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For weeks, Rachel Willard, the county health director in Wilkesboro, North Carolina, had watched with alarm as COVID-19 cases rolled in from the Tyson Foods chicken plant in the center of town. Then Tyson hired a private company to take over testing, and the information suddenly slowed to a trickle.
Blinded to the burgeoning health crisis, Willard and her small staff grew increasingly agitated. The outbreak had already spread across 100 miles of the North Carolina piedmont, and two workers had died. But nearly a week after Tyson's testing ended in May, the county health agency had received less than 20% of the results. The little information it did receive was missing phone numbers and other data, hindering critical efforts to follow up with infected workers, to tell them to isolate and to trace their contacts.
"Our fear and alarm is the fact that close contacts and positive cases are walking around, potentially shedding the virus and infecting others," Willard, who was coordinating the response while on maternity leave, wrote to state officials on May 14.
Only after the state public health director warned Tyson that failure to turn over information could result in "injunctive relief or prosecution" did the testing company release the information. As of Wednesday, 599 workers had tested positive, more than a fifth of the plant's workforce.
The dangerous delay by the nation's largest food company is one of a series of breakdowns revealed in tens of thousands of pages of emails, text messages, meeting notes and reports that ProPublica obtained from dozens of public health agencies across the country.
As the coronavirus swept through the nation's meatpacking plants this spring, chaotic scenes like those in Wilkesboro have played out in small towns that have become some of the country's biggest hot spots. The candid, often emotional messages provide a real-time reckoning of how the companies responsible for a critical part of the food supply chain were hazardously unprepared and how a system that relied on tiny local public health agencies was quickly overwhelmed by the consequences.
In Tama, Iowa, where more than 250 workers at a National Beef plant tested positive for the virus, one local health official emailed her colleagues a meme of the chef Gordon Ramsay shouting, "SHUT IT DOWN!"
"They just don't get it!" Mindy Benson, the county emergency management coordinator, later wrote to the group. "They will keep going until all of their employees have this virus. They would rather risk their employees' health and keep their production going." (National Beef did not return calls and emails seeking comment.)
The nation's meatpackers along with federal and state officials have for years planned for pandemic flu outbreaks that could wipe out herds and flocks and threaten America's food supply. But those efforts focused on animals rather than the army of humans -- mostly immigrants, refugees and African Americans -- hired to slaughter them and cut them up for restaurants and groceries.
The failure to have a coordinated plan for workers left small, often rural communities vulnerable. More than 24,000 coronavirus cases have been tied to meatpacking plants, ProPublica has found. Though many haven't suffered severe symptoms, at least 87 workers have died. More than 25 of the dead worked for Tyson.
The coronavirus response was complicated by a lack of clarity over which agency had the authority to order meatpacking plants to make changes or shut down. The Centers for Disease Control and Prevention could only offer guidance. The U.S. Department of Agriculture dealt with animals and food. The Labor Department had few rules that applied to a virus. And the power of local and state health officials varied from state to state.
In an emailed response to questions, Tyson acknowledged the delay in releasing the test results in North Carolina. "When we learned that there was a delay with our lab partners, we acknowledged the urgency of the situation and worked to address the situation immediately," spokesman Gary Mickelson said.
He said Tyson formed a coronavirus task force in January to assess risks and work on mitigation plans and began engaging with the CDC and other health officials shortly thereafter. "At the majority of our facilities across the country, there have been no cases of COVID-19 that we know of," he said. ProPublica found cases at slightly less than half of Tyson's major processing plants.
But the scores of emails and other records show that best practices to protect workers, such as slowing the processing line to accommodate social distancing, installing plexiglass barriers and having workers wear masks, weren't implemented until outbreaks began to occur. Instead, meatpacking companies spent crucial early weeks urging officials to keep their plants open.
In mid-March, a few weeks before a massive outbreak at its South Dakota pork plant, Smithfield Foods' chief executive Kenneth Sullivan sent a letter to Nebraska Gov. Pete Ricketts saying he had "grave concerns" that stay-at-home orders were causing "hysteria."
