Hundreds of people die every year in the United States after eating food tainted with salmonella, listeria and other dangerous pathogens. As wrenching as those deaths are, though, they are only the tip of the toll that food poisoning takes on the United States, where millions more people are sickened each year.

Salmonella is a leading culprit, with an estimated 1.35 million infections a year, resulting in thousands of hospitalizations, according to the Centers for Disease Control and Prevention.

For many of those victims, the effects can be life-altering. There can be kidney or gastrointestinal troubles that persist for years. There can be staggering hospital bills that for some patients, especially those without health insurance, seem to never let up.

And long after the worst of the illness has passed, anxiety about eating and the frustrating, often futile, search for answers can linger.

The rate of illnesses caused by salmonella hasn’t lessened in 25 years in the U.S., which continues to lag many countries in curbing the spread of the pathogen.

A ProPublica investigation of the U.S. food safety system found that federal regulators don’t have the power to stop meat and poultry contaminated with risky strains of salmonella from being sold to consumers. When the U.S. Department of Agriculture, which oversees meat and poultry, detects the pathogen, the agency can’t issue recalls or halt plant operations. It can only act if it is able to tie a case or cluster of cases of foodborne illness to a particular product. Inhibiting oversight further, a total of 15 federal agencies have a hand in food safety, with much of the responsibility split between the USDA and the Food and Drug Administration, a fragmented structure that critics say has impeded progress.

Nationally, the price tag in costs of treatment, lost work hours and premature deaths is estimated at $4.1 billion a year, according to the USDA.

“Salmonella is a very expensive pathogen, partially because it causes a lot of illnesses and partially because it can cause pretty severe disease as well,” said Sandra Hoffmann, a senior economist at the USDA. “You think, ‘Oh, foodborne illness is just a bellyache,’ but it is quite costly.”

The experience of Carter’s loved ones would end up a testament to the toll salmonella can take and to the obstacles to holding anyone accountable when illness strikes.

Austin Public Health opened an investigation into the outbreak shortly after it began, but investigators couldn’t pinpoint the source of the illness — a fate that befalls most such inquiries.

McDowell, now 68, hoped to fight through her illness at home. But the next day, she still felt sick. And that night, her watch sounded off with warnings that her heart rate had reached 130 beats per minute.

“I never felt so weak like that in my life,” she said.

By the time she arrived at Dell Seton Medical Center in Austin, others from the funeral were already at area hospitals. Before long, doctors had identified the source of the spate of illnesses as salmonella.

“You hear it advertised on the TV that so many people die a year of salmonella,” McDowell said, “but you never think that it’ll hit home. But it did.”

After the result of lab tests came back, Austin Public Health was notified on Nov. 5, three days after Carter’s funeral.

The health agency would eventually identify 84 people who attended the funeral reception. At least 26 of them were hospitalized, some for more than a week. The youngest person hospitalized was 1, the oldest 92. Servers who tasted the food also ended up sick.

The health agency interviewed 67 of 84 funeral attendees, asking each of them to recall what they had eaten, when they started feeling ill and what the symptoms were. The agency found that the rotisserie chicken was eaten by more of the sick people than any of the other foods served.

But as clear as the cause might have seemed to the victims, determining that the chicken was in fact the source of the salmonella outbreak still wasn’t going to be easy. One reason was that so many of the mourners fell ill. Only two of the people who were identified as having eaten at the funeral didn’t get sick, which left investigators unable to effectively distinguish between what the sick people ate and what the healthy people ate.

“It’s plausible that the chicken was the cause of the illness,” Jen Samp, a spokesperson for Austin Public Health, said in an email, “however, we did not have statistical evidence to prove which food was the culprit.”

A spokesperson for Sam’s Club, Erin Hulliberger, told ProPublica in an email that the company is “committed to providing high-quality products” and noted that the Austin investigators had said they were unable to determine the source of the illness.

The possibility of cross-contamination presented another investigative challenge. The brisket and chicken had been served with the same utensils, so if salmonella was originally present on one but not the other, the bacteria could have spread between them.

Monroe, who had picked up the rotisserie chickens and cut them up before the reception, was among those who ended up sick. He and his son sampled a few bites while prepping the food, and by the time the service was over, he was in such pain that he went home instead of going to the reception. It wasn’t until that night, as he heard of others who had become ill, that he realized that the rotisserie chicken might be the cause of all the sickness.

A little over a week later, after he had recovered, Monroe gave the health agency what seemed like a valuable clue: a whole rotisserie chicken that was one of the 15 purchased for the funeral reception but had been sitting, unopened, in Monroe’s refrigerator.

For investigators, an unopened package of a suspect food can be a vital, if rare, piece of evidence. Usually, the food suspected of causing illness has already been eaten, opened or discarded by the time illness emerges and an investigation is launched.

The health agency picked up the chicken from Monroe’s home, placed it on ice inside a double layer of biohazard bags and took it to a state laboratory in Austin for testing, according to Samp, who said the agency followed state protocols.

The state lab, however, determined the chicken wasn’t suitable for testing. A spokesperson for the Texas Department of State Health Services told ProPublica that Austin Public Health had collected two leftover rotisserie chickens from Monroe’s house — one in the unopened package and one in an opened package — and transported them in the same bag, creating the potential for cross-contamination. “We have very strict protocols that must be followed to ensure the integrity of the samples collected for testing,” the spokesperson, Lara Anton, said.

So what could have been the key to determining what made everyone sick ended up unexamined, underlining one of the challenges inherent in investigating foodborne illnesses.

“That’s the nature of the beast,” said Jack Guzewich, who for 11 years led the FDA’s foodborne disease surveillance and response program. “There’s so many other things that can go wrong that you end up inconclusive.”

