Essential and Expendable

 

On April 16, 2020, 67-year-old Bui Thi Hiep came home feeling ill after working an eight-hour shift at Cargill’s beef processing plant in High River, Alberta. Two days later, Hiep was rushed to the hospital and admitted to an ICU bed. She died the next day. Nearly three weeks later, another Cargill worker, Benito Quesada, a 51-year-old father of four, died in hospital after spending weeks on a ventilator in a medically induced coma.

Between April and mid-May 2020, over 950 Cargill workers — almost 45% of the plant’s workforce — tested positive for COVID-19, which was then a new and poorly understood respiratory illness. Half of the plant’s food inspectors and an unknown number of contractors also contracted the virus. At the time, this was the largest industrial outbreak of COVID-19 in North America.

Infections varied in severity. The lucky ones had no symptoms, but most workers experienced a cough, headache, and fever; many were bedridden for days due to fatigue. Eventually, 18 Cargill workers were admitted to the hospital, eight requiring life-saving care in the ICU. An unknown number experienced a complex range of health issues associated with what came to be known as long COVID.

It wasn’t just the illness that affected the workers’ well-being. There was constant anxiety about spreading the virus to family members and friends, and, for some, a palpable fear of death. One worker recalled thinking about making a will.

After cases among Cargill workers reached a peak, growing numbers of close contacts — family members, friends, and others in their community — started to become ill. Four of them died, and at least 25 were hospitalized. Public health epidemiologists would later link the Cargill cases to at least 22 other outbreaks — mostly in care homes — though they stopped short of confirming the directionality of the spread.

A Forgotten Tragedy 

In May 2020, faced with questions about the provincial response to the Cargill crisis, then-Alberta premier Jason Kenney promised a review of the outbreak as part of a future examination of the province’s overall response to the pandemic. However, neither the Government of Alberta’s pandemic review panel reports (2023) nor Alberta Health Services’ (AHS) internal review (2022) made any mention of the tragedy. Further, no charges were brought under Alberta’s occupational health and safety (OHS) law or as a result of a separate RCMP criminal investigation. 

This report investigates how and why the Cargill outbreak occurred and what can be done to prevent similar incidents in the future. It is based on an analysis of publicly available documents, select interviews, and thousands of pages of documents obtained through freedom of information requests.

At its heart, this is a story of systemic regulatory failure by the Alberta Ministry of Labour and Alberta Health Services. The response to the crisis was defined by a lack of preparedness, inaction, overconfidence, cultural stereotypes and racism, incompetence, and deliberate aversion to using available enforcement measures.

The evidence shows that there was nothing inevitable about the scale of the outbreak. The tragedy occurred in a political environment that openly and enthusiastically prioritized economic growth over the health and safety of a largely invisible and vulnerable group of workers, most of whom were immigrants and temporary foreign workers.

The Cargill outbreak had no single cause. Like many major tragedies, it was the product of complex, layered factors.

COVID-19

SARS-CoV-2, the virus that causes COVID-19, first emerged in Wuhan, China, in late 2019. On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a global pandemic.

The virus is spread among humans via aerosol transmission. The period during which someone with COVID-19 can transmit the virus varies depending on factors such as the variant and severity of illness, but transmission can occur both before and after symptom onset. Some infected individuals never experience illness but still spread the virus to others.

In the early months of the pandemic, many public health leaders believed COVID-19 spread through large droplets and close contact, and that asymptomatic transmission was not occurring. As a result, early public health measures in industrial workplaces primarily focused on implementing physical barriers, physical distancing, hand washing and, where available, the use of surgical masks in crowded areas. Improved ventilation and high-quality respirators (e.g., N95) were initially not considered necessary except for frontline health-care workers. Vaccines — another critical layer of protection — were not widely available until 2021.

Designed for speed, efficiency, and food safety, the features of meat-processing facilities (e.g., low temperatures, crowding, humidity, and insufficient ventilation) contributed to the spread of the virus in plants around the world. Studies found high rates of infection (50%+) among workers in these plants.

Statutory Responsibility for Occupational Health and Safety in Alberta

The Alberta Ministry of Labour and Immigration, as it was known in 2020, was responsible for overseeing OHS in provincially-regulated workplaces. Under Alberta’s OHS system, the regulator is not responsible for controlling workplace hazards; the employer is. OHS officers play a vital role in ensuring employers meet their safety obligations by conducting inspections, issuing compliance orders and carrying out investigations. Jason Copping was Alberta’s minister of labour in 2020. At no point during his tenure did he delegate his ministry’s responsibility for OHS to AHS or another body.

For its part, AHS led the overall public health response to the pandemic in Alberta. Its activities included detection and testing, contact tracing, outbreak management, data modelling and projections, public communication, among others. Early in the pandemic, AHS public health was a focal point for providing information and guidance to employers regarding COVID-19 prevention in workplaces.