"We are increasingly at a very high risk that food production employees and others in critical supply chain roles stop showing up for work," Sullivan wrote. "This is a direct result of the government continually reiterating the importance of social distancing, with minimal detail surrounding this guidance."
"Social distancing," he added, "is a nicety that makes sense only for people with laptops."
In a statement, Smithfield said, "We have continued to run our facilities for one reason: to sustain our nation's food supply during the COVID-19 pandemic."
Once the virus hit meatpacking towns, it quickly overwhelmed rural health departments whose primary role before the crisis involved maintaining vital records and promoting public health initiatives. Before the virus, many health officials, the documents show, didn't have much contact with the local meatpacking plant, even though it was often the town's largest employer.
Decisions about what authority health officials had over meatpacking plants, who would test workers and who would notify close contacts were made on the fly. In Dakota County, Nebraska, home of Tyson's largest beef plant, the health director wrote the state on April 16, "We are at capacity for our monitoring as we only have one nurse." That was at 22 cases. The plant now has nearly 800.
The companies, which often employ large contingents of employees from Asia, Africa and Latin America, nevertheless didn't have health guidance translated in the languages of their employees. And as the virus raged, public health officials struggled to communicate with patients in languages as varied as Q'anjob'al (Guatemala), Karen (Burma) and Tigrinya (Ethiopia and Eritrea). Workers' phones were often disconnected, and they lived across county or even state lines, making coordination difficult.
In some states, laws aimed at protecting individual privacy barred health officials from releasing names of businesses where outbreaks were occurring, preventing them from alerting their communities. In Louisa County, Iowa, where more than 200 Tyson pork workers have tested positive and two have died, the county health director said she felt that she couldn't even ask her board of health or emergency management coordinator for help "because I couldn't release the information about the outbreak."
When local health officials did try to take action, the documents show that meatpacking companies used their power to go over their heads. In Schuyler, Nebraska, the regional health officer reached out to Cargill regarding a "considerable outbreak" to find out what the company was doing to prevent the spread. But instead of working with local health officials, Cargill appealed to the governor's office to intervene, which emails suggest it did. Cargill spokesman Daniel Sullivan said the email to the governor's office was an effort to collaborate with officials at all levels.
In some communities, the fear of tangling with the main economic engine was palpable, especially given the intertwined relationships of a small town. When workers at a Tyson chicken plant in Camilla, Georgia, started complaining about safety issues, the county health director had a problem. "My husband and I are chicken growers for Tyson," she wrote the state. "I want to recuse myself from any investigation into these allegations based on the fact that they can and will pull my contract if I am involved."
In Waterloo, Iowa, where more than 1,000 workers tested positive at Tyson's biggest pork plant, the chair of the county board of health excused herself from discussions about whether to urge it to shut down because she worked as a chaplain for Tyson.
A Tyson spokesman said, "The contract grower should have no fear of her contract being canceled."
The meatpackers' push to keep their production lines moving ultimately won over the nation's highest office when in late April, President Donald Trump issued an executive order to put federal muscle behind ensuring meat processing plants could remain open. In emails, local health officials expressed frustration that it would only embolden the companies to ignore their advice. One Kentucky health director, faced with repeated reports that Perdue Farms was pressuring sick and quarantined workers to return, wrote, "My guess is they will force them to work citing the presidential order to stay open." Perdue said it has strictly followed CDC guidelines and the safety of its employees is its top concern.
Battles between health officials and the companies were compounded by constantly changing guidance from the CDC about how long essential workers who tested positive needed to quarantine. Initially, the CDC said two weeks but amended that guidance several times, eventually saying that asymptomatic workers could go back to work immediately.
All along, the documents show, some corporate and government officials sought to shift the focus away from meatpacking plants and onto the workers themselves, blaming the crowded living situations, carpooling and lifestyles of immigrants and refugees. In Kentucky, Tyson asserted the outbreak spiked after 30 Burmese refugees gathered for an Easter celebration, even though the first infection at the plant was recorded nine days earlier.
