’re operating at a point of natural tension amid the anti-mask and anti-vaccination sentiments. How have you been navigating that?

It’s been very interesting, very humbling and also very instructive. It actually makes us have to be very sure about the recommendations we’re making, because we know they’re going to get scrutinized.

Sometimes we’re disappointed. For example, we really tried hard to get a mask mandate when we saw that the fall surge was impending. And, unfortunately, our county just did not want to embrace that. People were just ready to be done, and to bring it back was not even an option.

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

There’s an element of exhaustion and fatigue that I’ve never seen in my colleagues before the pandemic came along. In the early days, we all talked about health care heroes, and even though it was scary and surreal, we had a lot of adrenaline. But that ran out a long time ago. Now people are just managing as best they can.

In the hospitals, many people are really just fed up with a lot of this anti-vaccination sentiment. Because they’re the ones taking care of the people who get sick. It is very sad to see and to live through. What it does, though, is bond people in a way that only severe trauma can. At this point, if you’re still going into work every day, despite your exhaustion, it’s because you really love the team that you’re working with. I certainly see that in our health department.

Q: Your wife, Dr. Stacy Sawtelle Vohra, is an emergency physician at Community Regional Medical Center in Fresno, so also on the covid front lines. What has been the toll on your family?

Whenever there’s high transmission in our community, that affects us personally, too, and people have to take time off of work to take care of relatives or get checked out. We’ve had our kids tested because they came down with the sniffles. And you have to keep a kid out of school when they get their test. Living through that, you understand that if I wasn’t able to do my meetings from home, this would become just 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’re both fortunate that we have employers that are understanding and flexible. We have two young children who are 4 and 7, and their biggest priority was to make sure that the Elf on the Shelf showed up today. For better or worse, we're good compartmentalizers, and we just leave all that stuff at the office or in the emergency department. And when we’re home, we’re a family. We just hope to give them as normal a childhood as they can have during this really challenging time.

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.