PROVIDENCE, R.I. — The numbers began ticking up in September. After a quiet summer, doctors at Rhode Island Hospital began seeing one or two patients with Covid-19 on each shift — and soon three. Then four.
Cases climbed steadily until early December, when Rhode Island earned the dubious distinction of having more cases and deaths per 100,000 people than any other state in the country. The case rate still puts it among the top five states.
Where did this tightly knit state go wrong? Former Gov. Gina Raimondo’s “pauses” on economic activity were short-lived and partial, leaving open indoor dining, shopping malls and bowling alleys. But the shutdowns were no patchier than those in many other states.
Until late summer, she was lauded for reining in the virus. Even now, few residents blame her for the bleak numbers. (Ms. Raimondo was sworn in as the secretary of commerce on Wednesday night.)
Experts point instead to myriad other factors, all of which have played out elsewhere in the country but converged into a bigger crisis here.
The fall chill sent people indoors, where risk from the virus is highest, and the holidays brought people together. Rhode Island is tiny — you can traverse it in 45 minutes. But crammed into that smallish area are a million people, for a population density second only to that of New Jersey. If everyone in the world is connected by six degrees of separation, Rhode Islanders seem to be connected by maybe two.
Central Falls, the epicenter of Rhode Island’s epidemic, has a density of 16,000 people per square mile, almost twice that of Providence. “Just imagine, 16,000 people per square mile — I mean, that’s amazing,” said Dr. Pablo Rodriguez, a member of the government committee that guides Covid vaccine distribution in Rhode Island. “It doesn’t take much for the spark to create an outbreak.”
Apart from its density, Rhode Island has a high percentage of elderly residents in nursing homes, accounting for the bulk of deaths. Packed into the state are multiple urban areas — Central Falls, Pawtucket, Providence — where language barriers, mistrust and jobs have left immigrant families in multigenerational homes particularly vulnerable. The state is also home to multiple colleges that set off chains of infection in the early fall.
For months, the hospitals in Rhode Island were understaffed and overwhelmed. Doctors and nurses were trying to cope with rising caseloads, often without the protective equipment they needed, with constantly shifting guidelines and with their own resilience stretched to the limit.
Dr. Megan Ranney, a researcher and public health advocate, is also an emergency room physician at Rhode Island Hospital who has witnessed the full scope of the state’s crisis firsthand. What she saw unfold over a single shift offers a window into what happened.
Image Dr. Megan Ranney, an E.R. physician at Rhode Island Hospital in Providence. “I’ve just got to plow through it,” she said during a surge in December.Credit…David Degner for The New York Times An ambulance outside Rhode Island Hospital last month.Credit…David Degner for The New York Times A map on the asphalt of a school parking lot in Pawtucket.Credit…David Degner for The New York Times
One day in late December, as the crisis reached new heights, Dr. Ranney girded for a long eight-hour shift. The sores behind her ears, where her glasses and the straps of the N95 and surgical masks dug in, still had not healed. But how could she complain, Dr. Ranney said, when her medical residents “eat, sleep, breathe Covid” five days a week?
The patients had it worse, she knew. Anxious and isolated, they became even more discomfited by the masked and unrecognizable doctors and nurses rushing around them. During Dr. Ranney’s shift the prior week, she had seen a broad spectrum: elderly people on a downward spiral, otherwise healthy young Latino men, Cape Verdean immigrants with limited English comprehension.
These demographics are partly what made Rhode Island particularly susceptible, said Dr. Ashish Jha, dean of the School of Public Health at Brown University in Providence: “Certainly in New England, it is the poorest state — so a lot of poverty, and a lot of multigenerational poverty.”
As in most of the country, the Latino community has borne the brunt of the epidemic. In Rhode Island, Latinos have 6.7 times the risk for hospitalization and 2.5 times the risk of death, compared with white people.
In the days before her shift, Dr. Ranney had been working in a part of the hospital intended to deal with non-Covid cases. But even people with other ailments, like ankle fractures, turned out to be positive for the virus, she found.
“I never know from day to day how bad the surge will be,” she said. “I’ve just got to plow through it.”
It turned out to be an extraordinarily busy day. “The E.R. is full, the hospital is full, the intensive care unit is full,” Dr. Ranney said. “All of our units are moving as quickly as they can, but the patients keep coming in.”
Every time she took off masks during a shift, she ran the risk of contaminating herself. She had had four cups of coffee before this shift, and nothing since.
The average age of the patients that night was about 70. One elderly woman who had trouble breathing could not isolate because she lived with her children and grandchildren. At any rate, she arrived at the hospital 10 days into her illness, too late for isolation to matter.