The declaration of a public health emergency on March 17, 2020, provided Alberta’s chief medical officer of health, Dr. Deena Hinshaw, and cabinet with extensive authority to manage the emergency, including requiring that individuals and organizations take or refrain from taking specific actions, restrictions on freedom of movement, cessation of business activities, and implementation of protective measures.
 

Precursors to the Outbreak

Before the Cargill outbreak, there were plenty of signs that both government and industry wanted to keep meat-processing plants operating through the pandemic. As the public health emergency was declared, the agricultural industry was actively lobbying the Government of Alberta to head off potential shutdowns of the plants. On March 17, Alberta’s minister of agriculture and forestry, Devin Dreeshen, gave assurances that the entire industry would be declared an “essential service.” A formal designation — with no basis in law — followed, making these “essential industries” exempt from any public health measures related to gathering sizes, physical distancing and, importantly, temporary closure orders.

On March 26, Harmony Beef, a small meat plant near Calgary, was partially shut down for three days due to concerns about the adequacy of its COVID-19 prevention measures. In response, Jason Kenney publicly chastised federal food inspectors for “impairing our entire livestock industry.” The message was clear: industry prerogatives mattered more than worker health and safety rights.

Concerned about potential declining attendance due to fear of exposure to the illness, Cargill management implemented a $500 attendance bonus and a $2 hourly wage increase, incentivizing workers to go to work (in some cases, even when they were ill). Most workers had families to support in Canada and/or in their home country. They also lacked alternative sources of income: like all essential workers, those working at meat-processing plants were ineligible to receive the federal pandemic income supplement known as the Canadian Emergency Response Benefit.

By late March, conditions were ripe for a massive outbreak at Canada’s largest beef processing plant.

Twenty Days of Fear

On April 3, AHS was made aware of the first Cargill worker to test positive for COVID-19. Additional positive cases followed on April 6, at which point AHS formally assigned a case number to what became known as the “Cargill staff and contractor outbreak.” At the time, an internal email from the assistant deputy minister of agriculture and forestry stated: “No disruption to the plant operations is expected.”

On April 6, the union representing Cargill’s hourly staff, the United Food and Commercial Workers Local 401 (UFCW), wrote to the plant’s general manager, Dale LaGrange, demanding that more information and protections be put in place.

The virus spread rapidly among plant workers, contractors, and food inspectors. Epidemiological analysis conducted in June 2020 showed that the peak of daily confirmed positive cases occurred around April 9, with a total number of approximately 300 cases. The analysis also revealed positive cases among workers in late March.

On April 12, the president of the union demanded that the plant be immediately closed. Cargill said that it was complying with all public health guidance, and closure was unnecessary. The next day, the company cut one of the plant’s two shifts due to staffing shortages.

Mounting cases, growing fear among workers, and declining attendance prompted senior Cargill managers and provincial government officials to hold a joint telephone town hall with workers on April 18. Dr. Hinshaw and senior medical officers of health told workers at the town hall that carpooling and crowded living conditions — not conditions in the plant — were responsible for the spread of the virus, while Minister Devin Dreeshen cautioned them not to “get distracted by misleading noise or inflammatory rhetoric” about the plant’s safety. In no uncertain terms, Dreeshen assured workers that their workplace was safe. Internal government communications prepared for the premier and others stated: “The Cargill plant is completely safe from an OHS and AHS perspective.”

However, just hours after the town hall, Hinshaw asked senior public health officials to determine the proportion of the Cargill cases that were due to workplace, carpool, household, and community transmission. It was an admission that AHS’ public statements and messages to workers were not based on a rigorous analysis of the outbreak data.

On April 19, the union held its own town hall, with 600 Cargill workers in attendance. At this meeting, the union reiterated its concerns about the plant’s safety and informed workers of their rights under the Occupational Health and Safety Act, including the right to refuse dangerous work. That same day, Bui Thi Hiep died in hospital.

On April 20, Cargill voluntarily announced that it would temporarily halt operations.

Regulatory Failure

Alberta OHS had the primary responsibility for worker safety and AHS led the overall public health response to the pandemic. Both failed to respond effectively to the Cargill outbreak.

In March, as AHS scrambled to scale up operations, contact tracing and linked data were not initially available. As a result, early positive cases among Cargill workers were not linked back to the plant. As one public health manager later recounted: “By the time we got to the first inspection [of the Cargill plant], we’d already lost the battle.”

AHS’ inadequate surveillance system, however, was not the only issue at play. Even though the Ministry of Labour had jurisdiction for OHS, it was AHS that assumed the lead for responding to the Cargill outbreak. With no experience or expertise in overseeing worker health and safety in large industrial workplaces, AHS made significant errors in its approach to managing the outbreak.

