What happened In Marion County? High concentrations of coronavirus blamed on inequality of care

A sign directs patients at Salud Medical Center in Woodburn on Wednesday, April 29. (Amanda Loman/Salem Reporter)

The employees of the farmworkers union in Woodburn got a jolt during their weekly meeting in early April, conducted as usual over Zoom.

An organizer shared the grim news that Héctor, a farm laborer known for his talkative presence on their Radio Poder station, was hospitalized, seriously ill with COVID-19. He drove a van for other workers.

His son was sick too.

“Everybody was just shocked,” said Reyna Lopez, PCUN executive director. “This is a man who seemed so strong … It was really hard to hear that someone who has been so close to our movement has been so affected.”

By the time of that April 1 meeting, nearly every community organization in Woodburn was aware that the virus was spreading at a rapid pace among the area’s most vulnerable residents. They were mostly Latinos, often undocumented and not speaking English, working in nurseries, food processing plants and grocery stores.

Days passed before the Marion County Health Department approached the groups to ask their help to slow the rapidly escalating number of infected individuals.

By then, Marion County was evolving as the place in Oregon with the worst concentration of COVID-19 victims and remains so today. Public officials say they still can’t explain why matters took such a harsh turn for one of Oregon’s most populous counties.

But an investigation by Salem Reporter found that state and Marion County health officials were slow to get timely, accurate information about COVID-19 to agricultural workers and non-English speaking residents in the north county. 

Constrained by limited testing capacity, limited staffing and sometimes days-long delays in getting results back, health officials reacted as new cases were reported, but did little to proactively ensure some of the county’s most vulnerable residents were armed with information to protect themselves and their families.

That left community groups to forge their own hastily-made plans to address a growing epidemic.

The delays in addressing the unfolding health crisis likely contributed to county residents becoming infected at a rate more than double that of the state.

Aurora Espinoza, left, and Adela Montes-Romero wait for patients at the screening area in front of Salud Medical Center in Woodburn on Wednesday, April 29. Patients check in at the tent and have their temperature taken prior to their appointment. (Amanda Loman/Salem Reporter)

As of Wednesday, 22 of every 10,000 Marion County residents are known to have the virus – nearly double the toll in Multnomah County, which has tested a far higher share of residents. 

And Marion County’s infection rate is nearly three times the state average of eight in every 10,000 residents.

Colm Willis, chair of the Marion County Board of Commissioners, noted that only the sickest have been tested and that the county’s residents have higher rates of chronic illnesses than other Oregonians. He said that the virus-related hospitalizations among county residents has declined.

“Relative to other parts of the country, even Marion County has a relatively manageable infection rate,” he said in an interview last week.

But case numbers are still climbing rapidly. Marion County now has 746 residents known to have COVID-19, with 153 of those added to the county roster in the past week. The county recorded the single largest one-day tally in the state with 43 cases posted last Saturday.

In the ZIP codes including Woodburn and Gervais, the infection rate is even worse. A fourth of county residents confirmed to have the virus live in the Woodburn ZIP code, an area with about 8% of the county’s population.

Community leaders said in interviews in recent days that they’re still fighting to get needed testing and aid to those most impacted. They also are battling stigma blaming those Latinos who are sick for not following health guidelines.

Levi Herrera Lopez, executive director of Mano a Mano, said he’s seen people suggest on social media that Latinos in Woodburn should be locked up to contain the virus.

“People are taking this to mean it’s the Latino community’s fault that numbers are high,” he said.

The truth of what happened in Marion County emerged from dozens of interviews with state and county health workers, public health researchers, Marion County doctors and Latino and Russian community leaders, as well as a review of public state and county data.

 The mystery

Officials announced the first instance of a Marion County resident testing positive for COVID-19 on March 8. Health workers provided few details, but later said that person lived in Woodburn.

By late March, state and county health officials realized that Marion County had a higher rate of cases than nearly any other part of Oregon.

“From the start, our epidemiologists have been tracking cases and trends to inform the work of our incident response team. As needs for increased communication or partnerships are identified, the county acts on them to prevent the spread of the virus,” said Katrina Rothenberger, director of the Marion County public health department. 

