CENTREVILLE, Ala. — Cases were spiking again. Hospitals were filling up again. The latest wave of the coronavirus pandemic was raging across Alabama, and inside a rural clinic in one of the state’s least-vaccinated counties, a doctor scanned a chart for her first case of the day: 84 years old. A routine exam. Unvaccinated.

“Mr. Potts,” Lacy Smith said, greeting a man in dark slacks and a maroon T-shirt leaning on a cane. “How’ve you been feeling?”

Even at the most urgent of moments, it was the most ordinary of questions because of what the doctor understood: that if Alabama had any chance of turning things around at this point, it was no longer a matter of what Dr. Fauci said on CNN, or what some celebrity posted on Twitter but rather what was about to happen now, a delicate conversation between a doctor and a patient, the vaccines in a cooler down the hall just in case. Between Smith and two colleagues, there were 10 unvaccinated people on the schedule this day, and the first was Potts.

“Oh, pretty good, considering my age and the heat,” he replied as the doctor reminded herself to be patient, because the question wasn’t whether to bring up the vaccine, only how.

She asked about his garden. They discussed his vitals.

“So,” she finally said. “What are your current thoughts about the covid vaccine?”

“People getting pretty sick, aren’t they?” he said.

“Super sick, especially with this delta,” she said, referring to the variant.

“That shot I get for the shingles, that’s a vaccine too, ain’t it?” he said.

All similar, the doctor said, as she had in their three prior conversations.

“The benefits outweigh the other side, don’t it?” Potts said.

“Very much so, yes sir,” she said, letting a promising silence hang in the air.

He tapped his cane on the floor. “I believe I’ll think on it,” he said, and so the morning began with a no as the situation in Alabama continued to degenerate. An average of nearly 3,000 new covid-19 cases a day. Roughly 65 percent of the population still not fully vaccinated. And now, as Smith’s colleague John Waits headed into Exam Room 4, the message was spreading that nearly every hospital in the state was turning away emergencies because they were too busy with covid, as had first happened a few days before, when a doctor had to do CPR on a man in the back of a pickup truck as she waited for an emergency room to open up, which it never did, and the man died.

“Okay, Ms. Willie,” Waits said now. “The covid vaccine. Tell me what you’re thinking.”

“I don’t want it,” said the woman, who was 91 and there for high blood pressure and a diabetes checkup.

“Well, I want to go one more round on that,” Waits said and began a data-laden speech he’d been giving for months to his patients, his family, his friends, his pastor and even his own staff at Cahaba Medical Care, which still included a few employees who were unvaccinated.

“You’re primed for it to be bad if you get sick, Ms. Willie,” he said. “You’re also primed for this vaccine to work really, really well.”

“I don’t want nothing,” she said, so the doctor gave up and moved on to Exam Room 6.

“Uh-uh,” said the unvaccinated woman in there, who had come in with her mother, an elderly woman in a wheelchair who had already been vaccinated, and so he began the speech again. Millions vaccinated. Minimal side effects. High efficacy.

“Y’all got a big family — you want to get yourself and everyone protected,” Waits said as he examined what seemed to be a blood clot on her mother’s lower leg, but now the daughter was looking away, and now he was watching her wheel her mother down the long hallway, past the nurses, past the cooler where a batch of 5,844 doses had recently expired, and past Exam Room 2, where Smith was knocking and going in.

“Anything new going on with your lungs, Ms. White?” the doctor asked a 75-year-old woman in a wheelchair who’d survived five bouts of lung cancer.

“I’m determined they’re not going to get all of that left lung,” the woman said, her mask sitting just below her nose. “They done got my right one.”

They moved on to her asthma, her thyroid, her chronic headaches.

“So,” the doctor said, typing notes on her laptop. “Tell me your thoughts about the vaccine.”

“There’s too much news about people that had problems after they get it,” the woman began. “What did they do back when typhoid ran around the country?”

“When the what?” the doctor said. She stopped typing.

“When typhoid fever was everywhere.”

“Mm hmm,” the doctor said.

“And rheumatic fever,” the woman said.

“Mm hmm,” the doctor said.

“And when TB first come out,” the woman said. “They didn’t go crazy over all this mess. They suffered the best way they could and got treated with whatever they could, even if it meant burning down the house, and everything they had with it.”

