For most Californians, the continuing drought means a crash course in learning how to conserve water and adjusting to warmer temperatures. But for some of the state’s residents, the drought has also brought about increased health challenges.

From reports of West Nile Virus and Valley fever, to a greater incidence of respiratory illnesses, the state’s changing climate continues to yield a variety of health concerns. As the California drought enters its fourth year, health officials are seeing how increased air pollution and fires, food and water contamination, and new pests and pathogens are all impacting public health.

A Spike in Air Pollution and Respiratory Problems

Many rural towns in California have been hit especially hard. One of the areas most severely affected is East Porterville, a town located 75 miles southeast of Fresno and composed primarily of low-income Latino farm workers. As residents struggle with a lack of running water and increasingly dusty air, local hospitals have reported an increase in patients suffering from respiratory problems.

The Sierra View Medical Center in nearby Porterville says the number of patients visiting the emergency room and complaining of breathing issues, has increased by more than 25 percent over the past five years. Other hospitals report similar findings.

“We have definitely seen more cases of asthma and Chronic Obstructive Pulmonary Disease (COPD),” says John Gasman, a pulmonologist and chief of pulmonary services for Kaiser Permanente, Fresno. “The drought affects air quality, and increases dust, and grass fires, leading to allergies, asthma and chronic bronchitis. “

In their 2015 State of the Air report released in April, the American Lung Association (ALA) noted that particle pollution has increased in 25 California counties. Throughout the state, 28 million people live in counties that received a failing grade for air quality, making up 73 percent of the state’s population.

Numerous fires in the state, combined with temperatures well over 100 degrees, are two factors that public health officials say are adding to the rise in acute lung problems. And while doctors used to see cases of asthma peak during the autumn months, they are now seeing flare-ups year-round, with patients reporting symptoms such as coughing and wheezing lasting for longer periods of time.

“Since the drought began, the volume of air particles has been spiking throughout the year due to lack of rain and a longer wildfire season,” Gasman says. “Here in the San Joaquin Valley, we are surrounded by mountain ranges and get little coastal air, so the air and soot are basically trapped.”

While Gasman says that children, the elderly, and those with asthma, heart, and lung conditions are most vulnerable to the effects of air pollution, he cautions everyone to be to be on alert when the air is smoky and polluted.

“To avoid breathing problems, we advise the public to limit their time outdoors, close the windows in their homes, and avoid any strenuous outdoor activities on ‘Spare the Air’ days,” Gasman says. “People who are at high-risk may want to consider taking a vacation, or at least leaving the valley until the air clears.”

In Search of Safe Water

In rural communities such as East Porterville and other agricultural areas, residents who are not connected to a water system rely on private wells supplied by groundwater. But with the continued drought, these wells are running low on water and many have become contaminated with bacteria and nitrates. Less rainfall also means that contaminants become more concentrated in the groundwater.

In July, the U.S. Geological Society released a survey showing that about one-fifth of the state’s raw groundwater contains high levels of contaminants. The study also reported that several million people in California rely on public water systems whose raw supplies have potentially unsafe levels of uranium, arsenic and manganese, contaminants that can lead to health issues, including gastrointestinal illness, reproductive problems, and neurological disorders.

Tulare County has received more than 1,500 dry well reports, says Karen Haught, Tulare County’s Public Health Officer.

“Our Office of Emergency Services has water delivery programs in place to deliver bottled water, a mobile shower unit and 2,500-gallon potable water tanks that are placed outside a home and connected to each home’s plumbing system,” Haught says. “We’re also working to continually expand the program and looking at long-term solutions in the event the drought continues.”

While water deliveries help with running toilets and showers, the supply often isn’t enough for residents to use in cooking or washing dishes. Their dry wells also pose a long-term problem for residents on fixed incomes since they typically have to bear the cost of fixing or re-drilling wells. Last year, Tulare County received $4.1 million from the United States Department of Agriculture (USDA) to help defray the costs of installing new wells, pumps and electrical systems, but for many of East Porterville’s residents who work on farms, the cost of a new well, ranging from $10,000 to $30,000, is still prohibitive.

Rise in West Nile Virus and Valley Fever

Experts at the California Department of Public Health say the ongoing drought is also creating favorable conditions for infectious diseases once only seen in hotter, drier, climates. In April, state health officials reported that last year California saw a record-breaking number of deaths related to the West Nile virus (WNV) with 31 fatalities recorded.

“Drought years are worse for WNV and other mosquito-borne diseases than years with more rain because there are fewer watering holes forcing birds and mosquitoes to congregate at the same locations,” says Deborah Bass, public affairs manager for the Contra Costa Mosquito and Vector Control District, who reports that her county actually has less WNV activity than in years past. “Birds are the reservoir for the virus and mosquitoes pick up the virus from the birds when they take a blood meal from them. The mosquitoes can transmit the disease when they subsequently bite people.”

Bass says how WNV will impact the state if the drought continues remains unclear.

“While we have less WNV activity than last year, there are many factors to contemplate,” says Bass. “According to a report released in August by the California water boards, residents reduced their water usage in June by 31 percent. Less landscape watering leads to less water in the street catch basins, a prominent place for mosquitoes, especially the species that transmit West Nile virus, to thrive. “

In addition to WNV, the changing climate has also been linked to increased cases of Valley Fever, a respiratory infection caused by microscopic spores that live in the soil, and is spread through the air when dirt is disturbed or kicked up and then inhaled. According to the state’s department of public health, cases of Valley Fever have been reported in most California counties, with cases quintupling from 816 in 2000 to more than 4,000 cases in 2012. More than 75% of Valley Fever cases occurred in San Joaquin County.

Earlier this year, the state had to move more than 2,100 inmates from Avenal and Pleasant Valley state prisons to another prison after showing they were susceptible to contracting valley fever. Skin tests showed that another 3,050 inmates have already been exposed to the illness.

In surveying residents in Tulare County, one of the hardest hit by the drought, Dr. Haught has found that one of the most common health implications is the social impact that the drought is having on families.

“One of the main things we hear is that people are experiencing an increase of stress and anxiety not knowing how they will continue to obtain water if the drought continues,” Haught says. “And for the many people who work in farming and nurseries, the drought is tied to their livelihood, which can also bring about financial worries.”