DETROIT — Dr. Abdul El-Sayed knew he had to come home.

Last summer, the university professor and former Rhodes scholar was in New York, having already earned a doctorate in public health at Oxford and a medical degree at Columbia. At 31, he was a rising star in the study of how social factors affect public health.

But then, as El-Sayed recalls it, he decided he wanted something more. He was tired of simply studying public health problems. He wanted to help solve them. “I think I want to be the health commissioner for Detroit,” he told a mentor.

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Three years earlier, the city’s entire health department had been all but dismantled, and whoever took the job would have to rebuild it practically from scratch. But having grown up in Detroit, El-Sayed wanted to try. He reached out to Mayor Mike Duggan. He tried his best to sell himself over lunch. He made a good impression.

And now he’s here, figuring out how to do everything from testing children for lead exposure to fixing a troubled animal control office to making sure kids in low-income families get the eyeglasses they need to read the blackboard.

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El-Sayed, the son of Egyptian immigrants, is doing it all in the poorest major city in America, one where public health tends to take a backseat to simply getting by.

“The hard thing about a turnaround is, there’s no launch date, right? You already launched a long time ago,” El-Sayed told STAT during an interview in his Detroit office. “You have to keep and improve, even, the quality of city services even as you are fundamentally [shifting] the gears inside the machine.”

The biggest issues for Detroit’s health department are tied to poverty — 4 out of 10 residents live below the poverty line — or to decades of neglect that have hit the city’s African-American majority especially hard.

Infant mortality is higher here than in any other major American city, and higher than in some foreign countries, including Mexico. Nearly 4 out of 10 Detroit adults are obese. The rate of asthma hospitalizations in the city is more than three times higher than the state average.

“I think on the one hand, one can focus on the challenges … of that, which is to say, ‘My God, our health department has been really decimated. We’ve literally lost so much,’” El-Sayed said. “At the same time, though, you can look at it and say, ‘This is a cocoon phase, and this is an opportunity for us not to be wedded to the structure of the past, but to rebuild it for what it should be.’”

He’s driven by what he has learned through his research, but also what he’s learned through experience.

On trips to Egypt as a child, El-Sayed saw the home where his father grew up with his five siblings — a one-bedroom residence above a fish market in Alexandria, Egypt. He said he developed a “particular empathy to the kind of challenges that people face” when they’re poor and don’t have the advantages of money or education. He also learned he “fundamentally got lucky.”

“I think it forces you to appreciate the world for what it is, which is to say that there are a lot of reasons why some people have and some people don’t,” he said. “And you can either be a part of equaling that playing field or driving it in the direction that it’s already going.”

El-Sayed took over an office that had been gutted and privatized. He was told: “Rebuild it.” Laura McDermott for STAT

Massive challenges

The challenge, though, is: Where do you start?

Detroit’s poorest neighborhoods — especially in the east — are endless landscapes of abandoned homes or houses that are just falling apart. Peeling paint, bent wooden steps and railings, and overgrown grass and bushes are everywhere; mattresses and couches litter front yards. Driving on the cracked streets feels a bit like driving over the craters of the moon.

It’s a picture of a depressed city — a reminder of how much of Detroit’s population has been lost over the past several decades, down from a peak of 1.8 million in the 1950s to around 680,000 now.

But it’s also an illustration of one of the city’s biggest public health problems: elevated lead levels in the drinking water.

Detroit isn’t Flint. In fact, the number of children in this city with high amounts of lead in their blood has actually dropped by more than 50 percent since 2009. But kids here are still four times more likely to have elevated lead levels in their blood than children elsewhere in the state, according to a health department report.

That’s not because of a bad water system — it’s because of the old pipes in aging houses and school buildings. A water test in the public schools last month found 15 school buildings that had high lead levels.

El-Sayed can’t fix the pipes, but he said his department has now restarted its lead screenings for children at clinics like the Samaritan Center in east Detroit. The department also secured a $135,000 grant from the Children’s Hospital of Michigan Foundation to help pay for the testing of the schools.

Those efforts are a testament to El-Sayed’s belief that progress begins with small, tangible steps.

“It’s hard to move the needle on these social problems, but for him, it’s the ultimate challenge,” said Dave Chokshi, an assistant vice president at the New York City Health and Hospitals Corporation who knows El-Sayed as a fellow Rhodes scholar.

J. Ricardo Guzman, chief executive officer of Detroit’s Community Health and Social Services Center, recalls turning on the television one night and seeing El-Sayed meeting with a group of residents to discuss the city’s animal control operations. The office has a reputation for mistreating dogs, and is now under the health department’s control.

“I was sitting in my chair saying, ‘Damn. He’s out there.’ That’s a good thing. We haven’t seen that in years,” Guzman said.

“I think we’re at that crossroads where people are starting to feel good about what’s happening,” both under the mayor and under El-Sayed, said Guzman. “He is setting the tone for the department, and it’s a very positive one.”

‘Rebuild it’

El-Sayed’s first priority is to bring the Detroit health department back to life.

In 2012, the health department was gutted and privatized, as the previous mayor, Dave Bing, turned most of its services over to a newly created nonprofit, the Institute for Population Health. At the time, the department had been considered to be bureaucratic and inefficient. But the decision turned out to be disastrous, and at its low point, the department was down to five people.

“That decision, in the grand history of the telling of health in Detroit, I think will prove one of the worst,” El-Sayed said. For example, some of its federal grants for lead screenings had to go to other city departments when the health department was privatized, and the coordination between the programs broke down, he said.