"This is a culture issue," notes from a conference call local officials had with Tyson about the outbreak read.
For health officials like Willard, the issue was even more basic. It was unclear whether she could do anything about it.
As officials in Wilkesboro discussed how to respond to the growing Tyson cluster, Willard told them the department couldn't even make a statement about a business having an outbreak. "We have no regulatory authority over Tyson," she wrote local officials. "We are not legally able to mandate that they put any additional measures in place or shut down." In an interview, Willard explained how that created a difficult dynamic.
"Meat processing plants sit in this weird limbo where the USDA has some authority, but then the health department doesn't really regulate them," she said. "So there's this weird gap of who really has the power and authority to make any decisions to shut the plant down."
National planning for pandemic influenza began during the George W. Bush administration, largely in response to the H5N1 bird flu that arose in the late 1990s and wiped out flocks in Asia, Europe and Africa.
"It is impossible to predict whether the H5N1 virus will lead to a pandemic," the plan issued in 2006 warned, "but history suggests that if it does not, another novel influenza virus will emerge at some point in the future and threaten an unprotected human population."
Over the next 14 years, meat producers, animal disease researchers and government regulators developed detailed and coordinated systems for planning and responding to animal outbreaks. But protections for workers further along the supply chain at meatpacking plants were not considered in those preparations.
So when a virus that was infecting humans alone began in other parts of the world, the meat industry had no clear model to follow. When the virus hit China hard in January, the country locked down. Throughout China, slaughterhouses and poultry processing plants closed and didn't reopen for weeks, wreaking havoc on the nation's meat supply but largely preventing outbreaks.
Those events appeared to do little to mobilize U.S. meatpackers. In the cache of public records, there are no emails discussing the risk of coronavirus in meatpacking plants until March, when some companies began restricting the travel of their executives, increasing sanitation and educating workers about hand-washing and COVID-19 symptoms.
But other measures meatpackers took, such as using attendance bonuses to keep workers on the job, coupled with long-standing policies to discipline workers who called in sick, may have helped fuel the spread, the CDC and other health officials said.
Some of the first emails local health authorities received about the coronavirus and meatpacking plants came not from the companies but from workers and their relatives. On March 16, the mayor of Green Bay, Wisconsin, received one about a JBS beef plant.
"I have family members that work at JBS," the son of a longtime worker wrote, "and to my understanding there hasn't been any communication about the virus, what their plan is if someone gets infected or anything of the like."
Around the same time, 700 miles west, workers at a JBS plant in Grand Island, Nebraska, told the governor they were working shoulder-to-shoulder and sent him photos of workers eating in a crowded cafeteria.
Both plants would eventually have outbreaks infecting more than 300 workers each.
In fact, one of the first communications from JBS to public health officials in Colorado concerned not the workers in its Greeley processing plant, but whether the cafeteria at its corporate headquarters had to abide by the state's restrictions on restaurants. And it came from its executive chef.
The Greeley plant would shut down weeks later as cases among its workers multiplied. To date, nearly 300 workers there have contracted the virus and seven have died, state data shows.
JBS spokesman Cameron Bruett said in an email that the company began holding daily COVID-19 planning meetings to track CDC guidance in February. "Before and during this crisis, we have had regular, transparent and proactive communication with all applicable federal and state health organizations," he said.
Roxanne Smith, the health director in Louisa County, Iowa, was one of the first local health officials to contact a meatpacking company about the coronavirus when she asked for Tyson's help in getting public health guidance to the area's Burmese residents in early March. None of the Tyson managers she contacted responded. The situation, Smith said in an interview, was challenging.
Nearly a week later, the plant's nurse manager sent an email to introduce herself, part of what appeared to be a corporate initiative to establish communication and begin coordinating with local health departments -- or as a Tyson safety manager in East Texas put it, to "contain the spread of any of the negative around the virus, and the actual virus itself."
Several local health directors seem to have developed close working relationships with the nurses at their local plants. But those employees were often limited themselves in how much they could do.
