The COVID response, five years on: A reflection

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How does COVID look to us now, five years after its arrival? I had the challenge and privilege of serving as Minnesota’s health commissioner during the first three years of the pandemic response and have had time since to reflect on it. The view from five years on is decidedly mixed.

Since early on, perspectives on the pandemic have varied depending on one’s own experiences. If no one you knew or loved died, or had to be hospitalized, or even had a pretty rough bout, you might think COVID’s severity was exaggerated and the response was disproportionate. You might still be angry if you lost your business, saw your kids struggling, or couldn’t visit a loved one in a hospital or long-term care facility.

On the other hand, if you or a loved one had a severe case or still suffers with life-changing long COVID, or were among the estimated 20 million people who died worldwide — including over a million Americans and almost 17,000 Minnesotans so far — your grief may be joined by outrage that others didn’t seem to take COVID seriously enough.

And then there was the politicization of a pandemic that we might have hoped would bring us together. It seems that the divide in our perspectives has only deepened with time. That does not bode well for our healing as a community, nor for our preparedness to meet future threats.

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It’s worth recapping how much we learned about this novel virus and how quickly. At the beginning we watched the number of cases explode and hospitals become overwhelmed in places like New York City. We knew very little about a virus to which we were all vulnerable — how dangerous it was, how it spread and how easily it would move through a population. There were no validated treatments beyond comfort care. The only tools we had were those used for other infectious diseases — trying to slow the spread through measures like masking, social distancing, isolation and quarantine, contact tracing, and business and school closures.

Less than one year later doctors and nurses had learned how to better manage symptoms, and vaccines and treatments to limit disease progression and speed recovery had been developed and were beginning to be dispersed through complex logistics. This was a triumph of science, hard work, unprecedented collaboration and significant government funding at both the federal and state levels.

As more was learned, the COVID response evolved. Business closures became capacity limits, then were lifted entirely. Mandates for mask wearing and distance learning became non-binding recommendations. In Minnesota we worked hard to make testing and vaccinations easily accessible so people had the ability to know their status and protect themselves and others. We developed deeper partnerships with community groups through a Culture, Faith and Disability branch of the response structure, and made some progress closing disparities in outcomes and gaps in access experienced by many parts of the community. For instance, we worked with places of worship and faith leaders to host vaccination events in their locations, and prioritized people with disabilities for vaccine distribution in the early waves of eligibility when the vaccine supply was severely limited.

But through our different lenses, the evolution in the state’s response away from restrictions and mandates was too slow and too little for some, and for others it was too fast and left those at higher risk exposed. For many, the changing information and recommendations were confusing and led to skepticism and declining compliance.

From the outset, Gov. Tim Walz put health considerations front and center, while also looking to minimize economic harm and maintain social cohesion. During those early months we lacked useful data on the tradeoffs and impacts of various interventions. My colleagues and I worked hard to give him the best advice we could with incomplete information. The governor had many tough calls to make and he made them with care.

As the first wave of cases was receding, I recommended that we keep the capacity limits for businesses in place for an additional month or so as a precaution, but my colleague who was commissioner of the Department of Employment and Economic Development (Steve Grove, now the Minnesota Star Tribune’s publisher and CEO) recommended the soonest prudent opening given the economic harms being endured by businesses. In the absence of data to quantify the benefits of continued restrictions, the governor lifted the capacity limits earlier than many states did.

I believe his thoughtful approach served Minnesota well, and I am not alone in that view. The digital news provider Politico developed a State Pandemic Scorecard looking at four measures: health, economy, education and social well-being. It called out Minnesota for having the fifth-highest aggregate score and faring comparatively well and evenly on all four measures.

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I’m often asked what I wish we had done differently. Honestly, I still have more questions than answers. I think digging into these would be important to help us be better prepared for the next pandemic: What have we learned about the relative effectiveness of specific mitigation measures under specific conditions? Could we have pivoted earlier to a more targeted response? Could we have safely returned to in-person learning in schools more quickly, and what would have been needed for that to work? How could we better protect vulnerable people, including those in hospitals and long-term care, without the serious harms produced by isolation? How should we clarify the respective roles of private health care systems and public health agencies in different aspects of the response?

We accomplished a lot together, despite unclear roles and often conflicting incentives. These are all fairly technical questions for the smart folks in public health and health care to tackle, and Minnesota has some of the best in the nation. The University of Minnesota’s Center for Infectious Disease Research and Policy, led by Mike Osterholm, is a great resource for this kind of analysis (cidrap.umn.edu).

There also are broader questions that require conversations across the community. We’ve seen what happens when we underinvest in the public health system for decades. State and local public health agencies went into the pandemic badly understaffed and with antiquated information systems. Public health serves every American and every Minnesotan every day. That system needs to be built up — not dismantled, as seems to be the current sentiment at the national level.

Health care delivery systems are also seriously understaffed, especially in areas like long-term care. Here, too, we need investment, not cuts. But how do we build support for that in this divided climate? And how do we best balance individual rights and collective responsibilities, especially to protect the must vulnerable among us?

A fundamental challenge is the loss of trust that has developed over time and was exacerbated by the pandemic — loss of trust in government, in science, in public health, in a common set of facts, and in each other. I believe we need to start by acknowledging and exploring the differences in our perspectives, and doing so together. All “sides” need to recognize the limits of their own perspectives and listen to one another, building shared commitments from there.

As a particularly visible example, why have so many people lost faith in vaccines? That terrifies public health and health care folks because we can see the rise in vaccine-preventable illnesses and the severe consequences down the road.

People whose real-life experience leads them to believe they or their children have been harmed by vaccines feel they have been ignored and dismissed. We in public health put our faith in the statistics and the rigor of things like the Vaccine Adverse Events Reporting System (VAERS). People who’ve been harmed (and many of their legislators) believe there is tremendous underreporting into VAERS. So what are we doing to educate providers on the importance of reporting, and how do we assure that the reports are investigated and that the loop is closed with reporting providers, their patients and public health departments? (The solution is unlikely to be found by cutting NIH and CDC funding related to vaccine hesitancy, as has been proposed by the Trump administration.)

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Public health folks don’t appreciate being accused of launching conspiracies to hide data or of being in the pockets of vaccine manufacturers. We’re not likely to make much progress on rebuilding trust and strengthening our preparedness until we can have more compassionate, mutually respectful conversations. To this end, I was impressed by a conversation held between Dr. Francis Collins, recently retired director of the National Institutes of Health, and Wilk Wilkinson of Clearwater, in a cooperative effort between the Braver Angels Truth & Trust Project and Wilk’s podcast “Derate the Hate,” in which they modeled just such an exchange. (See tinyurl.com/collins-wilkinson.) I would love to see us replicate this in Minnesota.

Will we be better prepared for the next pandemic? There are some danger signs that we will not be if funding cuts are indiscriminate and if we drift further apart in our perspectives and actions. But we absolutely could be if we figure out — together — the proper lessons from the COVID experiences we’ve all had.

Jan Malcolm was commissioner of the Minnesota Department of Health from 1999 to 2003 and again from 2018 to 2023. More recently she was chair of the Governor’s Task Force on Academic Health at the University of Minnesota.