An opioid epidemic that has claimed the lives of hundreds of Minnesotans. A giant backlog of uninvestigated maltreatment complaints at senior care homes. Deep health disparities by race and income. Stubbornly low vaccination rates among Somali children. And an unexplained rise in suicides among older adults.

These are just a handful of the daunting public health challenges facing Jan Malcolm, named Minnesota’s new health commissioner last week by Gov. Mark Dayton. A seasoned administrator and nationally recognized expert on health policy, Malcolm will oversee a department with 1,500 employees and an annual budget of more than $600 million.

Her selection was met with rare and near-universal applause at the State Capitol, where lawmakers from both parties commended her political acumen and sterling credentials. Malcolm, 62, boasts a résumé of unusual breadth, having served as health commissioner under Gov. Jesse Ventura and then as a leader of some of the state’s largest nonprofit health organizations.

“If you had to choose one person who could steer the Health Department through this inferno, it would be Jan Malcolm,” said Rep. Jim Abeler, R-Anoka, chairman of the Senate Human Services Reform Finance and Policy Committee. “She has weathered the storms politically and comes with instant credibility.”

A star in health care policy circles, Malcolm succeeds Dr. Ed Ehlinger, who resigned in December amid complaints that the department had failed to protect vulnerable elderly Minnesotans from violence in senior homes. A Star Tribune investigation published last year chronicled breakdowns in the state’s handling of allegations of beatings, assaults, thefts and other forms of maltreatment in the state’s nearly 1,800 senior homes.

Malcolm wasted no time in signaling a tougher stand. At a news conference Tuesday announcing her appointment, she apologized for the breakdowns, including “the pain, the trauma, and all the difficulties” they had caused to affected seniors and families. That same morning, she fired off a message to the department’s entire staff, promising to eliminate a huge backlog of maltreatment complaints by the end of the year.

“This is a critical step in the process of restoring Minnesotans’ trust in the safety of their loved ones,” Malcolm wrote. “We will get this work done with the high standards Minnesotans expect and deserve of their government.”

In an interview this week, less than 72 hours after her return to state government, Malcolm sounded buoyant and hopeful, jokingly referring to her previous stint as “Malcolm 1.0.”

“I really got bit by the public health bug,” she said of her time under Ventura. “I knew when I left the commissioner’s role … that I would spend the rest of my career continuing to work on issues related to public health.”

Targeting tobacco

Malcolm is no stranger to the political spotlight — and the heat it brings. As Ventura’s health commissioner, from 1999 to 2003, she repeatedly locked horns with lawmakers over an expensive and edgy advertising campaign (known as “Target Market”) designed to reduce youth tobacco use. Later, despite skepticism from privacy advocates and some health plans, Malcolm helped build the state’s first medical research database using actual patient records, as a way to track wasteful spending and trends in health outcomes.

The Dartmouth graduate was also among the first Cabinet-level officials to take lawmakers to task for Minnesota’s persistent health inequities. The state’s strong performance overall on key health indicators had long masked the fact that Minnesota has some of the nation’s worst marks for health equity, including unusually high infant mortality and teen pregnancy rates among minority populations. In 2000 and 2001, Malcolm laid the groundwork for legislation that has resulted in tens of millions of dollars in community grants directed at reducing these disparities.

“Sometimes there is a job and a person that meshes up perfectly, as if they were made for each other,” said Steven Bosacker, who served as Ventura’s chief of staff. “Jan loved every second of her time as [health] commissioner, and really drove the public health agenda to new heights.”

Known as a deft negotiator, Malcolm also had to navigate conflicts within the Ventura administration, which sometimes lurched from one priority to another without a clear direction, former members of the administration said.

Over objections from some of Ventura’s anti-tax advisers, she persuaded the governor to support a hike in the cigarette tax as a means to deter smoking. “Governor Ventura was generally not crazy about raising taxes, but Jan prevailed,” said former state senator Linda Berglin. Malcolm also helped craft and promote an innovative plan to set aside a chunk of Minnesota’s $6.1 billion tobacco settlement for endowments to prevent tobacco use and promote public health. However, the endowments proved to be irresistible targets, and were used to balance the state’s budget under former Gov. Tim Pawlenty.

“That was both one of our greatest triumphs and one of our greatest sadnesses when it got undone,” Malcolm said.

At the same time, Malcolm pushed for a broad array of other public health initiatives, including an early plan to screen newborns for hearing loss, more transitional housing for people with mental illnesses, and a statewide emergency response system for infectious outbreaks and terrorist attacks.

Her former deputy commissioner, Julie Brunner, described Malcolm as “the quintessential public health junkie” who worked so many evenings and weekends that staff had to plead with her to take a vacation. She would insist that agency staff maintain copious databases highlighting the long-term cost-effectiveness of their initiatives, and would frequently arrive at legislative briefings with reams of statistics, colleagues recall.

“The irony of public health is, the better it works, the more invisible it is,” Malcolm said. “You literally never get the credit for prevention because it’s invisible.”

Malcolm carried her passion for numbers into the nonprofit sector. In 2005, she became president of the Courage Center, a rehabilitation center in Golden Valley for people with disabilities. While there, she pushed the large health insurers to pay for an array of services and technologies, like better wheelchairs, by citing Courage Center’s own data to show how they would reduce hospitalizations, recalled Michael Scandrett, a health care consultant and former board member of the Courage Center.

“Jan is singularly persistent, like water pouring over rocks,” said Pamela Wheelock, former state finance commissioner under Ventura. “She was so solid in her commitment to public health initiatives and so persuasive, that you wanted to jump on whatever bandwagon she was on.”

Challenge of elder abuse

Still, with less than a year left in Dayton’s term, Malcolm will have limited time to confront a range of new public health challenges.

Chief among them is restoring trust in her agency’s ability to investigate and resolve thousands of allegations of abuse in senior homes. That trust was badly shaken by published reports of chronic delays, lost or destroyed files, and poor communication with elderly victims of abuse and their families. Agency officials admit they were caught unprepared by a dramatic surge in maltreatment complaints. In 2016, the Health Department conducted on-site investigations of just 3 percent of the more than 25,000 allegations it received of abuse and neglect in senior homes.

“You can bet that her number one focus, like a laser, will be on elder abuse,” said Brunner, her former deputy commissioner. “She is all about getting the job done.”

Malcolm will face immediate pressure to undertake more far-reaching reforms to protect seniors. Last week, a working group of senior advocacy organizations and families of abuse victims released a 58-page report calling for a long list of reforms, including tougher criminal sanctions against abusers, greater access to state investigations for victims and their families, and stronger oversight of the lightly regulated assisted-living industry.

“The kind of change that is needed is not a ‘snap-your-fingers and fire these people and everything will work well’ kind of change,” said Larry Jacobs, a University of Minnesota political science professor who studies health care policy. Malcolm “literally has to go in and change the gears in that department, and that is going to be very hard.”