PROVIDENCE, RI – The numbers started to increase in September. After a peaceful summer, doctors at Rhode Island Hospital began seeing one or two Covid-19 patients each shift – and then three. Then four.
Cases increased steadily until the beginning of December, when Rhode Island won the dubious distinction of having more cases and deaths per 100,000 people than any other state in the country. The case rate still places it among the top five states.
Where did this rigid mesh state go wrong? The “breaks” of ex-governor Gina Raimondo in economic activity were short-lived and partial, leaving restaurants open, shopping malls and bowling alleys. But the shutdowns were no more patched up than in many other states.
By the end of the summer, she was praised for containing the virus. Even now, few residents blame it for the disheartening numbers. (Ms. Raimondo was sworn in as secretary of commerce on Wednesday night.)
Experts point instead to a myriad of other factors, all of which have occurred in other parts of the country, but have converged on a bigger crisis here.
The cold of autumn sent people into the house, where the risk of the virus is greatest, and the holidays brought people together. Rhode Island is tiny – you can cross it in 45 minutes. But huddled in this small area are a million people, for a population density second only to New Jersey. If everyone in the world is connected by six degrees of separation, the inhabitants of Rhode Island appear to be connected by perhaps two.
Central Falls, the epicenter of the Rhode Island epidemic, has a density of 16,000 people per square kilometer, almost double that of Providence. “Imagine, 16,000 people per square kilometer – I mean, this is incredible,” said Dr. Pablo Rodriguez, a member of the government committee that guides the distribution of the Covid vaccine in Rhode Island. “It doesn’t take much for the spark to create an outbreak.”
In addition to its density, Rhode Island has a high percentage of elderly people living in nursing homes, responsible for most deaths. Packaged in the state are several urban areas – Central Falls, Pawtucket, Providence – where language barriers, distrust and jobs have left immigrant families in homes of several generations particularly vulnerable. The state is also home to several colleges that triggered chains of infection in the early fall.
For months, hospitals in Rhode Island were understaffed and overburdened. Doctors and nurses were trying to cope with the growing number of cases, often without the protective equipment they needed, with ever-changing guidelines and their own resilience pushed to the limit.
Dr. Megan Ranney, a researcher and public health advocate, is also an emergency room physician at Rhode Island Hospital and has witnessed firsthand the full extent of the state crisis. What she saw unfold in a single shift offers a window into what happened.
Plowing through it
One day, in late December, when the crisis reached new heights, Dr. Ranney prepared for an eight-hour long shift. The wounds behind the ears, where the glasses, the N95 handles and surgical masks sank, had not yet healed. But how could she complain, Dr. Ranney said, when her resident doctors “eat, sleep, breathe Covid” five days a week?
The patients were worse, she knew. Anxious and isolated, they were even more disconcerted by the masked and unrecognizable doctors and nurses who ran around them. During Dr. Ranney’s shift the previous week, she saw a wide spectrum: elderly people in a downward spiral, healthy young Latinos, Cape Verdean immigrants with limited understanding of English.
These demographics are, in part, what makes Rhode Island particularly susceptible, said Dr. Ashish Jha, dean of the Brown University School of Public Health in Providence: “Certainly, in New England, it is the poorest state – there is much poverty and a lot of multigenerational poverty. “
As in most parts of the country, the Latin community suffered the most from the epidemic. In Rhode Island, Latinos have 6.7 times the risk of hospitalization and 2.5 times the risk of death, compared to whites.
In the days before her shift, Dr. Ranney was working in a part of the hospital designed to handle non-Covid cases. But even people with other illnesses, such as ankle fractures, were positive for the virus, she found.
“I never know, on a daily basis, how bad the wave will be,” she said. “I just have to go through this.”
It was an extraordinarily busy day. “The ER is full, the hospital is full, the intensive care unit is full,” said Dr. Ranney. “All of our units are moving as quickly as possible, but patients are still arriving.”
Each time he took off his masks during a shift, he was at risk of becoming contaminated. She had had four cups of coffee before that shift, and nothing since.
The average age of patients that night was around 70 years old. An elderly woman who had difficulty breathing could not isolate herself because she lived with her children and grandchildren. Anyway, she arrived at the hospital ten days after the illness, too late for isolation to matter.
The Rhode Island epidemic was disastrous for immigrant families in multigenerational homes. “How do you isolate yourself from someone when you have a bathroom?” Dr. Ranney said.
It is a problem in all this diverse state. When Djini Tavares, 60, became infected in July, she was willing to spend about $ 120 a night in a hotel – an amount that many in her Cape Verdean community cannot afford – to isolate herself from her vulnerable father. 86 years old.