The county soon turned to the state for help managing the unfolding health emergency. On March 23 – just two weeks after the first reported case – state officials dispatched people who are experts at setting up a command structure during a major event like a wildfire. A team of three people from the Office of Oregon State Fire Marshal walked the health department through an “incident command system starter kit.”

Mariana Ruiz-Temple, chief deputy state fire marshal, said her agency trained health workers to know their roles in the crisis, smoothing out operations.  

Ruiz-Temple said the state was receiving similar requests for help from across the state and could only lend the team to Marion County for five days.

 “We were already overwhelmed,” she said.

But the county told the state it also needed help “to give public health team time off.”

Ruiz-Temple said that was typical of requests from Oregon counties as the pandemic took hold in the state. 

“Nobody can take over for anybody. We know that everyone felt that way,” she said. “We can come in and be a resource and stand next to them.”

Staffers work together at the Oregon Heath Authority’s Agency Operations Center in response to coronavirus cases occurring in the state. (Jonathan House/Pamplin Media Group)

As the state team finished up its work, Marion County recorded its highest spike yet, with 26 residents testing positive on March 27. That same day the Oregon Department of Transportation building in Salem closed because an employee had tested positive for the coronavirus. 

Two days later, Marion County posted the second highest count of infected individuals with 109, second only to Washington County. 

The virus then hit Salem’s transit system, which shut down bus service on March 31 for the first time in its history. Seven employees tested positive for the coronavirus.

With cases piling up, workers at the county health department quizzed those who had contact with infected individuals while state officials examined data, all to find common factors among the ill that might explain the local surge.

That is a time-consuming process, said Dr. Paul Cieslak, a public health physician with the Oregon Health Authority. A doctor ordering a COVID-19 test will enter into an electronic database information about their patient, but reporting varies. Sometimes, the physician records only a name, birthdate and a phone number.

To get more information, county and state workers call the patient, asking about symptoms of illness and where the patient has been in public recently, as well as gathering demographic information like race, native language and occupation.

That information is meant to help determine patterns about who’s getting sick and why. Such work can also lag days or weeks behind when people begin showing symptoms.

Cieslak said the state could find no clear answer for what was happening in Marion County. The state couldn’t identify a “super spreader” event or location where dozens of people got sick.

Health authorities look for “clusters” of cases as part of their investigation, but state and county officials won’t disclose even basic information about such clusters, such as whether they were in churches, because of privacy.

Cieslak said, however, that no significant clusters outside of homes were identified in Marion County.

“They didn’t make me raise my eyebrows. They didn’t make me say, ‘Okay, there’s the problem,’” he said. 

With no clear source, health officials continued gathering information. 

“Normally we try to drill down and say, ‘Can we identify any particular subgroup within that population that is particularly affected?’” Cieslak said.

Marion County is home to four state prisons and the Oregon State Hospital, large institutions at higher risk for widespread infection because people live in close quarters. But none of them were yet reporting cases that would drive up Marion County’s rates.

Woodburn stays on the job

Community leaders and state health officials said Marion County’s outbreak is exposing longstanding inequities for Latinos and non-English speaking residents who are more likely employed in agriculture, manufacturing and other fields where work has continued despite the pandemic.

The leaders described as slow or inadequate the outreach early on that could have helped people still working in essential jobs better protect themselves and their families.

“The gaps that are already in our community, the gaps that have already been there between our Latinx community and our county, they’ve been magnified in a really big way,” said Lopez, the PCUN director.

In Woodburn, community leaders in mid-March were scrambling on their own to make sure information about hygiene and social distancing was getting to people who most needed it. 

The city of 25,000 is the epicenter of the Willamette Valley’s farming community. Its residents are mostly working class, with over half speaking Spanish at home, according to Census data.

Lopez said as Oregon imposed tighter restrictions on some employers, Marion County agriculture and food industries remained up and running.

“Our community is still out there working. We’re living in two different realities,” she said.

Workers in food warehouses, meat packing plants, nurseries and other agriculture and manufacturing businesses were still on the job. Those sectors are disproportionately Latino, both nationally and in Marion County.

