Bernardo Serpa cut pork legs eight hours a day, six days a week.
He made the same cut roughly 12,000 times per shift, wielding a sharp knife as a production line worker at the second-largest pork processing plant in the country.
Then the coronavirus pandemic hit. In one week, dozens of his colleagues at the Triumph Foods plant in St. Joseph, Missouri, got sick. It prompted the company to test all of its 2,800 employees. In late April, large white tents appeared outside.
When it was Serpa’s turn, he got his nose swabbed. Then he went back inside where he stood elbow to elbow, shoulder to shoulder, with dozens of other potentially infected employees to await the results.
His test came back negative, but his relief was short-lived. One week later, the Cuban immigrant was among hundreds of his co-workers to contract the coronavirus in what would become one of the nation’s largest meatpacking plant outbreaks.
Serpa would spend nearly four months in the hospital, much of it in a coma.
On Oct. 16, he died.
USA TODAY and the Midwest Center for Investigative Reporting spent five months piecing together the pivotal moments in the Triumph Foods outbreak, interviewing more than a dozen current and former workers and examining thousands of pages of government records.
The reporting found Triumph failed to respond with effective safeguards during a crucial period from mid-March to mid-April that could have contained the spread of COVID-19. And local health officials, who received complaints from employees and their family members, missed several opportunities to investigate. They instead took the company’s word that it was doing all it could to protect its workers.
As outbreaks spread through meatpacking plants across the country, some experts warned that Triumph and others in the industry would choose production over worker safety. Since then, workers and their unions have accused companies of doing the bare minimum to protect staff and time and again finding ways to keep their lines running.
At the start of the pandemic, Triumph Foods employees worked up to 10 hours a day, crammed side by side. Even after the U.S. Centers for Disease Control and Prevention recommended the general public wear face masks, the company did not require them for weeks. It initially did not screen sick employees and implemented a bonus program that rewarded workers for perfect attendance even as they complained and fell ill.
On April 19, the day before the plant’s first positive case, Triumph’s board chairman Glenn Stolt shared a coronavirus conspiracy theory video on his Facebook page that claims 5G cell towers were instead to blame for illnesses, that the virus is less deadly than the seasonal flu, and that the CDC’s recommendation on 6-foot social distancing was “misinformation.”
Weeks later, nearly 500 Triumph employees – roughly a fifth of its workforce – tested positive. Four workers, including Serpa, have since died.
Executives at Triumph Foods had known for weeks that meatpacking plants were particularly susceptible to COVID-19. By the end of April, thousands of meat plant workers across the nation were sick. At least 30 had died.
Factories in many industries – including at least 33 meatpacking plants – had shut down temporarily, sending workers home to protect them from infection. Triumph never did.
Instead, the company worked behind the scenes to lobby state and federal officials to push back on safety recommendations and keep its plant open.
State health officials, meanwhile, never used their authority to shut down the plant. Missouri economic and agricultural officials advocated keeping Triumph open. With Triumph’s input, local members of Congress lobbied the CDC and the Occupational Health and Safety Administration in mid-May for relief from COVID-19 guidelines such as those recommending workers stand at least 6 feet apart. Do the best you can, the CDC told them.
After the extent of Triumph’s outbreak became clear in May, the company withheld information on the total number of cases and encouraged state agencies to do the same, according to company emails and interviews with workers. Weekly reports to the union stopped. State and local health departments said cases from the plant spread to Kansas City, Missouri, and to eight counties in the state and Kansas.
Missouri’s Department of Health and Senior Services did all it could to help Triumph, its employees and the community, wrote Lisa Cox, an agency spokeswoman. That included testing and contact tracing designed to limit additional exposure. Based on the results, she said, state health director Randall Williams “determined closure was not necessary.”
A spokeswoman defended the state agriculture department’s involvement as helping Triumph ensure pork supply. “If we had any concern beyond protecting food workers,” wrote spokeswoman Sami Jo Freeman, “it was for our Missouri families heading to the grocery store.”