Guzewich, who left the FDA in 2011 and worked as a consultant on foodborne disease investigations before retiring, said that had the leftover chicken been tested, it might have shown whether the chicken from Sam’s Club was carrying the same strain of salmonella that made everyone sick. “If the chicken sampling had been done correctly, they might have had the smoking gun and met the gold standard,” he said.

Based on samples from 26 of the victims, investigators determined that the funeral goers had been infected by a form of salmonella known as Saintpaul. It’s one of a relatively small number of salmonella types that account for most of the salmonella infections documented by the CDC. In 2008, Saintpaul, named for the Minnesota city where a scientist first isolated the strain, caused an outbreak that led to more than 1,400 infections nationwide. In the years since, the CDC has documented about 200 cases a year, about a fifth of them leading to hospitalization. (The CDC estimates that for every confirmed salmonella infection, almost an additional 30 go unreported.)

Even as the Austin health agency was investigating, some of the victims were pressing for answers on other fronts, contacting Sam’s Club and enlisting a personal injury lawyer.

Two days after the funeral, one relative reported the outbreak to Sam’s Club through a contact form on the company’s website. About a week later, another reported the outbreak to Sam’s Club by phone. In an email to one of the relatives and a voicemail to the other, representatives of Sam’s Club said the company had opened an “investigation.”

Patrick Monroe, the relative who filed a complaint online, said a Sam’s Club representative called him several weeks later and said because government investigators hadn’t tested the chicken, there was “nothing” the store could do.

Keith Carter, the relative who had reported the incident by phone, said he didn’t hear anything back from Sam’s Club. “I kept calling them, and they never returned my calls,” Carter said.

Hulliberger, the spokesperson for Sam’s Club, said the company takes safety seriously. “We have policies in place to comply with strict food safety controls, which help ensure the food we provide is safe,” she said.

She pointed out that the investigation had not determined what food caused many of the mourners to become ill. “Based on its investigation, Austin Public Health reported it was statistically impossible to implicate any of the food items from the funeral reception in 2019 as the source of illness that ProPublica is attempting to link to Sam’s Club,” she said.

In its report on the outbreak investigation, the health agency said it visited the store where the rotisserie chickens were purchased. It inspected its “kitchen and process” and did not note any violations.

A few of the relatives had found a firm willing to represent them in filing a lawsuit. It wouldn’t be quick or easy, but it might give them some answers and perhaps some compensation for the harm endured by so many of the mourners.

But two months later, the firm, now known as Pastrana & Garcia, backed out. After the health department said it was not going to be able to pinpoint the source of the food poisoning, the lawyer who had agreed to represent the victims, Raul Steven Pastrana, told them the case was all but unwinnable. “Without the health department’s willingness to identify one source of the poisoning, there are too many possible sources to meet the ‘more likely than not’ standard,” he wrote in a letter to the relatives. In an email to ProPublica, Pastrana’s firm declined to comment.

In Dale, a community about 30 miles south of Austin where many members of Lovey Jean Carter’s family live, some in houses right across from one another, memories of the salmonella outbreak are still fresh. Intense pain, diarrhea, nausea and vomiting overtook every household in the family in the hours after the funeral reception. The youngest member of the family, a 1-year-old, was vomiting through the night while her grandfather anxiously looked after her. Several family members were taken to hospitals in ambulances.

It felt as if death was stalking them, Carter’s mother, Lola Monroe, 94, said. “I think about that so often. My daughter’s funeral, and right after the funeral everybody got sick.”

Hattie Tibbs, 74, a family friend who was taken to a hospital in Kyle, said the illness brought her to tears. “Oh my, the pain,” she said, “I wouldn’t wish that on nobody.”

Getting out of the hospital and over their symptoms wouldn’t be the end. After the hospital stays and doctor’s visits, bills began to arrive. For some, insurance covered nearly everything. Others still owe money to this day.

Keith Monroe, who stayed in the hospital for one week and didn’t have health insurance at the time, was billed about $49,000, which he still owes. On top of his medical bills, Monroe, a handyman, lost work in the four months he was recovering.

Keith and Russell Carter, who are brothers and nephews of Lovey Jean’s, held out for three days after the funeral, trying their best to avoid seeking care.

“We really didn’t want the hospital bills. I knew if we went in, it’d be no telling how much it’d be,” Keith Carter, 55, said. “We just tried to tough it out, and the more we tried to tough it out, the worse it got.” Carter was vomiting, nauseated and completely dehydrated. His pain level, he said, reached a 10.

After about eight hours in the emergency room, his charges came to about $15,000, of which he was responsible for $1,700. Carter has five daughters and works as an equipment manager for the state’s health and human services agency by day and as an airline baggage handler at night. He had to take time off from both jobs when he got sick.

“When you got five girls and you got other bills — you got car payments, house payments — it’s money that you’re spending that you really don’t have,” Carter said.

Having to pay for being sickened by the funeral food made the hospital charges all the more frustrating. “I really didn’t want to pay anything, especially when you’re not at fault,” he said.

Today, Carter still suffers from abdominal pain. Tibbs had to change her diet because her stomach can no longer tolerate some of the foods it used to. And Keith Monroe has to use the restroom much more frequently because of lingering kidney problems.

Patrick Monroe said he is troubled that his relatives never got answers about what made them so sick. “I just don’t know how something like this got passed over.”

He is still paying off medical bills for himself and his two children. He doesn’t eat rotisserie chicken anymore. And he gets anxious at doctors’ offices, which bring back memories of all the illness the family endured. “I felt like I was going to die.”

Michael Grabell, Mollie Simon and Bernice Yeung contributed reporting. Lexi Churchill contributed research.