“Mm hmm,” the doctor said, not understanding what any of this could mean.

“I’m not going to run and get some vaccine when I’m already full of problems,” the woman said, and now the doctor did understand. The woman was afraid that the vaccine was going to kill her.

“I hear you,” Smith said. “I just get concerned. Especially with patients like you that I care about. Because I know if you get covid, the likelihood you will survive is low.”

“I’m going to be here for a while,” the woman said, looking away.

“You’re tough, I know you’re tough,” the doctor continued. “But we’re seeing young healthy people die in the hospital with covid.”

The woman paused to consider this.

“And they don’t have medical problems,” she said.

“So the people who do have that, where their lungs just don’t have that much capacity to heal any longer …” the doctor said, not finishing the sentence so that the woman could imagine the end of it for herself, and for a moment, the only sound in the room was the whoosh from a noise-canceling machine in the corner.

“Well,” the woman said. “I am not going to get sick. I am determined I’m not going to get sick. I don’t go nowhere but the bank and the grocery store anyway.”

“I hear you,” the doctor said, returning to her laptop. “What else can I do for you today?”

It was almost noon, and at the Rockco Funeral Home next door, the director, who was vaccinated, was presiding over a covid burial. There had been another one a few days before, and another a few days before that. His secretary was out sick with covid. Church members. County workers. A note on the locked door of the local newspaper read, “This office has been exposed to Covid!”

Meanwhile, Waits was in Exam Room 4, 10 minutes into trying to understand a story that one of his oldest and dearest patients was telling him, by way of explaining why she did not want to get the vaccine. She said that when her own mother was in her 90s and sick in the hospital, she’d heard one of the doctors say, “She’s old, she’s not going to live anyway.”

“Dr. Waits,” she said now. “Would you ever do me like that?”

“You know that’s not my style, Ms. Lockett,” Waits said.

“See, I’m 83,” she continued, explaining that she believed the shot would make her sick with covid. “And I already got some kind of complaints, and all that with the kidney problems. So if I get the covid, they’ll just say, ‘She’s already got a lot of problems, just let her go.’ That’s the reason why I don’t want to take that shot, Dr. Waits.”

“That’s not going to happen,” Waits said. “We won’t say ‘Let her go.’ But let me tell you what will happen. Right now, every piece of equipment you need to do well from covid? Somebody’s on it. If you said no to a shot and got covid next week, and I had to ship you somewhere? All those places are filling up. Ms. Lockett, that shot won’t give you covid. That shot will help prevent you from getting covid. And that’s what I’m begging you to do today. Take that shot.”

“Well, I’m going to get it,” she said, and then Waits watched as she looked away. “But I don’t think I’ll get it today.”

He said his goodbyes, and moved on to Exam Room 6.

“Because of your asthma, you’re due for a routine pneumonia vaccine, and then you know that covid is stirring up again,” he tried. “What are your thoughts?”

“Uh-uh,” said his 53-year-old patient.

“I understand,” he said. “What, is there something’s that got you nervous?”

“Nope,” the woman said.

He retreated to his office to eat a spinach salad out of a plastic container. He thought about an essay he’d read recently titled “Let It Rip,” in which the writer argued that public policy at this point should be to allow sickness and death run its course and “let reality persuade the delusional and deranged.” But he was not there yet. He tried to remember the long-standing neglect in this part of Alabama. He reminded himself that he could be right and yet fail to be a human being.

“If persuasion is the only tactic you have left, you can’t be a jerk about it,” he said. “You’ve got to be gracious and gentle.”

He opened his laptop and checked his notes on the next patient. Carla. He kept many personal notes on his patients — about a sister who had died, or a son in college — anything to help maintain a rapport. “Blind pet frog died,” is what he had written on his file for Carla, who was always trying to save disabled animals.

“Don’t ask about the frog,” he reminded himself as he headed down a long hallway to an isolated part of the clinic where she was waiting. She had come in for a bad knee, but had troubling cold symptoms, so they gave her a rapid coronavirus test that was being processed in the lab. Waits put on a KN95 mask, then a face shield, and opened the door.

“I love it!” Carla said when she saw her doctor in the shield. “I need one of those for when I use my weed whacker.”