Triumph declined to make its top executives available for interviews and did not directly answer a lengthy list of questions. Instead, Triumph provided statements that pointed to efforts it took in response to the coronavirus, including providing personal protective equipment to employees, installing plastic barriers in tight working spaces and giving two weeks’ pay to those who had to isolate. Those efforts cost nearly $7 million, the company said.
“Because of our early, thorough, and proactive response to COVID-19,” Triumph CEO Mark Campbell said in the statement, “Triumph Foods became one of the industry leaders in the United States for its response to the pandemic and remains one today.”
The company stressed that its actions should be understood in the context of operating during an evolving pandemic and characterized its interaction with government as seeking clarification. The company “went above and beyond” government mandates, Triumph said. In fact, the government mandated little because Triumph and other meatpacking executives immediately pushed back against a host of recommendations that would have cost them time and money.
Triumph touted its preemptive effort to test its entire workforce. Without it, the company said, it would have kept sick workers in the plant and all but guaranteed further spread.
But Triumph did keep sick workers in the plant for days while they awaited test results. Testing was an unusual step for the industry at the time, but so too was keeping the plant open after recording hundreds of cases.
After getting their noses swabbed in the parking lot in late April, Serpa and his colleagues went back to work with people whom tests would later confirm had been infected and likely shedding the virus for days.
“They brought me back to work, for what?” Serpa said in a telephone interview from his hospital bed in July, three months before his death. “For me to die there?”
An overcast sky cast a pall outside the sprawling Triumph campus on the Friday afternoon in mid-March that President Donald Trump declared the coronavirus a national emergency.
Second-shift workers pulled into the parking lot as Trump entered the White House Rose Garden to announce measures that soon would lead to the mass closure of schools, restaurants and other businesses across the country.
At the time, more than 1,500 Americans had contracted the coronavirus and at least 40 had died from it.
Trump and a cadre of public officials in the Rose Garden urged people to take the pandemic seriously and practice good hygiene to keep themselves and each other safe.
“You want to wash your hands,” U.S. Health and Human Services Secretary Alex Azar said at the time. “You want to keep distance from people. And if you’re around someone sick, keep away from them.”
But for workers entering the plant that afternoon, it was business as usual.
Hundreds of them clocked in at the start of the shift. They crammed into locker rooms to don their white lab coats, hard hats and rubber boots. Many stood 3 feet apart along conveyor belts snaking through the facility where they slaughter, debone, slice and package as many as 21,500 hogs each day.
“As soon as I walked in there, people were speaking in each other’s faces,” said 22-year-old Biyanka Akur, who worked the afternoon shift trimming the fat off tenderloins until quitting this summer. “You have people who are, like, a shoulder-length away from you. You’re just kind of at risk.”
At that point, the nation’s meatpacking plants had yet to suffer a major outbreak. But Tyson Foods was already seeking more than 100 forehead thermometer scanners to screen its 5,600 employees across several plants in Missouri, according to agriculture department emails.
Triumph would not mandate employee temperature checks for several more weeks, a delay that meant the company potentially missed sick workers entering the plant.
In a March 19 Facebook post, Triumph outlined measures it was taking, including increased plant cleaning and temporary changes to employment and benefit policies. It encouraged social distancing in common areas, good hygiene and staying home when sick.
But employees were getting nervous. They started bombarding the company’s Facebook page with their concerns.
“All temperatures should be taken upon coming thru the doors,” one wrote.
“Need to do something about the cafeteria and the distance between each of us,” wrote another.
And from another, who wrote in Spanish: “There are only a few that use hand sanitizer and it doesn't feel safe but we have to be there.”
Since Triumph opened in 2006, it has become St. Joseph’s second largest employer. Jobs start at $16.25 an hour – good pay for immigrants who, like Serpa, speak little English.
Like in other meatpacking communities around the country, the opportunities attract a diverse workforce, particularly Latino, Southeast Asian and African immigrants and refugees. At least half of the plant’s employees are immigrants.
Now, plant workers watched with growing dread as the coronavirus fanned out across the United States.
By April 9, it had infected more than 450,000 Americans and killed nearly 17,000. It also started infiltrating the meatpacking industry, sickening dozens of workers across plants in Alabama, Delaware, Georgia, Iowa, Louisiana, Mississippi, Nebraska, Pennsylvania, and South Dakota. Several of them had already closed.