At the Tyson plant in Wilkesboro, health officials learned that the test data had to go from the lab back to the testing company and then through Tyson corporate before it reached the local nurses who could share it with them.
When the test results finally arrived, they were so disorganized that the communicable disease nurse had to spread them out on her kitchen table and enter the data manually. "I am having to work from 3 different spreadsheets because of the methods used to provide us with the data," she wrote to the state.
The burden the meatpacking plant outbreaks placed on health officials was evident across the country. Epidemiologists and nurses were updating colleagues after 1 a.m. They worked on Easter and Mother's Day.
In Tama County, Iowa, health and emergency management officials joked about snacking on Reese's Easter eggs to get through the stress and having Cheetos and Dr Pepper for breakfast. "I'm having one of those nights where it's just like I want to throw in the towel," Benson, the emergency management coordinator, wrote to her colleagues one evening.
As the outbreak unfolded at the National Beef plant there, Benson wrote, "That petri dish needs to close."
The truth, however, was that the local health agencies on the front lines had little power to make the plants do much of anything. And when plants did shut, or local authorities could order them to, the politics were tense, requiring the organized effort of multiple local officials and navigating last-minute appeals by company officials to governors. Health officials carefully worded their letters to the companies, often noting the plants' economic importance to the community.
After ordering the JBS plant in Greeley to close, local officials discussed whether to use the word "shall" or "should" when talking about the need for workers to quarantine. "Shall is a loaded word," the county health director replied. "Should is more collaborative."
In Nebraska, Gina Uhing, the director of the Elkhorn Logan Valley Public Health Department, wrote to the governor's staff after Tyson refused to give her department the names of workers who'd been exposed to someone infected so the workers could be tested. "We are being met with corporate gridlock," Uhing wrote, "and it makes containing these outbreaks incredibly difficult at the most inopportune time when time is of critical essence."
Tyson said that the email chain reflected only a small part of the discussion, and that the company worked collaboratively with the department.
As plants began to reopen, several health directors worried that the companies weren't doing enough to ensure the virus was under control. "I am very concerned about their handling of this situation," Smith, the health director in Louisa County, Iowa, wrote state officials. "I am concerned politics are winning over what we know is right for the citizens of our county and state."
Tensions with the companies were only one of the challenges. In Iowa, which saw some of the country's biggest outbreaks, the state communicable disease law prohibited local officials from disclosing the identity of a business where an outbreak occurred unless approved by the state medical director. Health officials in Sioux City noted that without being able to mention where the cases were coming from, "we're dancing all over the place."
The law stymied the local response and prevented health officials from informing other businesses about how to protect their customers and employees. In Louisa County, Kent Wollenhaupt, the president of the State Bank of Wapello, wrote to Smith to complain that he hadn't been told of the outbreak. The husbands of two of his three tellers worked at Tyson, he said, and the bank served many of the plant's employees. "We could have implemented these precautions 2 days earlier, if informed," he wrote. Privacy issues, he said, "should not come ahead of public interest."
After weeks of outbreaks across the state, Iowa Gov. Kim Reynolds eventually released staggering numbers in early May. It wasn't until then that the health director in Dallas County, Iowa, found out that 58% of the employees at the local Tyson plant tested positive, resulting in 730 cases. This was largely because testing was being done by the state, and most employees lived outside the county where the plant is located.
The chaotic nature of the response was underscored further by the lack of coordination among the hard-hit counties and the governor's office.
In mid-April, Reynolds suddenly announced the state was sending 900 tests to Tyson's plant in Louisa County -- without apparently coordinating with local officials on how the testing and contact tracing would be carried out. "Even with all the other counties helping, I don't think it can be done," Smith wrote to a state epidemiologist she had been working with. "What...900?" the epidemiologist replied. "You are joking???"
Reynolds' office didn't respond to a request for comment.
Communication issues were even greater for Iowa's Siouxland District Health Department, which borders Nebraska and South Dakota. A significant number of its cases came from Tyson's Dakota City, Nebraska, beef plant, where workers cross the Missouri River bridge each day for work.