A sign at Salud Medical Center in Woodburn on Wednesday, April 29. (Amanda Loman/Salem Reporter)

Employers in grocery stores, agriculture, manufacturing and construction weren’t required to follow all of the state’s guidelines about social distancing at work, though they still had an obligation to protect employees from COVID-19 under general workplace safety rules, according to Oregon OSHA spokesman Aaron Corvin.

Staying far apart from other workers is possible in some field jobs, but Lopez said PCUN received reports from workers that they were working “shoulder to shoulder” in farms and food processing plants and didn’t have hand washing stations or sanitizing supplies. PCUN encouraged people to file complaints with state agencies, she said.

Workers have filed 29 complaints with Oregon OSHA alleging Woodburn businesses failed to follow social distancing guidelines or provide protective equipment. Six relate to grocery stores and three to nursery and meat packing businesses. Most are still being investigated.

Close contact at work wasn’t the only concern. Workers often shared van rides to jobs, providing another way for the virus to spread. Many live in large households, making it easier for the virus to spread to a larger group if a working adult unwittingly brings home the disease.

Large households have been a common factor for people seeking COVID-19 testing at Woodburn’s Salud Medical Center.

“Family is the center. You may be interdependent on other portions of your family. Maybe your cousin is your babysitter. Maybe your grandparents live with you or your parents,” said Lori Kelley, director of quality for Yakima Valley Farmworkers Clinic, which operates Salud.

Access to health care also plays a role, according to Latino health providers and community leaders. State data shows that Latinos are less likely to have health insurance, meaning it’s more difficult to get testing.

That means those testing positive in official counts likely reflect a small portion of the true number with COVID-19. Kelley said the percentage of patients testing positive at Salud has been higher than at Yakima Valley’s other Marion County clinics, suggesting those coming in are more sick.

Salud offers care to those without insurance at a sliding scale, and testing is free, but Kelley said evolving health guidelines haven’t been well communicated. Early health messages about the virus told people to stay home if they had mild symptoms to reserve testing for the seriously ill, a message she believes is likely still prevalent.

“The variable none of us can control is whether an individual seeks care and decides to be tested,” Kelley said.

Viviana Gourley, a medical assistant at Salud Medical Center, adjusts one of her two masks at the center’s COVID-19 testing area in Woodburn on Wednesday, April 29. (Amanda Loman/Salem Reporter)

Many farmworkers are undocumented, rendering them ineligible for public health insurance, and Lopez said even people with green cards or visas may forgo employer insurance because of shared costs, or fear that using government benefits might impact pending immigration cases.

Yara Delgado, a bilingual family medicine doctor at Kaiser Permanente’s North Lancaster clinic in Salem, said accessing care is especially difficult now for those without health insurance.

“A lot of our free clinics have shut down during this pandemic and for a lot of immigrants and undocumented patients, that’s their main source of health care. They don’t have anywhere they can go to right now and they’re afraid to go to the emergency room. We’re seeing some of those discrepancies magnified during the pandemic,” she said.

Lopez said she’s heard reports of Latinos with COVID-19 symptoms turned away from testing sites in the county, sometimes because they didn’t have insurance. 

Without widespread testing, it’s more likely for people with no or very mild symptoms to spread the virus, especially if they’re still going to work. Public health workers are also challenged to identify where the virus is spreading when they can’t track all those who are infected, something that can revealed by extensive testing.

Health providers said the issue is especially relevant for low-income workers, who often can’t afford to miss work and won’t do so without proving positive for the virus. 

That reluctance was compounded by testing issues. Many clinics that began testing were constrained by low supplies in March or early April. While providers testing in Woodburn said that’s no longer a concern, the perception that testing is scarce has been hard to overcome.

“It was so limited for so long that I think a lot of people might have given up on looking for it or asking their providers for it,” said Nick Kashey, a family medicine doctor with Legacy Health, which set up a testing site in Woodburn on April 7.

A growing outbreak

The difficulties immigrants, agricultural workers and non-English speaking residents have finding health care were well known to elected officials and health authorities before the pandemic began.