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In the next week, two workers at a Tyson Foods pork plant in Iowa died after testing positive for the coronavirus.
Triumph still was not mandating face masks at this time. It was not enforcing social distancing at the plant. And while it told sick employees to go home – even relaxing policies that otherwise penalized them for missing work – it also offered a $100 weekly bonus for perfect attendance, a move the CDC later opposed because it could encourage ill workers to show up.
Triumph and its owners, a coalition of industrial hog farmers, would take a hit at two points in the supply chain if the plant closed or production slowed. The farmers could be forced to destroy hogs with nowhere to process them, and Triumph would lose the sale of the pork. Costs of a closure could quickly mount into the millions.
As other plants around the country closed, Christensen Farms, the largest of Triumph’s owners, made an economic case to remain open to Missouri’s agriculture director in mid-April.
Missouri agriculture director Chris Chinn offered help finding face masks and some reassurance. “Our Governor knows how important it is for these processing plants to stay running,” she wrote in an email, “he is a cattle producer himself.”
Workers saw the outbreaks in other plants, and they worried.
“When the coronavirus first started, they didn’t take it serious enough,” said Rodney Green, a former forklift driver who left Triumph in August when he secured a higher paying job. “There’s no way to contain it. It’s impossible, impossible to practice social distancing at work.”
Frustrated by the lack of action from Triumph, employees and their family members called and emailed St. Joseph Health Director Debra Bradley. They told her the company required people to work even after being exposed to the coronavirus, that they were standing “elbow to elbow in the cafeteria line” and that workers are were "coming to work with a fever, coughing on each other and the packaging."
Bradley couldn’t shut Triumph down. The state health director had already removed the authority of local public health agencies like hers to close a business in the food supply chain.
She received the complaints, but Bradley did not visit the plant to verify the conditions herself. Instead she sent the concerns to Triumph’s communications director, Chris Clark, who promised to investigate the claims, but ultimately dismissed them.
“You know how hearsay and rumors start, especially around this place,” Clark wrote.
Bradley said she took Triumph’s word. "They assured us that they were doing what was necessary to protect our workers," she said.
By April 9, at least three employees who would later test positive for the virus began exhibiting symptoms, a state epidemiologist later determined.
Clark reached out to Bradley that day with an update, alerting her to a "false rumor" that an employee posted on Facebook that the plant had two cases. Triumph had none, he assured her, and said the employee was “being dealt with.”
Instead, Triumph had an issue with strep throat, Clark told Bradley.
“We are seeing a bit of an uptick in that," he wrote. "Odd.”
Eleven days later, Triumph learned of its first two cases.
Arturo Chavez Valencia didn’t yet know it, but he would be next.
Chavez worked the late shift deboning pork shoulders. His wife, Gabriela Ramirez, worked the early shift cutting ham. They passed each other between shifts – often six days a week – tag-teaming work and caring for their three boys.
As the coronavirus pandemic spread, the couple worried about exposure – especially Chavez, who at 44 had a heart condition and diabetes. Before the first cases appeared, Triumph still had not mandated masks, separated workers or installed plastic barriers on the line.
Quitting was not an option; they needed the money. So the couple did the next best thing, wearing masks at work even before it was required.
“We protected ourselves,” Ramirez said in Spanish.
It was not enough.
Chavez worked on the same line as one of the first two infected employees. And both of the infected workers lived at Brittany Village, an apartment complex home to about a tenth of the company’s workforce, some 250 people.
Triumph’s executives were worried, emails among state officials indicated. An outbreak at Brittany Village could close the plant. Instead, they would soon learn, the outbreak was at Triumph itself.
Within hours of learning of the first positive tests at Triumph, Williams, the state health director, was on the phone with Triumph’s plant manager. That evening, he ordered 38 tests for workers on those lines.
Two days later, Chavez got his. It came back positive, making him one of the first 16 employees to become infected.
The company told all of them to self-isolate for two weeks with pay.
