If you look at the New York Times’ list of the metro areas where COVID is currently at its worst, you’ll find that 13 of the 20 most-afflicted towns are in Michigan, including Jackson, Detroit, and Flint. Dr. Anthony Fauci seems skeptical that outbreaks like the one in Michigan could become a full-blown “fourth wave” of COVID across the entire country. But Abdul El-Sayed, who is in the middle of one of these localized outbreaks, looks at what’s happening right now a little differently. El-Sayed is a lifelong Michigander and an epidemiologist who ran the Detroit Health Department a few years back. He says Michigan proves that unless our vaccination plans really ramp up, we’re in danger of losing a race with this coronavirus. Vaccines could smother the spread, of course—but only if they get into everyone’s arms, now. On Wednesday’s episode of What Next, I spoke with El-Sayed about the weak spots in our distribution plan, how variants are raising the stakes in our national race to get vaccinated, and how our progress against the virus, which seems to have stalled in other areas, could even get reversed. Our conversation has been edited and condensed for clarity.

Abdul El-Sayed: I’m not going to lie: In early March, I felt really good about everything I was hearing and seeing. Spring was on its way. We had a couple of really nice days. When things started to level off in a real way and then tick upward, that’s when my feeling of optimism started to fade a little bit. Michigan is “going vertical” with new cases—when you start to go vertical, you’re talking about many more people infected per person. And that exponential growth is where we are in the state.

Mary Harris: I wonder if you see Michigan as being a warning to the rest of the country.

I want to be wrong about this. I want the future to look like everyone learned their lesson. But I am looking at this moment and I’m thinking that every single person who gets infected right now is an opportunity for a variant to pick up a set of new evolutionary traits that could potentially lead it to escaping our immune responses, whether natural or vaccine-mediated.

So it could get worse.

I don’t want to say that, but there is a theoretical possibility that it could get worse.

Let’s dig in exactly what the numbers are and what we’re seeing. My understanding is that Michigan is leading all other states in terms of new cases. Are these cases concentrated in a particular area, or is it really just everywhere?

The outbreaks started out being concentrated in Michigan’s “thumb,” for folks who are familiar with the geography of Michigan. But you still had cases growing in other communities. And now, people are gathering and doing things that they were not doing last year around this time. So it’s spreading across the state. Just the other day, we broke 10,000 cases. The day before we were out at about 8,500. That gives you a sense of the trajectory.

My sense is that because some people are vaccinated and yet there are these coronavirus variants, the rising caseload looks a little bit different than what we’ve seen before. Do we have a good sense of what’s causing the spike?

You have a more transmissible, more virulent form of the virus—that’s what B.1.1.7 is, it’s faster to transmit and it makes you sicker. And then you have reopening, which is bringing people together in this context. If those folks aren’t vaccinated, then what you end up having is this toxic brew where you have a more virulent, more transmissible version of the virus spreading among people who are now mixing at a higher rate than they had been in the past.

And these are people who may be feeling safe because younger people weren’t getting as sick in the beginning.

That’s exactly right. That is one of the alarming pieces of this: If you look at the increases in hospitalizations, it’s among young people. That’s probably attributable to the fact that B.1.1.7 is more virulent than the initial coronavirus. For that reason, we are in a situation where people who feel safe, who are looking at the optimism that’s generated by the headlines that the vaccines are on their way, are taking more risks in the consequence in the context of a riskier version of the virus.

“We are in a situation where people who feel safe are taking more risks in the consequence in the context of a riskier version of the virus.”

— Abdul El-Sayed

My understanding is that Michigan is about average in terms of how the vaccination rollout is going, but there are these gaps in terms of who’s able to get access.