Another recent discovery hit the former academic especially hard: The health department’s library, which it had collected over decades, was gone. “There’s something about libraries, that they hold our collective knowledge about ourselves and about what we do, and that they’re never built quickly — they’re almost always built over time,” he said. “And so when you lose one, I think that just means a lot.”

So when Duggan hired El-Sayed in August, he gave him one mandate with regard to overseeing the department: “Rebuild it.”

El-Sayed has started the process. He’s staffing up, and hopes to have anywhere from 16 to 25 full-time employees on board by July.

He’s also planning to reorganize the department into five teams that will help Detroit residents based on different stages of life, including a “healthier maternity” team, which would focus on infant mortality and teen pregnancy; a “healthier childhoods” team, mostly aimed at young children; and “healthier lives,” which would address the needs of adults and senior citizens.

The process hasn’t always gone smoothly, and sometimes small changes can have unintended consequences. Alena Hickman, a registered dietician at a clinic for low-income mothers and children, said El-Sayed’s office moved the clinic to a different location when it took over. Some women who used the clinic but don’t have cars said the new location was inconvenient. Others stopped showing up.

Still, El-Sayed is looking for ways to coordinate the city’s health services better and make them less of a hassle.

At a leadership retreat last week, one health department staffer suggested that the health department should keep track of how many kids are referred for eye exams. El-Sayed countered that they should try to enlist the help of glasses makers to eliminate the need for second appointments, and make sure “the kid has glasses waiting for them at school two weeks from now.”

The road to Detroit

El-Sayed’s rise to the top public health job in Detroit may have seemed quick, but it only came after formative experience and deep frustration.

Two videos capture El-Sayed’s transformation from affable young college student to serious academic. In the first, from 2007, he’s the student speaker at his University of Michigan graduation. He’s casual and funny, getting laughs and applause from the other students with lines like, “What would it be to walk between classes and not see your upper-level biology professor jamming it up on a harmonica?” And, “Go Blue.”

El-Sayed’s speech, and his easy ability to find common ground with his audience, caught the attention of the commencement speaker: Bill Clinton. At the end of the video, Clinton gestures to El-Sayed and says: “I wish every person in the world who believes that we are fated to have a clash of civilizations and cannot reach across the religious divides could have heard you speak today.”

The second, from 2014, shows El-Sayed as a fully formed scholar, giving a talk at Johns Hopkins University about how people’s social environment can affect public health trends like obesity. He’s picked up academic jargon, and says things like, “Systems approaches to obesity matter. … Interactions matter.”

By that point, El-Sayed was an assistant professor of epidemiology at Columbia University’s public health school. He was especially interested in how social factors affect public health.

The field appealed to El-Sayed’s interest in figuring out why public health problems are so much worse among some populations than others, especially among minority groups.

“I think Abdul has always been driven to improve the health of the population and narrow the health gaps,” said Sandro Galea, a mentor of El-Sayed’s and dean of the Boston University School of Public Health. “He’s an exceptional person. He’s smart, he’s thoughtful, and he’s well-intentioned — and that’s fairly rare, frankly.”

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But El-Sayed also discovered the limits of practicing medicine — and one incident at NewYork-Presbyterian Hospital was so disturbing that it convinced him not to apply for a residency.

A woman who had been drinking and hit her head had come into the hospital, El-Sayed recalled. She had AIDS and was likely an alcoholic, but El-Sayed had a plan to help her: She would go to rehab for two weeks, then back to specialized housing to take care of her medical needs. Instead, he said, she insisted on going home with her daughter, whom she hadn’t seen in two years.

El-Sayed tried to talk her out of it, but she insisted. Two weeks later, he got on the subway to go to dinner with a friend — and there was the woman, sleeping on the subway.

“I went home that night and pulled my residency application,” El-Sayed recalled. “Medicine is not the way to solve these kinds of problems. … This was a woman with an eighth-grade education who the system failed far, far before she was a patient at that hospital that day.”

By June of last year, though, El-Sayed was getting underwhelmed by academia, too. The academic world, he realized, “forces you into asking questions that aren’t really the questions that matter. They’re the questions that someone else has decided matter.”

So when he went to an academic conference with Galea in June, he had little patience when other researchers congratulated him.

“I was getting clapped on the back. People were like, ‘You’ve made it. You’re making such a contribution to the field.’ And I was like, ‘This is a contribution to the field? If this is a contribution to the field, I don’t want to be here anymore,’” El-Sayed recalled.

That’s when he decided to contact an old friend who was working for the mayor of Detroit.

El-Sayed sent in his curriculum vitae, and it didn’t get much interest at first. Eventually, though, it got to Duggan’s desk. The mayor called El-Sayed, who wrote up a proposal that they discussed over a two-hour lunch.

At the end, El-Sayed said, Duggan told him the job was his if he wanted it.

Along with everything else, El-Sayed is now trying to change the culture of city services. He’s trying to build a “sense of partnership” between his department and other city agencies — but is already finding it hard to get rid of the bureaucratic inertia.

He responds, he said, by reminding them of the struggling people they’re supposed to serve.

“Are there people suffering? Yes. OK, then clearly the way that we’re doing it right now is not working,” he said. “So if we can forget ourselves for a minute, sit down together and say, ‘Who has what ingredient to try and bake a better loaf?’”

“Let’s do that together.”