Ramirez put Chavez in one of the family’s bedrooms and isolated their sons in another. She didn’t want the boys to get sick. She brought food to their rooms, wearing a mask and gloves to enter, and scrubbing the surfaces she touched with Lysol or bleach as she left.
“I didn’t let them touch me or hug me because I was afraid that they would get infected,” she said.
Back at the plant, the mood shifted. The pandemic had arrived. Workers felt at risk.
Their infected colleagues had “walked the entire plant, used the cafeteria, knocked on doors, used the bathrooms,” one employee said in an email to Bradley. “Workers are scared but equally afraid of retaliation the plant may take against them. Can the government take action on the matter for the protection of workers and the city?”
Rather than take action, the city relied on Triumph to call the shots. Bradley said she asked the company’s CEO to shut down a line where sick employees worked and was told her request was unreasonable.
“I said, ‘Well, this virus spreads rapidly and easily, and there is a risk to people in your plant,’ ” Bradley said in an interview. “They were aware, and they knew the risk and wanted to try other options.”
That wasn’t strong enough for St. Joseph Mayor Bill McMurray.
“Shut it down,” he wrote the city attorney on April 22.
But only the state could close the plant, and Missouri's health director wanted more test results first. With the state’s help, Triumph secured 2,800 testing kits – enough for each of its employees – and on April 26 finalized plans to test workers in the coming week.
That same day, the CDC and OSHA released guidelines for meatpacking plants. Triumph had already adopted some of them, including asking workers each day if they had symptoms, providing sanitizer and cleaning the facility more frequently.
But guidelines for the industry did little to address crowded conditions at the plants. The federal government told meatpackers to space workers 6 feet apart, “if possible.” Triumph didn’t.
Nine current or former workers told reporters that Triumph has never implemented social distancing in its plant. Many spoke on the condition of anonymity, for fear of losing their jobs or harming future employment opportunities.
Meanwhile, case counts at the plant were climbing. By the end of the week, dozens more employees had tested positive, including Ramirez. What started as a couple of cases now stood at 46.
It was about to get worse.
Trump handed meatpacking plants a gift on Tuesday, April 28, signing an executive order declaring them “critical infrastructure.” It stopped short of ordering plants to stay open, but companies and government officials took it as a pass.
Nearly 1,000 of Triumph’s workers lined up outside the plant that same day, spaced 8 feet apart, shuffling through white tents during the second of five days of coronavirus testing.
The company later would discover more cases from this day’s swabs than any other. Rather than wait for results, Triumph sent potentially contagious workers back into the plant immediately after testing.
That same week, one janitor went home feeling sick the day he was tested. But he worked Wednesday and part of Thursday before a supervisor found him in the cafeteria and pulled him out. His test was positive, the supervisor told him, and he had to go home.
He spent nearly a week in bed, drained.
“I’m pretty sure I had it a couple days prior before they tested me,” he said, “and I touched every part of that building and every part of that place.”
Serpa was tested this week, too. His results came back negative, so Triumph kept him on the line. He would soon blame the company for that decision.
Martin Rosas, president of United Food and Commercial Workers Local 2, says more workers fell ill during the days they were in the plant with their infected co-workers.
Throughout the pandemic, the CDC has said critical infrastructure workers with exposure to COVID-19 could return to work as long as they don’t have symptoms and they take precautions. Those include mask wearing, which workers say wasn’t consistently enforced at Triumph at that time, and social distancing, which still isn’t happening.
Triumph’s employees knew that was a problem.
Workers called for Triumph to close the plant for at least a week for cleaning and quarantining after testing. The wife of one worker started a Change.org petition calling for closure. By early May, more than 1,000 people had signed it.
“It would have given people that tested negative a chance to make sure they were safe,” one worker said. “We went back in there and worked for two or three days next to a person that tested positive.”
Lynelle Phillips, vice president of the Missouri Public Health Association, said as a precautionary response Triumph should have quarantined all workers for two weeks.
In defense of its decision to remain open, Triumph pointed to Trump’s order and a recommendation from the state health director.
But the meatpacking industry influenced the executive order the company now uses to justify its actions. A week before Trump signed his order, the North American Meat Institute, where Triumph’s CEO is a board member, shared a draft containing similar language with the U.S. Department of Agriculture.