Even before the pandemic, Ms. Tavares was meticulous with hygiene, keeping lots of handkerchiefs and cleaning supplies at home at all times. She couldn’t imagine where she got the virus from. The loss of her godmother and a friend from Covid-19 shook her.
Cape Verdeans are a very close-knit community, and not being able to mourn the dead is painful, said Tavares: “Culturally, I think it’s making us hurt even more.”
In turn, Dr. Ranney found Covid-19 patients who had blood clots or heart problems, or who still needed oxygen weeks after diagnosis. Many patients were very careful – or said they had – but were infected after a family member brought the virus home.
The story is told very often in Rhode Island. Abby Burchfield, 58, lost her mother and stepfather to Covid-19 a few days apart at a community center in New Jersey in April. Devastated and afraid, she and her family stayed away from restaurants, washed their hands frequently and tried to wear masks everywhere. It was not enough.
Burchfield’s youngest daughter, Lily, 21, was infected at her college in Virginia in August and was hospitalized. Then, in late October, her husband, Jimmy, 58, got the virus from a co-worker who was infected but was not wearing a mask.
Despite Mrs. Burchfield’s best efforts, she was also infected. She was hospitalized after she suddenly passed out in the family’s kitchen. She has recovered, but her husband, who was also admitted to the hospital, still has no taste, a limited sense of smell and continued tiredness.
“My biggest fear now is to protect my eldest daughter,” said Burchfield.
Workplace exposures have particularly hurt the Latvian and Cape Verdean community, many of whom have jobs that cannot be done at home. But in state surveys, it was also obvious that people still had meetings of 15 to 20 people, even with the spread of the virus, said Dr. James McDonald, medical director of the Covid-19 unit of the Rhode Island Department of Health.
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“People were not willing to live differently during the pandemic,” he said.
Dr. Ranney said there were several such cases in the emergency room that night.
“It is frustrating to see patients arriving from car accidents without a seat belt, or to see patients with gunshot wounds because the gun was not stored safely,” she said. “It’s just like seeing people with Covid.”
The masks ‘were disgusting’
Some nights in emergency medicine, diagnoses and treatments are immediately obvious.
But in this change, Dr. Ranney said, “there was very, very little that was straightforward or smooth”. Several patients with substance abuse problems appeared, as well as people with mental illnesses who became a danger to themselves. And “we are seeing a lot of lonely people,” she said.
Dr. Ranney would have a truce, but many resident doctors and nurses in Rhode Island were already running out. Some felt that hospital administrators did not protect them.
At the beginning of the pandemic, most health professionals in Rhode Island, as in other parts of the country, did not have N95 masks. The masks are disposable, but when the nurses received an N95 each, they were asked to put them in paper bags at the end of the shift and put them back on the next day.
“They stank, they were sticky, they were disgusting. They made your face explode, ”said a nurse at Rhode Island Hospital, who spoke on condition of anonymity because the hospital instructed staff not to speak to the media.
If a handle were broken, the mask would be returned with new stapled handles. “The staples would stick to your face,” said the nurse.
Many nurses were left with only 40 hours of sick leave per year, which translated into three 12-hour shifts; a fourth day away can yield a reprimand.
Because of this, many nurses were not tested and some came to work even when they were sick. At Eleanor Slater Hospital in Cranston, RI, sick employees caused an outbreak of at least 29 employees and nine patients. It is a phenomenon observed in hospitals in the United States.
The rules for patients are not always in line with science, said a nurse at Rhode Island Hospital. At first, the hospital did not allow anyone to leave the emergency room until the test results were back. But as the first wave subsided, the rules became flexible.
Patients were sent with pending test results, potentially exposing other patients, as well as the nurses who cared for them. After treating one of these patients, at least nine nurses tested positive for the virus, the nurse said.
The policy of most hospitals in Rhode Island now is to have healthcare professionals wear N95 respirators or similar reusable masks at all times and to test anyone suspected of having Covid-19. But this does not take into account patients who may be asymptomatic and who have other illnesses.
Rhode Island has taken an unusual approach: authorities are distributing vaccines to anyone who takes them in Central Falls, regardless of age. It is a strategy that few other jurisdictions have tried.
“We decided to do this because of the terrible number of the pandemic in these communities,” said Dr. Rodriguez, a member of the vaccine committee. Twenty percent of adult residents received at least one dose at local clinics, not including those who may have been immunized at work or elsewhere.
The state’s plan to immunize those most at risk by age and geography, he added, “will put out the fire where it is burning most intensely.”
In recent weeks, the number of cases in Rhode Island has declined, as has the rest of the country. And fewer health workers are getting sick because they’ve been immunized, so hospital shifts are better than they used to be, said Dr. Ranney.
But cases in the state are still the country’s third largest per capita. And doctors continue to see patients who have been called Covid Long, she said: “The problem is that once patients are admitted, they won’t go away.”