Two years of the pandemic have been particularly long for Dr. Richard Palahniuk, Minnesota's first known case of COVID-19.
Since testing positive on March 6, 2020, the retired anesthesiologist has feared the return of the worst illness of his life. He'll never forget days of shivering in a parka while huddled by a fire. Or nights of burning up in sweat-soaked sheets. Or struggling with exhaustion for days or losing his sense of taste and smell for three months.
Only recently has the 77-year-old stepped out with his wife for an early dinner or matinee.
"We're sitting a mile from the nearest other person," he said.
Palahniuk's caution exemplifies Minnesota after two years of COVID-19. State leaders hope after five waves and 1.4 million confirmed infections, the pandemic is transitioning into a predictable and manageable endemic.
But they haven't forgotten the premature celebrations last summer, when hopes were dashed by a fast-spreading delta coronavirus variant that prolonged the pandemic. Another 4,300 COVID-19 deaths have occurred in Minnesota since July, pushing the toll past 12,000.
"It was heartbreaking ... the gut punch of thinking things were stabilizing or getting better and then the next thing comes along," state Health Commissioner Jan Malcolm said.
Minnesota now may be in for a break since the five-month-long delta wave gave way to an omicron variant that produced record infections this winter. An estimated 70% of Minnesotans have temporary immunity against omicron because of vaccination or infection, according to the Institute for Health Metrics and Evaluation (IHME) in Washington state.
Nobody thinks COVID-19 will disappear, though. State leaders are assessing whether Minnesota is in a stronger position to handle any future surges or a weaker position because the public is worn down by two years of infection, social isolation, economic disruption and hospital crisis.
"Omicron moving through such a large percentage of the population will give us some degree of population immunity," said Matt Aliota, a University of Minnesota expert in emerging infectious diseases. "But until we get enough high-quality vaccine to as many people as we can, there will be another variant. It's guaranteed. It's just a matter of when and how severe it will be."
The state's fatigue shows in surveys of people who usually wear masks in public. Minnesota had one of the highest rates at 92%, but it plummeted below 20% after Gov. Tim Walz lifted a statewide mandate in May 2021 and stayed below the national average even during the latest waves, according to Carnegie Mellon University's COVIDcast.
The state's divisions show in vaccination data. More than 3.8 million Minnesotans are fully vaccinated and 2.1 million also have received boosters, but 1.1 million eligible residents 5 and older haven't received any shots against COVID-19.
As a hair stylist and mother of three, Ariel Iverson of Robbinsdale wants normal life back. Unemployment payments supported her family during Minnesota's spring 2020 lockdown, but school closures that fall forced her out of work on weekdays.
Business was brisk after Minnesota's two stay-at-home orders in 2020, because people emerged with unkempt hair or uneven coiffures from trying to cut it on their own. But Iverson, who is vaccinated, missed four weeks this winter after her children brought COVID-19 back from a trip to St. Louis.
Iverson couldn't walk from her bed to the bathroom without collapsing in dizziness. She was hospitalized with COVID-19 and a dangerously low blood oxygen level.
"We're at this point where we just shake our heads and go 'Yup, OK,' but I feel like there is a tipping point," she said. "People are getting worn down. Eventually they are going to lose it."
Advances in prevention, PPE
Minnesota has more knowledge and resources than two years ago when Palahniuk was the state's first confirmed COVID-19 case. The state now has adequate access to masks and tests along with vaccines and antiviral pills. Prevention efforts are focused on airborne transmission as there is little evidence that hand-to-surface contact spreads the virus.
Palahniuk and his wife took a Pacific cruise in February 2020, during renovations to their house in Vadnais Heights, and learned immediately upon return that COVID-19 had spread on the ship.
M Health Fairview St. John's Hospital in Maplewood had only one test to offer when the couple sought care for symptoms and gave it to Palahniuk because he appeared sicker. His positive test was publicly announced the same day he received the result.
Palahniuk was so sick he needed a 15-minute rest after putting on socks. Even so, he has mixed feelings about Minnesota's pandemic response and whether attempts to slow viral spread with business closures and social restrictions were effective and worth the costs.
"I thought the reaction was an overreaction," he said.
Walz said he knew at the pandemic's start that public patience was finite, and he used a lot of it on the 51-day stay-at-home measure in spring 2020, and the four-week pause on business, school and social activities in fall 2020 to buy time for vaccine approval.
Concerns about burnout factored into Walz's decisions to end a mask mandate earlier than expected in May 2021 and move to in-person learning in February of 2021.
"There is a limit," he said. "You can only go to that well so many times, because it truly is fatiguing for people."
Some decisions came late, including Minnesota's four-week pause after the state's second COVID-19 wave had peaked. Tools such as wastewater sampling can predict changes in pandemic trends before they show up in case numbers and can result in faster decisionmaking.
The challenge will be to convince a tired public of the need for COVID-19 mitigation strategies before the need is obvious, Walz said. "I think you have to be in the midst of it."
Larry Eidem of Denmark Township is a Republican who doubted the Democrat Walz but nonetheless wore masks and got vaccinated last June. The retired printer said he has lost confidence in what protections are needed, though, and declined a booster shot when his doctor offered it last month.
"I don't know what makes sense anymore," he said. "There's so much misinformation."
Eidem, 64, said he probably will get a booster shot before a trip to Canada but feels like he is being pushed into things about which he isn't convinced. Eidem trusts his doctor for management of Type 2 diabetes but wondered if even he had a profit motive.
"To me it becomes like a dull hum in the background," said Eidem, whose brother-in-law died of COVID-19. "It's the same thing droning on and on and on."
People lost trust in government COVID-19 responses because states took conflicting and partisan approaches, raising questions about whether any were based on science, said Dr. Frank Rhame, a virologist with Minneapolis-based Allina Health. An IHME study last month found higher infection rates in countries where people had less trust in government and one another.
"What people do is they go with their hunch, and then they seek information to support their hunch, and then they never see or believe or trust information to the contrary," Rhame said.
The divisions meant "abysmal failure" for the U.S., because mask-wearing and vaccination campaigns need broad participation, Rhame said. The U.S. COVID-19 death rate is 15th highest among nations.
Minnesotans are fearful of school or business closures, but Malcolm said future lockdowns are "very unlikely" because the state has tools that didn't exist at the start of the pandemic. Makeshift transitional care sites also helped Minnesota preserve hospital beds during the last two waves, and those sites could be used again.
"We haven't been restricting anybody's activity for a very long time," Malcolm said. The challenge is "getting people to understand you don't have to shut everything down to do things that makes sense."
Malcolm said she hopes people have learned to take their own precautions, putting on masks when they perceive risks and understanding that a new variant in other countries could quickly be a threat in the U.S.
The hope is that the coronavirus mutates out of self-preservation into something that kills fewer people. The omicron wave offered hope because the variant spread easily, even among vaccinated people, but wasn't as lethal as previous variants. The seven-day average of COVID-19 deaths declined from 39 in early December at the end of Minnesota's delta wave to below 20 by March.
COVID-19 was the third leading cause of death in Minnesota in 2020 after cancer and heart disease. The cumulative rate of known coronavirus infections resulting in death has declined the past two years in Minnesota from 2% to 0.9%, but that is still almost 10 times more deadly than typical seasonal influenza. The level of COVID-19 mortality that would no longer require a heightened response is unclear, Malcolm said.
"Endemic control would have to mean 'low' death rates and that's a tricky societal discussion," she said. "What are — I don't want to use the word acceptable — but really the death rates that are in a range that you would expect with a respiratory disease?"