I was the health commissioner for the city of Detroit, which is America’s largest majority-Black city and its poorest city. Those two things are not a coincidence. I walked into a department that had five city employees and 85 contractors in the back of the building because the city of Detroit made the decision to defund its public health department. It did not have a functioning department for years. My job was to rebuild it. You think about where we are right now, where the city of Detroit is battling the worst pandemic in over a century with a health department that’s functionally 5 years old—that is a function of choices that we make about how we allocate a whole bunch of different resources. It’s not just health care, but it’s also who gets access to good, stable housing, who gets access to water, who gets access to good schools, who gets access to the jobs that come with that that education. The other part of that is that your experience in the health care system is you are constantly looked down upon because we as a society don’t provide people universal health care. You may be someone who has health insurance via Medicaid, which commands far lower reimbursement rates, and doctors and hospitals see you as a charity case and therefore look down on you because our system literally discriminates against you and says your body is not worth giving health care. That’s the experience a lot of people have.

There’s this other issue that isn’t just about access, which is folks not wanting to get vaccinated in Michigan. Who is saying that they’re going to take a pass this time?

Michigan is almost a microcosm of the United States: We have a large urban community, we have a large suburban community, we have a large rural community. You have two large main hesitancy groups. The first is conservative white folk in rural parts of Michigan, and the second is people of color whose hesitancy is more born out of a distrust of their own experience with the medical system. It’s not a one-size-fits-all hesitancy, and I think we have to think about dealing with it on different fronts.

Are you seeing targeted campaigns looking to reach each of these groups of people?

I think there’s been a real concerted push to take this on. I don’t think it’s been enough and I also don’t think it’s been imaginative enough. But I think it’s been great to see leaders of church communities take up the cause, and I think they’ve been met by a set of leaders at the federal and state levels who want to empower them and make sure they have the resources that they need to take on this this hesitancy. But I think that it’s sort of been a secondary goal rather than being the focus.

Do you think that’s a mistake?

Oh, absolutely. Here’s the thing: We’re going to come to a point in the next month where the the amount of vaccine outstrips the demand for vaccine. Solving the supply problem obviously is a key goal, but the thing about demand is it takes more time.

It takes more trust.

Exactly. And that takes time. It takes a level of prolonged, consistent conversation. If you’re looking at a set of institutions that you don’t trust and all of a sudden they’re like, “We really want you to take this vaccine and then we’re just going to go back to where we were before that,” that’s not really a trust-building exercise. It does take a concerted long-term investment. And we don’t have that much time.

The thing about leadership that matters is that it signals what ought to be done, even more so than just doing it right. When you signal that we are now reopening, what that tells people is, be merry, enjoy what’s being reopened, and it sends the wrong signal. It’s not just the actions that need to be taken, but it’s also the message that needs to be delivered through those actions about the fact that this thing is serious.

You had this really elegant idea, which was that the state should be tying reopenings to local vaccination rates. Mayors really want to open up their cities for a lot of reasons. They need that tax base back. They want their cities to feel “normal” again. If everyone were on the same page about the vaccinations, it would help. It would at least be a start, even though vaccinations can’t be everything. Is anyone taking that idea seriously?

I don’t know. I hope that they are, because I think one of the things we need right now is an incentive to work toward. I actually kind of worry that the freedom that ought to come with a high-enough vaccination rate has come without that vaccination rate. It’s like, just because the vaccines exist, in theory, we’re sort of acting like everyone’s been vaccinated—and those two things are not the same. I think what we need to say, “Look, here’s the benefit for all of us,” not just in saying that I’m protected and I can do things safely, but in saying, “I really want to go to a local restaurant. That’s my favorite place. I really want to go back to a gym. I really want to be able to go to a concert. Here’s what we need to do to get there. Let’s do that thing.”

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Biden has said he’s hoping that the Fourth of July can look something like it does usually, where we could gather in small groups and celebrate outdoors. I’m wondering if what’s happening in Michigan changes your thoughts about how realistic that idea is?

The distance between now and July is really quite long. A lot can go right if we make the right decisions to get us back on track, but I also worry about where other states are going to be. Like I said, Michigan is not the only place with these kinds of dynamics. It’s just the place where it’s happening first. If we start to see these dynamics happening in other states a couple of weeks from now, a month from now, it really could throw that timeline off. The important thing to remember is that the more we do now to prevent that kind of thing from happening, the closer we are to the ultimate “normal” that all of us would like to get to. It’s a matter of choices that we make. The virus doesn’t have a mind of its own. It just follows the path that we create for it. And our job is to shut those paths down.

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