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Good afternoon readers. If you want to add a note of distress to your day (and who wouldn’t), take a look at the U.S. map at the New York Times’ COVID-19 tracking page. One thing will unquestionably and immediately leap out at you:

Michigan.

While most U.S. counties are tinted strangely comforting yellows and light oranges indicating 50 or fewer new daily COVID-19 cases per 100,000 people, Michigan glows a furious dark umber, indicating case rates of closer to 100 per 100,000. Michigan has experienced a sevenfold increase in cases since late February. Experts who consulted with Michigan Governor Gretchen Whitmer have said the state is “losing the race to the virus,” even as most of the U.S. appears to be poised to beat it back before most other wealthy Western nations.

So what happened?

As with most things COVID-related, answers are complicated and not entirely clear. There has been some focus on Michigan’s vaccine rollout, but the state is now keeping pace with the rest of the U.S., with 26% of residents fully vaccinated. According to a Vogue interview with University of Michigan immunologist James R. Baker, those vaccinations were tightly focused on residents over 65, where he says there’s no surge. That would be good news, though the state’s death rate is also up a catastrophic 84% in the past two weeks, which you might not expect if older folks most at risk for death were well-protected.

Baker also cites Michigan’s lifting of statewide COVID control measures in February. The reopening included indoor dining, a well-known and major vector for the spread of the virus. Restrictions were lifted before vaccinations were widely available, but when Michiganders were suffering what Baker describes as “significant lockdown fatigue.”

That’s likely the understatement of the millenium: lockdown winter here in the urban northeast was rough, but I can’t imagine what it was like in the windswept upper Midwest. Some local reports suggest restaurants were quickly packed, including with patrons specifically thumbing their noses at COVID-related restrictions. That almost certainly would have helped prime the pump for the current surge.

But Michigan’s main headwind may be, tragically, politics. Even as her state buried 60 people per day, Governor Whitmer on April 9 issued a mere recommendation that people avoid indoor dining for two weeks. According to the New York Times, Whitmer likely chose not to mandate new restrictions because she’s up for reelection in a deep purple state where she needs to court anti-lockdown Republicans. (Whitmer’s direct emergency powers were stripped by the Michigan Supreme Court in October, but the state’s director of health, appointed by Whitmer in March, retains the power to issue emergency health orders.)

There’s one other element here that may not be relevant, but is at least intriguing. Michigan is right across the border from Ontario, Canada, which is in the midst of its own terrible COVID-19 surge, more clearly a product of slow vaccinations and the U.K. variant. Now, that shouldn’t really matter much: The U.S. border with Canada has now been closed to non-essential travel for a staggering 14 months, and most of Michigan’s border with Canada is formed by… the Great Lakes.

I don’t think COVID-19 has learned how to sail yet, but major highways do run directly from Toronto to Detroit, so it would be interesting to know just how much “essential” traffic is crossing that land border – and what unlisted cargo it might be carrying.

Clarification 4.21: Michigan Governor Gretchen Whitmer no longer has the direct power to order lockdowns, but could still do so through powers held by her appointed Health Department director.

David Z. Morris
david. morris@fortune.com
@davidzmorris

DIGITAL HEALTH

Novartis joins Kaiku Health for remote melanoma monitoring. Kaiku Health, billed as a symptom-monitoring app for cancer patients, is joining forces with Novartis to develop a monitoring module specifically for melanoma patients. Kaiku says its app is intended to help patients manage their symptoms, and to notify doctors if a patient's symptoms worsen during treatment. Melanoma is a particularly pernicious cancer, and outpatient telemedicine solutions have surged in popularity thanks to COVID-19. (Kaiku Health)

INDICATIONS

One vaccine dose ineffective in those who had mild COVID-19. A new study from Northwestern University has found that a single dose of the Pfizer or Moderna vaccine does not provide strong protection from the virus for patients who previously had a mild or asymptomatic COVID infection. This apparently puts to rest prior speculation that one shot might be enough for those previously infected. Patients who previously had severe COVID-19 cases, however, do experience a “very strong antiviral response” after a single dose of the two-dose vaccines, matching the findings of other studies. (NBC 5 Chicago)

THE BIG PICTURE

Lack of sleep increases dementia risk. A new study in Nature finds that adults in their 50s and 60s who consistently reported sleeping six hours or less on weeknights were about 30 percent more likely to develop dementia later in life than those who consistently slept seven hours or more in middle age. The study used data on 8,000 participants over 25 years, which is important in part because sleeplessness caused by pre-dementia brain changes can appear about 15 to 20 years before dementia symptoms. By looking further into the past, the study gets closer to establishing lack of sleep as a cause of later dementia, rather than just an early symptom. The study also factored out smoking, BMI, and other risk factors. (New York Times)

Marijuana is here to stay. It’s 4/20, the ‘high holiday’ of weed buffs. This year, it comes amidst a giant surge in legal cannabis sales in the U.S.: According to analytics firm Akerna, sales grew 71% in 2020 to $18.3 billion, compared to $10.7 billion in 2019. That growth is expected to continue as more states legalize and pot becomes (even) more culturally acceptable. One projection has the industry hitting $41.5 billion by 2025. (Fortune)