The recommendation from the state health director that Triumph touts came before anyone knew the full extent of the outbreak.
Workers were still lining up for nasal swabs on April 30 when Williams, the state health director, joined Missouri Gov. Mike Parson for a COVID-19 news conference. Williams told reporters he knew of 132 positive cases by that point. Asked whether he’d recommend that the plant shut down, he responded, “I do not.”
Within days, the number of confirmed cases would more than triple.
In a video addressing employees that Triumph released after its outbreak, CEO Mark Campbell said 90% of those cases were asymptomatic. But that wasn’t true. State records show far more workers had symptoms at the time of testing.
Missouri health officials interviewed 266 of the Triumph employees who tested positive and found half had a history of symptoms. At least 81 said they felt ill before the mass testing began.
Rather than being a stealth virus that was spreading undetected among workers who had no symptoms, the signs were there for Triumph to pick up on.
After two weeks in quarantine, Chavez talked to his wife about returning to Triumph. He felt weak but recovered enough to eat more than the soup he’d lived on for two weeks.
But early that afternoon, he slumped over in the living room drenched in sweat. His vision was blurry, he told her. As she helped him walk, Ramirez asked their oldest son, Brian, to call 911.
Paramedics found Chavez unresponsive on the couple’s bed. For 30 minutes they tried to revive him, shocking his heart and deploying a robotic chest compression device.
At 1:15 p.m., they pronounced him dead.
At that moment, executives from Triumph were on the phone with aides for two of Missouri’s congressional representatives, Republicans Vicky Hartzler and Sam Graves, according to a company email.
Triumph is in Graves’ district, and Hartzler sits on the House agriculture committee.
The executives came to that meeting with a list of six CDC and OSHA meatpacking guidelines that they questioned. Key among their concerns: Spacing workers out more than 6 feet would take months and require “a significant stoppage and reengineering of our facility."
In his response to that letter in June, CDC Director Robert Redfield repeated that the guidance was just that, a recommendation. Meatpacking plants “should” space workers 6 feet apart “wherever possible.”
Triumph still has not done that.
Five days after that meeting, a temperature check caught Serpa’s fever as he arrived at the plant for his shift. At 64, his age, weight, high blood pressure and diabetes put him at high risk.
He went home worried. By that afternoon, he leaned on staffers at Mosaic Life Care hospital as he staggered through the doors. Diagnosed with COVID-19, he’d soon be in a monthlong coma, passing his 65th and final birthday alone in the intensive care unit.
“They knew that the plant was contaminated, and they never closed it,” said Serpa’s wife, Maritza Drake, in Spanish. “They had a lot of cases and they never closed the plant.”
Meanwhile, Chavez's widow said she doesn’t blame Triumph for her husband’s death and that the company was attentive during his illness.
After Ramirez took time off to take her husband’s remains to Mexico, she returned to work at Triumph, crowded in with other employees.
Life now is difficult. Chavez used to get their boys to school in the morning. Now a friend does it so Ramirez can report to the plant at 6 a.m.
“I’m still working there because I need to work. I have three children. Obviously, there are other jobs. I understand there are other jobs,” Ramirez said. “But this is the only one I see where I can work overtime. And, I want to work overtime to make more money to have a better life for my sons.”
The outbreak left Triumph short-staffed. Hundreds stayed home to quarantine. Others quit, unwilling to risk a life-threatening illness for their paycheck.
Inside the plant, Triumph moved workers to keep the lines running. Other lines it closed. Without the staff to make the fine cuts to turn pork belly into bacon, it instead used that part of the hog for dog food and biodiesel, the union president said.
“It was pretty much, ‘We’re gonna work until there’s not enough people to do the job,’ ” one worker recalled.
Production fell from 21,500 hogs per day to 8,000, one worker said. Quality suffered, too, and USDA inspectors noted complaints of wire, wood chips and a nail in the pork during this time.
Triumph’s chief operating officer lamented the test results because they left the plant short staffed.