Her own mask was under her nose. Her rubber gloves were ripped. She coughed. Waits bent down and checked her knee, which seemed to be mostly fine.

“What else do you need, Carla?” he said.

“I still have a runny nose,” she said. “I remember that horrible story about who was it, a famous guy? He always had a runny nose. He had a doctor test it and found out it was brain fluids. I did have that neck surgery.”

“Yeah,” Waits said through the shield. “The neck surgery wouldn’t be anywhere close to sinuses, Carla. But we got your rapid covid test cooking. Ready for the vaccine?”

“No!” Carla said.

“What are you thinking?” Waits said, and Carla began telling him about a friend who had gotten a vaccine last year and then “woke up paralyzed.”

“Doesn’t it make you nervous?” she said.

“Well, I’m a little human too,” he said. “My body’s no different than anybody else, and one of the things I know is, the one in a million — the one in ten million — that get that syndrome after vaccines, it’s at the level that happens in the population.”

She looked puzzled, so he tried again.

“It would be like saying, ‘I had a friend of a friend that had a car accident, and so now I’m not going to drive,’ ” he said. “Or better yet, their seat belt broke. It’s like a freak thing. But what I do know is, 150 million people have gotten the vaccine this year and we’re not seeing an uptick in anything. So I’m not trying to pressure you or anything, but you’re asking me if it makes me nervous, and it absolutely doesn’t make me nervous because I know this syndrome is a random, super-rare thing and that it can happen without vaccines.”

“Yeah, true,” said Carla, and Waits decided to leave her to ponder this for a moment as he walked over to the lab for the test results.

He watched as a machine counted down the final 30 seconds. He took off his face shield. He took off his mask. “Must be hard with all this on for a whole shift,” he said, thinking about his hospital colleagues. The machine beeped. Negative.

“Negative!” he said when he returned to Carla, and again brought up the vaccine. “So, what do you think?”

“You’d have to sign a thing that said you’re going to take care of me for life,” Carla said. “And nobody’s going to do that.”

“I will take care of you for life, Carla,” Waits said. “But I can’t pay your bills for life.”

“That’s what I mean. Take care of everything. And if I wake up and I’m paralyzed from the neck down I can live at your house and you’re gonna take care of me for life,” she said. “Nobody’s going to do that, are they?”

“I can put a house out by the dog run,” Waits said, but Carla was a no.

By late afternoon, the nos had reached seven, and in another wing of the clinic, a physician assistant named Chasity Clark was seeing the last unvaccinated patients of the day.

There was Shannon, 28, saying: “There was this lady, on social media, or the news? She ended up in a wheelchair and that was after having both vaccines.”

She was number eight.

There was Tina, a guard at the local corrections facility getting married in January, saying: “I had Covid last year. Both my daughters had covid. Then my captain, he just got it. And my major, he has it.”

Number nine.

There was a young woman named Meeka, who had come with her two boys.

“Okay,” Clark said, exhaling as she walked down the hall. “End of the day.”

She opened the exam room door and closed it behind her.

“So how do you feel about getting the shot?” she said, and then she listened.

“I never even had a flu shot, nothing like that,” the woman said. “I had covid last year. And my daddy was just sick with it here recently. It’s a scary thought. And see, I clean houses. I smoke. Didn’t really affect my breathing when I got sick last time.” She paused. “Can I get it again?”

“Yes, I know people who got it twice,” Clark said. “Different strands.”

“My daddy, he quit smoking three years now and he couldn’t breathe when he had it,” the woman continued. “You can’t see 'em once they’re in the hospital. I couldn’t see my daddy.”

“Yeah,” Clark said quietly.

The noise machine was going, blurring out the distractions.

“I think I’ll get it,” the woman finally said.

“I’ll be right back,” Clark said.

She hurried down the hall to the cooler before the woman might change her mind and hurried back with a syringe. The woman was still sitting in the chair.

“Which arm?” Clark said.

“Right,” the woman said.

She rolled up the sleeve of her T-shirt, and toward the end of a day in a state where every ICU bed would soon be filled, the yeses were up to one.

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Photo editing by Bronwen Latimer. Copy editing by Wayne Lockwood. Design by J.C. Reed.