But community leaders say their groups were largely left without government support to share vital information.

The Oregon Health Authority published Spanish-language guidelines to avoid the virus early in the outbreak. County health workers shared information with groups like PCUN and the Farmworker Housing Development Corporation in Woodburn.

From there, it was left to community leaders and health centers like Salud to reach out through northern Marion County to address questions and combat misinformation with no extra funding or people.

Maria Elena Guerra, executive director of Farmworker Housing Development Corporation, said her organization recruited volunteers to call individuals in her nonprofit’s housing complexes to tell them about social distancing when the coronavirus first started spreading throughout the county.  

Her agency houses around 1,500 people who speak either Spanish or one of nine other native languages of Central America. No health information was available in those indigenous languages. But the Rural Women’s Health Project, a nonprofit based in Florida, translated materials in indigenous languages and shared them online.

Jaime Arredondo, executive director of Capaces Leadership Institute, said leaders of local Latino organizations met on March 13 to plan how to respond to the coronavirus, focusing on ensuring the Latino community had access to information in Spanish and indigenous languages.

Lopez said government health authorities should have worked with rural radio stations, Spanish language media or other similar outlets. Even when social distancing guidelines did get out, she said they often failed to address the realities of daily life for people who carpool to work or live in large households with a single bathroom.

“What I mostly heard was confusion from our Latinx community, especially our elders, saying ‘Hey, am I going to get arrested if I go out to work?’” Lopez said.

On April 1, a group of Latino organizations headquartered in Woodburn launched a project to coordinate the identification, translation and dissemination of information. They posted on social media pages, shared it on weekly Zoom calls and aired information on Radio Poder, a local Spanish radio station that broadcasts throughout the mid-Willamette Valley. 

Lopez said by then, PCUN started receiving more requests for donations to pay for funeral expenses for elders who had died from the virus.

On April 2, the union launched an emergency fund to help undocumented workers facing expenses like funeral or health care costs, or lost wages due to being sick. So far, $30,000 has been paid out, Lopez said.

The impact on the Latino community became evident when the Oregon Health Authority reported on April 7 that Latinos in Oregon were testing positive for COVID-19 at twice their share of the state population. It was the first publicly available information showing the virus’ impacts were not spread evenly by ethnicity.

The report didn’t show numbers for Marion County, but local health officials saw a similar trend. Latinos are about 26% of Marion County’s population but represented 35% of cases as of April 29.

As April wore on, matters got worse in northern Marion County.

Working on a Saturday, Marion County Health epidemiologist Aryn Walker spotted a spike in residents testing positive for the virus.

The details were in the state’s morning report of April 18, showing 19 county residents, most in Woodburn and Gervais, had recently tested positive for COVID-19. The following day, another 27 Marion County residents were shown infected.

Walker sounded the alarm to Rothenberger, the public health director.

The county took a new tack to determine what was making Marion County so extraordinary, reviewing cases by ZIP code.

That’s an imperfect way to assess where a virus is spreading, since people often work outside their home ZIP code, but is more revealing than looking at an entire county. 

The county had been collecting ZIP code data from the start of the outbreak in March, county spokeswoman Jenna Wyatt said. 

Rothenberger said the county wanted to use that information to verify a hunch that Woodburn was more affected than other parts of the county.

The hunch was right. The county shared details by ZIP code with the public for the first time on April 23. There was no question: Woodburn and Gervais had been especially hard hit.

Wyatt said when epidemiologists identify a case, they work with local governments and community organizations to educate and quickly trace the source of any infection.

“To be clear, we have not seen an outbreak in the farm worker population in north county. We acted early to interrupt the spread of the virus in the area. With the help of our partners, we will continue providing resources needed to ensure the health of all of our community members,” Wyatt said in an email.

But community leaders said the problem is more widespread than the field hands most people picture when they hear “farm worker,” and includes people working in food warehouses, processing plants, grocery stores and other industries that put food on the table and have gone on despite the shutdown of much of daily life.

Woodburn Mayor Eric Swenson found out that Marion County had a significant infection rate April 22 during a Zoom call with city officials and elected leaders.

