Nursing homes were ravaged. New Jersey’s own mismanaged Veterans Homes became the focus of a federal investigation. Hospitals were overwhelmed with sick and dying patients.
Now, nearly four years after Gov. Phil Murphy promised what he called a “postmortem” review of what the state did and did not do right, a 910-page report into how New Jersey responded to the pandemic released on Monday concluded the state fell short in dealing with the crisis.
“Neither the state nor the federal government had clear, executable plans in place to respond to and manage such limited resources in an uncertain and rapidly evolving environment,” the report found, blaming both for a “collective failure.”
At the same time, it said that little had been learned since the crisis.
“Despite the lessons of the last four years, New Jersey remains underprepared for the next emergency,” the report warned.
The review by the law firm of Montgomery McCracken Walker & Rhoads, working with Boston Consulting Group, was led by Paul Zoubek, a former assistant state attorney general. It cost the state $9 million, including a $5 million fixed fee for the consulting group and approximately $4 million for the law firm, based on billable hours.
Launched in November 2022, two years and eight months after Murphy started promising one in the early days of the crisis, it said the state was simply not ready for the catastrophe that struck.
Among its key findings:
- New Jersey , like many states, was caught unprepared for the scale and severity of the pandemic and faced challenges in rapidly mobilizing resources, coordinating across various levels of government.
- The report hit hard on keeping schools closed for as long as we did, saying in hindsight that kids would have benefited from schools opening sooner.
- While the state Department of Health in 2015 created a Pandemic Influenza Plan which was extremely accurate in predicting what would eventually happen during the pandemic, that plan was not widely known within senior state leadership by the time COVID-19 hit.
- Death counts in the state’s Veterans Homes were likely underreported. The report attributed the high fatality rate in two of those three state-operated nursing homes in part, to “a lack of healthcare experience by the administrators at the two northern facilities compared to Vineland,” where the CEO there had significant prior healthcare and long-term care experience.
- The pandemic had deep economic and social impact, with widespread job losses, business closures, and disruptions to education. While the state implemented various support measures to mitigate the impact, challenges remained in fully addressing the needs of all communities affected.
- The state’s efforts to vaccinate its population and address vaccine hesitancy through public health campaigns were key factors in moving towards recovery.
Many of those findingsvwere nothing new and had been the focus of much attentions both in the media and before the state Legislature. But it remains undeniable that the cost in lives here was devastating.
According to the Centers for Disease Control and Prevention, New Jerseyans suffered nearly 3,000,000 cases of COVID-19 and more than 33,000 deaths between March 2020 and May 2023. There were families here in which both parents died of COVID-19, leaving their children orphans.
“We were told about families who lost more than 10 relatives. We know about the heart-wrenching experience of having an end-of-life call with a quarantined family member,” the report said. “We heard about nurses, social workers, and police officers who were terrified to bring the virus home to their families.”
In the face of these dire events, the said the state went to “extraordinary lengths” to support its residents,” there were areas in which it fell short especially in the early days of the pandemic.
The Department of Health’s 2015 pandemic flu plan was all but ignored or forgotten when the crisis hit, the report said.
It also concluded the specific roles and responsibilities of the two lead groups of the emergency — the Office of Emergency Management and the Health Department , “were not clearly defined, which led to initial uncertainty about who was in charge of what, and where the lines of authority ran.”
Communications between state agencies and state leadership during the crisis was at times inconsistent and unclear, it said.
“One comment we frequently heard in interviews was that ‘nobody saw this coming.’” While it is true that COVID-19 was a never-before-seen disease, New Jersey — and the rest of the world — had been through pandemics and large-scale infectious diseases before and knew how vital it was to prepare for the next one,” the report said.
The virus also hit some harder than others. Some populations in New Jersey, including elderly people and those without regular access to healthcare, were particularly susceptible to COVID-19.
“The pandemic compounded issues that were already present in the healthcare system, worsening inequities that already existed,” the report pointed out.
Those living in congregate settings, such as nursing homes, suffered enormously given the virus’ ability to spread rapidly through close contact. Some of the Veterans’ Homes were particularly hard-hit because of a combination of factors including “wholly inadequate infection controls,” it added.
New Jersey’s personal protective equipment (PPE) stockpiles were insufficient as well.
“On top of that, the breakdown in the global supply chain prevented quick acquisition of additional supplies,” it said.
While New Jersey learned a great deal from the experience, the report said that learning came at a steep human cost. And it that if the state did not not act now to codify those lessons, it would lose the critical knowledge and skills developed during the pandemic to fight the next one.
Murphy, in releasing the report, said New Jersey was the only state in the nation to have completed such an independent and comprehensive review.
“I know New Jersey will be better off because of this review, and my administration looks forward to working with the Legislature on its recommendations,” said the governor.
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Staff writer Karin Price Mueller contributed to this report.
Brent Johnson may be reached at bjohnson@njadvancemedia.com. Follow him on X at @johnsb01.
Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio.
Ted Sherman may be reached at tsherman@njadvancemedia.com. Follow him on Twitter @TedShermanSL.
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