“If we had not done comprehensive testing, we would have had 370 people come to work,” Matt England wrote to Williams as test results continued to roll in. “Doing testing, however, to be more precise in our response now results in a substantially different outcome.”
Since the outbreak, the company has resisted releasing information about cases at the plant.
On May 15, after the mass testing, the state reported 490 plant workers had tested positive for the coronavirus. Since then, Triumph has released no new numbers and Bradley told a reporter in August she didn't know the latest total.
On Aug. 24, the Kansas City, Missouri, health department shared communications from the state agency showing the total was 622. Cox of the state health department repeated that figure to reporters this month.
England told state officials in an email in early June that workers and contractors were denied medical care and service at businesses because of the outbreak. In one instance, England said an employee who returned to work with a bloody nose after an altercation with her husband had been denied refuge at a domestic violence shelter.
That’s why, he argued, the state should “minimize the usage” of names of businesses with cases.
By late June, England said the company had “learned our lessons the hard way about general public notices with respect to COVID-19.”
In the same email, England offered a rosy update on the company, writing, “The news continues to be good at Triumph Foods.”
But within a week of each other in early July, two more workers died from COVID-19. One was a maintenance worker in his 50s who fell ill in early June; the other a man in his 60s who tested positive in early May. Relatives of both men declined to speak to reporters.
Since the pandemic began, OSHA has opened four investigations at Triumph, each in the wake of a coronavirus-related death. The agency sent Ramirez letters in English, which she does not speak, saying it is investigating her husband’s death.
In Serpa's case, the agency has ruled his death wasn't related to work and wasn't from COVID-19, but Drake said the toll the virus took on his body led to his death. OSHA has not ruled on the other cases.
By mid-June, Triumph announced that “nearly all” employees had recovered, noting around 50 people were still out sick. “Our production volume continues to improve due to the stabilization of our workforce,” it stated.
Workers say conditions in the plant have improved, but that all issues are not addressed. Since the outbreak, plastic dividers separate workers on the line and sanitizer is readily available. Workers with coronavirus symptoms are sent home. New hires must test negative for the coronavirus before they start.
The union says workers still can’t distance from each other. Shift changes are particularly crowded. Union leaders continue to advocate for additional paid sick leave and hazard pay. Some workers say mask use is now enforced, while others say that it is inconsistent.
“I try to be careful. Wash my hands,” said one worker, who described frequent encounters with unmasked co-workers. “I follow the rules, but sometimes I feel like the crazy one.”
Triumph has changed its policy about testing, workers said. Now workers who are tested are sent home until they know their results.
The policy change was too late to help Bernardo Serpa, who couldn’t walk and relied on supplemental oxygen when he returned home from the hospital and rehab in late August. Maritza Drake, his wife of 26 years, had to bathe him and help him up the stairs to their home.
She was by his hospital bedside when he died in the early morning hours of Oct. 16. Doctors told Drake that his kidneys and lungs failed. Now she awaits a chance to take her husband’s ashes back to Cuba.
Across the highway, Triumph continues churning out pork.
“They think workers are like dogs,” Serpa had told a reporter from his hospital bed in July. “If we don’t work, they get rid of us. And in any case they get new workers.”
The team behind the investigation
REPORTING: Rachel Axon, Kyle Bagenstose, Kevin Crowe and Erin Mansfield, USA TODAY; Sky Chadde and Frank Hernandez, Midwest Center for Investigative Reporting
EDITING: Doug Caruso, Emily Le Coz, Chris Davis, USA TODAY; Pamela Dempsey, Midwest Center for Investigative Reporting
COPY EDITING: Melissa Galbraith
TRANSLATION: Javier Arce
GRAPHICS AND ILLUSTRATIONS: Veronica Bravo, Jennifer Borresen, Javier Zarracina, USA TODAY; Shane Keyser, Midwest Center for Investigative Reporting
DIGITAL PRODUCTION AND DEVELOPMENT: Veronica Bravo, Mara Corbett
SOCIAL MEDIA, ENGAGEMENT AND PROMOTION: Nicole Gill, Mary Bowerman, USA TODAY; Cynthia Voelkl, Midwest Center for Investigative Reporting.