For a few days in December, Rhode Island was one of the worst places on the planet when it came to new cases of COVID-19 per capita.
Hospitals hit capacity as the rate of new cases topped the nation, nearly double the rate in neighboring Connecticut. The state's record for daily COVID-19 deaths, set in April, was broken. Faced with a worsening crisis, Gov. Gina Raimondo reluctantly re-imposed tougher restrictions on businesses.
"I am surprised that we have done so poorly," Dr. Keith Corl, an emergency physician and faculty member at Brown University's Warren Alpert Medical School, said last week. "We are all exhausted, and now we're talking about staffing more ICU units."
The nation's smallest state by area has reported 1,870 pandemic deaths so far, far fewer than many states but giving Rhode Island the nation's sixth highest COVID-19 death rate. Like other Northeastern states, Rhode Island was hit hard early in the pandemic. Cases fell in the summer, but climbed through the fall.
"The state has done as good of a job as they could. We've got to be optimistic now that we've got the vaccine on the way," said Rhode Islander Donald Ritter as he ran errands in Providence on Monday. "But it's been quite a ride."
A Dense — And Old — Population
Experts who have studied the state's bout with COVID-19 say it offers lessons for other parts of the country confronting the same factors that drove its surge.
Among them: dense communities; high numbers of seniors in nursing homes; an economy reliant on tourism and low-wage workers who can't work from home; restrictions that sought to balance health against economic activity; and a refusal by some to heed guidance on masks and social distancing.
"There are lots of reasons," Raimondo said last month. "There's no excuse for it. It's not a distinction we want."
With 1 million people squeezed into 1,200 square miles, Rhode Island's population density is second only to New Jersey. That concentration creates opportunities for the virus, which spreads most easily between people in close contact.
Many of the state's poorest residents live in dense neighborhoods in cities like Providence, Pawtucket and Central Falls, often in multi-generational households.
These residents often hold jobs that cannot be performed remotely, and are seeing higher rates of COVID-19 as a result, said Dr. Michael Fine, a former state health director. Fine now advises Central Falls, a city of 20,000 people that occupies a little over 1 square mile.
"They work two or three jobs and they have to go to work every day. They get infected at work, and come home to these densely packed communities," Fine said. "The decisions we made about how to do the lockdown, and the population we have, essentially conspired to sicken our most densely populated communities."
Large Numbers in Nursing Homes
An aging population plays a role, too. Rhode Island has the nation's third largest percentage of residents living in nursing homes. Nearly three-quarters of the state's COVID-19 deaths have been among nursing home residents.
A key challenge for nursing homes has been preventing staff from transmitting the virus. Employees at the 11 facilities operated by Health Concepts Ltd., are now tested twice per week to ensure they don't spread the virus even if they're symptom-free, said Kelly Arnold, the company's chief operations officer.
Arnold said she's more hopeful now that her residents are scheduled to be vaccinated later this month. "There has to be some light at the end of the tunnel."
More on the Coronavirus in Rhode Island
The College Town Factor
While younger people aren't as likely to get very sick, college students have done their part to spread it. Clusters of cases among students were reported this fall at the University of Rhode Island, Johnson & Wales University and Providence College.
Like other states, Rhode Island limited indoor dining and customer capacity at many businesses in the spring and temporarily shuttered bar areas, gyms and theaters. Tougher rules were reinstituted for the first three weeks of December after case numbers began to tick upward.
While physicians like Fine and Corl argue the restrictions haven't gone far enough, many business owners have expressed concerns about long-term economic damage to the state's hospitality and tourism industries.
Bob Leonard is the co-owner of the Coast Guard House, a seaside restaurant in Narragansett popular with tourists. He said his business worked hard to comply with the restrictions and doesn't think restaurants are responsible for the recent rise in cases.
"From what I've seen, it's people being at home and letting their guards down," he said.
Spotty Distancing & Wearing of Masks
Residents who ignore guidance on masks and social distancing also deserve some blame, Raimondo has said.
The Democratic governor also points to the state's vigorous testing program as an explanation for the recent surge. Rhode Island has performed more than 2 million tests, more per resident than any other state, according to Johns Hopkins University data. More testing means more asymptomatic cases will be identified — cases which might go unnoticed in other states.
But testing doesn't fully account for December's increases in deaths and hospitalizations too, said Dr. Ashish Jha, a physician and dean of Brown's School of Public Health. Jha said he believes population density and poverty are bigger factors.
"Pandemics are complex. They are not simple, straightforward things," Jha said. "But we are learning a lot."