Both OHS and AHS stood back waiting for positive cases or formal complaints from workers or the workers’ union before inspecting facilities. At Cargill’s invitation, on April 7, AHS inspected the plant and made non-binding recommendations related to carpooling, masking, use of barriers, and other items. This would be the only formal in-person inspection by either AHS or OHS before Cargill decided to idle its plant on April 20.

Despite their inexperience and lack of expertise, and in absence of an epidemiological analysis, Hinshaw and other health leaders made public comments that projected confidence in their knowledge of where the virus was (and was not) spreading among Cargill workers.

AHS did not conduct follow-up inspections or reach out to workers to hear from them about conditions at the plant. Instead, it simply assumed that Cargill had fully implemented its recommendations. Throughout April, AHS officials were aware that workers who were ill were incentivized to come to work through Cargill’s incentive pay initiative. They understood the impact this had on transmission of the virus in the plant, but still refrained from issuing a directive to Cargill to cease the incentives.

On April 15, eight days after the AHS inspection, an OHS officer conducted a 30-minute “virtual inspection” of the plant in response to a demand from UFCW. The inspection was recorded on a Cargill manager’s phone and was conducted without the participation of a trained industrial hygienist. The officer did not evaluate all areas of the plant or assess compliance in terms of OHS regulations relevant to biological hazards, nor did they speak directly with frontline workers. Even though several hundred workers were ill, the inspection resulted in no compliance orders.

Neither OHS nor AHS used enforcement measures to gain compliance from Cargill. When an AHS manager sounded the alarm in internal email messages, speculating that “drastic” measures might be needed, there was no action. Before the April 18 town hall, AHS and OHS did not prioritize sharing the results of their inspections with workers or their union. Compounding the problem, there is no evidence of information sharing or coordination between AHS and OHS until after the plant closed.

During the April 18 town hall, Minister of Labour Copping made clear that his ministry was following public health guidance in exercising its oversight and enforcement activities at Cargill. OHS, which has primary regulatory authority over the workplace, seemed to accept that its role was subservient to public health, even though no directive delegated its authority to AHS.

There was also a disregard by regulators and government officials for basic worker health and safety rights — the right to know about hazards and participate in the control of hazards, and the right to refuse dangerous work. Premier Kenney had earlier publicly chastised inspectors from the Canadian Food Inspection Agency (CFIA), falsely claiming that a work refusal led to the short partial closure of the small meat plant. During the town hall, Copping failed to provide any information regarding basic workers’ rights under the OHS Act, nor did he affirm the importance of these rights.

When Cargill reopened on May 4, an internal briefing note to the minister of agriculture and forestry and the premier stated that workers could not use the right to refuse dangerous work because public health deemed the plant was safe. The right to refuse dangerous work, however, exists outside the authority of public health, and is meant to protect workers in situations where there isn’t scientific certainty about the transmission and health impacts of a new airborne hazard.

OHS and AHS were also inconsistent in their guidance related to masking. AHS’ April 7 inspection led it to recommend masking where physical distancing wasn’t possible. However, Cargill didn’t implement masking until April 16, and even then, there was insufficient supply for all workers. Furthermore, the surgical masks that were used provided inferior protection to workers working for eight hours a day, in close quarters, and in an environment with potentially insufficient ventilation.

On May 3, Copping approved a ministerial order requiring KN95 or equivalent masks to be used to control biological hazards, a recognition that basic surgical masks were insufficient in protecting workers in a workplace setting. That day, OHS inspectors informed AHS that they planned to wear N95 masks during their inspection of the plant, which was set to reopen the next day. However, an internal AHS email suggests that Hinshaw did not share this view. The inspection report for May 4 noted that workers received a surgical mask upon entering the plant. Officers did not issue an order requiring Cargill to comply with the ministerial order and distribute N95 or equivalent masks. Nor did the officers comment on the plant’s ventilation system in their inspection report. AHS issued no directive to Cargill regarding N95 or equivalent masks.

Systemic Discrimination

AHS not only made incorrect assumptions about how the virus spread but also where it was spreading. Explanations for the source of the outbreak relied upon cultural stereotypes about living arrangements. On April 13, six days after the outbreak was declared and without sufficient evidence, Hinshaw publicly attributed the rapid increase in positive cases in Cargill’s High River plant solely to household spread and carpooling.

In the absence of an epidemiological analysis, AHS officials continued to believe that transmission occurred among workers outside of work. This belief persisted in spite of evidence from workers, infections among CFIA inspectors (who were not as dependent on carpooling), and multiple internal AHS emails during the period confirming transmission of the virus in the plant.

Assumptions about where the spread was occurring were treated as fact by elected officials, who repeated claims that the outbreak was due largely to household transmission, further stigmatizing Cargill workers and fueling community-level racism toward these workers and their families.