This was the first time they were presented with data by ZIP code. Swenson was struck that the Woodburn area was experiencing a surge in new cases even though the community appeared to be dutifully following social distancing requirements and clinics were reporting a low number of cases. 

He said he suspects that the source of new infections are spread throughout the ZIP code where public health messages have taken longer to sink in.  

“I’m out observing the community and Woodburn is staying home,” he said.

But on April 28, Woodburn police responded to a wake at the Metropolis Marketplace and Event Venue, located at 347 N. Front St. in Woodburn. According to the police report, about 40 people were attending. 

According to the report, an officer observed well-dressed people in the downtown plaza entering Metropolis. Outside a man wore a black hat with white letters that read “SECURITY.” 

Inside, flower arrangements decorated the scene while people congregated, according to the report. The coffin was open for viewing.

Some mourners were six feet apart while others weren’t, according to the report. Officers shut down the event without issuing citations. According to a second report filed April 29, police again responded to the location. By then, the wake had been going for three days. 

Other theories

Cieslak, the state public health doctor, said he’s heard various theories seeking to explain Marion County’s high case rate, but they aren’t supported by the data he has access to.

One involved a community of about 10,000 Russian Old Believers, clustered around a group of about 10 churches spread between Marion and Clackamas counties. 

Anna Kasachev, president of the Russian Old Believer Community nonprofit, said that there were a handful of people who came down with COVID-19 but there were no deaths. The community has continued holding church services even while the governor’s banning gatherings of 25 people was in place, she said. 

But Kasachev said the churches took measures to stay safe by reducing the number of people in attendance. Older and more vulnerable people have stayed away from church services, she said. Even during Easter, most people stayed home, she said. 

 “Early on, our messaging started right away and we took it seriously,” she said.

In late April, the Oregon Health Authority reached out with materials in Russian to help get out the word.  

The form health workers to report a COVID-19 case to the state asks a patient’s native language and their ethnic background, which includes options for “Eastern European” and “Slavic” under white. Such information could help investigators pin down the source of an outbreak.

Those fields aren’t always completed, Cieslak said, but his review of that data doesn’t show the Russian community has been a significant factor Marion County infections. And while the state Health Authority has heard reports of events like the wake and church services conducted in violation of the governor’s orders, he said similar reports have come in from across Oregon – they’re not unique to Marion County.

The state Health Authority wouldn’t release data showing the number of Marion County infected residents by their language. The agency said that was to preserve privacy.

Now, state and county health agencies are rushing to expand their view into the region’s outbreak by expanding testing and pressing ahead with more education. In early May, the state Health Authority published information sheets on stopping the spread of the virus for farmworkers and agricultural employers in English and Spanish, and is working to translate them into indigenous languages, spokesman Jonathan Modie said.

State health workers on a daily basis discuss the disproportionate impact of the virus on Latinos, in Woodburn and around Oregon, he said.

“It’s an issue that’s very concerning for those of us in public health, and one which we’re working with county public health department, city leaders, those in health care, and community partners to address by ensuring our messaging about protecting yourself … is reaching all populations in a timely and effective manner,” he said in an email. “We know we can do a better job with our outreach efforts to certain communities, and we continue learning from every situation to improve our responses.”

County officials last week said they would award up to $9,000 to groups working with Spanish and Russian communities in order to enhance outreach. 

Last Wednesday, the county dispatched another 200 virus tests to Salud and another 200 to Salem Health’s Woodburn clinic.

That same day, Marion County’s commissioners insisted matters were well in hand and that Gov. Kate Brown ought to open the county to more normal business by this Friday. Brown denied the request Wednesday.

Six days later, the state Health Authority said it could finally assign out highly-desired testing machines – the Abbott ID NOW – that give medical professionals a much faster way to process tests and detect surges. Medical workers can get test results on the spot in about five minutes, shaving days off the process of sending coronavirus tests to laboratories.

The authority had just a dozen to share across Oregon.

Two were assigned to Woodburn.

Contact reporter Rachel Alexander: [email protected] or 503-575-1241; Saphara Harrell: [email protected] or 503-549-6250; Jake Thomas: [email protected] or 503-575-1251.