Because some testing of Iowa residents was done in Nebraska, Siouxland had to rely in part on the Nebraska Department of Health and Human Services. "To further compound the situation, the DHHS system they set up has a glitch in it and we are not even getting phone numbers for many of the positive cases," Siouxland's director Kevin Grieme wrote in one email. "It has created an undue burden upon us and my staff bears the brunt of the frustrated individuals that are already nervous about their results and then can't get them."
In an interview, Grieme said the glitch delayed the response four to five days.
Grieme also touched on one of the key frustrations of health officials: In the middle of a fast-moving pandemic, neither the meatpacking plants nor the health departments were prepared to deal with so many patients who didn't speak English.
Many of the workers they needed to contact, he said, spoke only Spanish, Vietnamese, Oromo, Tigrinya, French or Somali. "My language line bill is at $9,000 with only three weeks of work," he wrote in one email. It's usually $600 a month, he said.
In Dallas County, Iowa, health officials ended email after email with the word "Ugh" as they tried unsuccessfully to communicate with Burmese workers or dialed out-of-service numbers. In other areas, public health officials showed up to an address to find a vacant lot. And when they reached out to the companies for help, the human resources offices didn't even have current contact information for their employees.
In Owensboro, Kentucky, the hospital's patient access director noted that it often took 30 to 40 minutes to get a language interpreter on the line. But many of the Burmese workers couldn't understand the directions to the COVID-19 clinic and didn't know how to use GPS. Some of them couldn't read.
By the end of April, as dozens of plants closed in response to local pressure to control outbreaks and implement safety measures, meatpackers began witnessing huge drops in beef and pork production. Tyson took out full-page ads in The New York Times, Washington Post and Arkansas Democrat-Gazette and warned, "The food supply chain is breaking."
Tyson's message was so effective that the next day, Trump signed his executive order, promising to help keep plants running and try to shield them from liability. The news was a gut-punch to many of the local health departments that were still struggling to rein in multinational corporations that already had far more power than they did.
"This is completely disgusting to me," Julie Pryde, the administrator of the Champaign-Urbana Public Health District in Illinois, wrote. "This is literally putting human lives at risk. It is also shifting the cost of their lack of response to local communities. >: ("
In Western Kentucky, officials at the Green River District Health Department already suspected the local Perdue plant was not giving them the full picture of what was going on inside.
"We hear proactive steps from corporate representatives about solid preventative practices being put in place," Green River health director Clay Horton wrote his colleagues a week before Trump's order. "But at the contact investigation level, we are hearing stories of management pressuring people to work while symptomatic and other anecdotal stories that don't square with the official corporate line."
One worker who tested positive and still had a cough and sore throat told the department that Perdue told him "as long as he didn't have a fever he needed to return to work." Another who tested positive said that Perdue had fired her because "they didn't believe I was sick." Conference calls between health officials and Perdue's medical director had become heated at times, and Kentucky officials strongly considered recommending the plant be temporarily closed.
But after Trump's executive order, Horton said in an interview, "it was more of like: 'We can't listen to you because of this executive order. We have to stay open.'"
The situation was frustrating, Horton wrote in one email, because the company wanted public health agencies to provide it with "$65,000 worth of testing" without even committing to bar workers who tested positive from the plant.
"I believe we/they should err on the side of caution," Horton wrote. "They are erring on the side of you better get back to work."
So far, nearly 300 workers have tested positive at the plant and at least one has died.
On Tuesday, the Trump administration announced a new milestone: beef, pork and chicken plants were back, operating at more than 95% of their average capacity compared with this time last year. A statement from the USDA credited Trump's executive order with "the safe reopening" of America's meatpacking plants.
Local officials, however, have been left thinking about how the virus exposed the fragility of the system designed to protect the nation's food supply and how few tools they had to respond. The worst part, Benson, the Tama emergency coordinator, remembers, was watching what was happening and feeling helpless.
"We were flying the plane as we were building it because you didn't have all the pieces that you needed," she said. "But you were still in the air and still trying to keep things from crashing and burning, and we were doing the best that we could."