Even though frontline Cargill workers were the experts of their own work, OHS and AHS did not speak directly to them to learn about their experiences in the plant.

It was not until mid-April that AHS officials learned that most workers’ first language was not English. Even with this knowledge, the Government-Cargill telephone town hall meeting on April 18, which was the first opportunity for officials to hear directly from workers, offered no translation services. 

When determining appropriate actions, none of the regulatory bodies seemed to consider that temporary residency status increases economic vulnerability and dependence on an employer. No steps were taken to address language and literacy barriers, cultural differences, or residency status until after the plant closed. Nor was any action taken before the closure to address the lack of alternative transportation options for workers.

Industry Capture

Industry capture played a role in weakening the regulatory response by AHS and OHS.

While the Ministry of Agriculture and Forestry was an interested party in how COVID-19 impacted the operations of the province’s meat plants, it had no regulatory authority for occupational health and safety or public health. Despite this, Minister Dreeshen played a central role in shaping the response to the Cargill outbreak. His ministry’s goal was the industry’s goal: uninterrupted operation of Alberta’s meat-processing plants.

Dreeshen and his officials led efforts to create designations and processes that AHS and OHS worked within (essential services designation, a business resumption protocol), even though they were not designed with worker safety at the fore. Instead of a mindset centred on preventing worker exposure to the new virus, Dreeshen’s comments suggest that he thought infections were inevitable and that if large numbers of workers became ill with COVID-19, they could be replaced through undefined contingency plans in order to maintain operations.   

Email correspondence and the actions of AHS officials throughout the course of the outbreak suggest that they believed it was their role to help Cargill continue to operate. In one internal email to Cargill management, an AHS public health official admitted: “We are trying to prevent shutdowns.”

Regulators should not need the assistance of those they regulate to do their job. AHS required Cargill’s support with contact tracing and related outbreak support. This created a dependency that should have been better managed. Over time, AHS acted as a partner with Cargill in trying to address the crisis. In doing so, it inappropriately took on some of the responsibility for the control of risk in a workplace.

AHS officials seemed to be torn between adhering to the public health mantra, “education is prevention,” and wanting to do more but being unable to act. The evidence shows that AHS did not see itself as a regulator vis-à-vis Cargill, even though it had regulatory powers and was exercising that authority in other settings during the same timeframe (e.g., the closure of a restaurant found in non-compliance with public health orders).

For its part, OHS performed reactive, substandard inspections, failing to enforce sections of the Act and Code that were obviously relevant to preventing worker exposure to an infectious disease. Most concerning, on April 15, OHS needed a Cargill manager to record its inspection, a decision that seriously undermined the integrity of that inspection and the independence of the ministry’s work.

The April 18 town hall meeting created the perception of a “one team” approach where provincial bodies and Cargill were working together to convince workers that the plant was safe. The meeting placed Copping and Hinshaw in a compromised position, sitting alongside the employer. Both told workers their workplace was safe, even as evidence mounted showing that there was transmission in the plant. Copping failed to state the regulatory independence and powers of his ministry to keep workers safe.

We cannot fully explain why Alberta OHS abdicated its important responsibilities in response to the largest outbreak of COVID-19 in Canada. We can say that political pressure, deference to public health, negligence, and incompetence all contributed to the tragedy. Further evidence suggests that government officials prioritized the interests of the meat-processing industry over the health and safety of meat-packing workers. Whatever the causes, their inaction represents a clear case of industry capture and regulatory failure.

Recommendations

This report includes 36 recommendations that address the need for accountability and openness in regulatory enforcement and seek to strengthen the independence of Alberta’s OHS and public health regulators as well as the protection of vulnerable workers. The main recommendations are:

1. AHS, OHS, and the Government of Alberta should acknowledge and publicly apologize to Cargill’s workers and their families for the serious shortcomings of their response to the outbreak.
2. Alberta’s health agencies and OHS must adopt the precautionary principle when responding to new respiratory illnesses. It should require employers to provide the strongest possible safeguards for employee health until there is greater certainty about the transmission of a new respiratory virus.
3. The Government of Alberta should amend the Public Health Act and Occupational Health and Safety Act to make it clear that during a public emergency, OHS continues to be responsible for leading the response in workplaces.
4. Alberta’s provincial auditor should undertake a comprehensive review of the internal processes, policies, and practices of OHS — including the staffing of key positions such as industrial hygiene officers and the director of occupational health, the authority of the minister, and the safety officers' professional responsibility guide — to determine what contributed to the regulatory failure before and during the Cargill outbreak.
5. The Government of Alberta should utilize the Alberta Labour Relations Board to create a standing list of essential services in preparation for the next public health emergency to better clarify the rights of essential workers.