How tiny Rhode Island became a central player in the coronavirus saga

Not only could Black people in Rhode Island get the disease, but the minority community would be disproportionately affected by it. Blacks make up about 6 percent of the state’s population, but they represent 13 percent of the confirmed cases where race or ethnicity has been tracked, according to the Department of Health. A whopping 44 percent of infections where ethnicity is known involve Latinos, even though they make up just 16 percent of the population.

The virus also has cruelly targeted the most fragile people in society. More than 70 percent of those who have died in Rhode Island were residents of nursing homes, their families prohibited from visiting during their final days. Nearly 80 percent of the people who have died were at least 70 years old.

It has been two months since the first confirmed cases hit Rhode Island, and the state has become known nationally for two distinct reasons: It’s testing more people per capita than any state in the country, and at 19.8 percent, the rate of unemployment claims is tied for fourth-highest in the country, according to the Tax Foundation.

But as Governor Gina Raimondo prepares to lift a stay-at-home order for all residents, reopen certain businesses, and begin Rhode Island’s long path to recovery, the state is still seeing hundreds of new positive tests a day, a higher percentage of its deaths are in nursing homes than other states, and there are few signs that the spread of the virus is slowing in the most vulnerable communities.

Worse yet, doctors say they’re struck by how many questions they still have about this wildly contagious virus, which has now infected more than 9,400 residents, killed 320 people, and changed the lives of everyone forever.

“As a public health expert, I have a profound respect for the virus,” said Dr. James McDonald, the medical director for the state Department of Health. During a telephone interview last week, it was a phrase he repeated several times.

McDonald and other health experts say they have every reason to believe the disease was in the United States — and likely Rhode Island — long before the first positive cases showed up, but it will take more serology tests before that can be proven.

What is known is that the first confirmed case in the state involved a school administrator from Saint Raphael Academy in Pawtucket who took a group of students on a trip through Mediterranean Europe during February vacation. At least one other adult who traveled with the group, as well as a student, also became infected.

It would take weeks to learn that an individual who is asymptomatic could still transmit the virus, which is now considered one of the primary reasons it has spread so fast across the country. By the time it was clear the state was seeing “community spread,” it was nearly impossible to trace its origin points. The state has now implemented a robust contact tracing program.

“What really killed us was when it spread to Europe,” said Dr. Philip Chan, an infectious disease physician at the Miriam Hospital Immunology Center in Providence who has been assisting the state with its response to the virus since the first positive case.

Chan said he believes the virus had “multiple introductions” to the region and most cases initially came from people who had recently traveled, or been in close contact with, a person who had traveled.

Rhode Island didn’t immediately see an influx of new cases, but doctors caution that because so few tests were available, it’s difficult to pinpoint when the true spread started. The state didn’t see double-digit positive tests on a single day until March 17, but it has seen at least 100 new cases every day since April 4. As of Sunday, the state had 9,477 confirmed cases.

“Some people would say we got caught with our pants down nationally,” McDonald said, referring to the minimal number of tests and personal protection equipment that was available in early March. “I say we didn’t have our pants on.”

Even Raimondo admits the state was often flying blind in those early days. She said one of the most difficult parts of the crisis was that “the information is imperfect, the situation is constantly changing, and also we don’t have a lot of time.”

But the state moved quickly to establish drive-through testing sites at several public colleges, and then Raimondo struck gold when she convinced Woonsocket-based CVS Health to open its first rapid testing facility in the parking lot of Twin River casino in Lincoln. The company has since announced it will offer tests in up to 1,000 locations across the country.

Rhode Island is now testing more than 3,000 people per day, the most per capita in the country, well ahead of New York and Massachusetts. A study released by researchers at Harvard University last month recommended that states should be conducting 152 tests per 100,000 people before they begin considering relaxing their restrictions, and at the time, Rhode Island was the only state that was meeting the mark.

As testing increased, so did the number of positive cases, hospitalizations, and, sadly, deaths.

On April 15, Dr. Deborah Birx, the response coordinator for the White House Coronavirus Task Force, warned that Rhode Island was caught between “two incredible hot spots” in New York and Boston, and said the state was experiencing an uptick in cases.

With just over a million residents, Rhode Island is the seventh-least populous state in the country. But at 814 cases per 100,000 people, the state had the fourth-highest infection rate in the country as of April 30, according to a tracker published by The New York Times. Only New York, New Jersey, and Massachusetts ranked higher. With 25 deaths per 100,000 people, the state had among the 10 highest death rates in the country.

Matos, who is Dominican, has witnessed the spread in Providence firsthand. A day after she told the Haitian community that Black people can contract the coronavirus, she learned her father had tested positive for the disease. He ended up on a respirator before making a miraculous recovery, but she said last week that she still hasn’t been allowed to visit him.

At least three other members of her family also fell ill in March with what they believe was the virus, but at the time, they were encouraged to recover at home.

Meanwhile, the community she represents has been hit uniquely hard. Providence has 30 percent of all of Rhode Island’s confirmed cases, and her zip code has the highest number of cases in the state.

There is no one reason that Latinos make up more than 40 percent of the known cases in the state, but Chan said underserved communities are often disproportionately affected by diseases. He also noted they tend to live in high-density, urban areas, which has been a common spreading ground for the virus in other states, too.

Chan had one additional theory: “Our messaging is largely geared to English-speaking, more educated people,” he said.

While the question about how the disease spreads among different races may have been farfetched, Matos said she has found herself correcting an inordinate of misinformation over the past month. In many cases, people aren’t fully aware of how serious the virus is.

“Our community is not watching TV in the middle of day,” Matos said. “They're working.”

While the minority community may have the most confirmed cases, they have, by far, the fewest number of deaths, thanks to a mostly younger population. Instead, death has struck the elderly with a vengeance: Most of the people who have died lived in Rhode Island’s nursing homes.

Roughly 230 of the 320 people who succumbed to a coronavirus-related illness lived in long-term care or assisted living facilities, according to the Department of Health.

The available data varies from state to state, but a report from the Kaiser Family Foundation shows that at 71 percent, Rhode Island appears to have the highest percentage of coronavirus-related deaths at long-term care facilities in the country. Massachusetts ranks second, at 63 percent.

“People in the nursing homes don't do really well with any disease,” McDonald said.

But he said the coronavirus has been particularly devastating to the elderly and those with underlying conditions because it attacks their respiratory systems and they don’t have the necessary reserves to fight it.

Is a vaccine or treatment on the horizon? A clinical study of one drug, remdesivir, released last week showed promising results in shortening the duration of the illness, but McDonald warned that it could be a long time before doctors are certain that they can treat the disease.

“We want our treatment to be done in a microwave and sometimes it needs to be done in a crockpot,” he said.

The public health crisis in Rhode Island also created an economic crisis.

In an effort to contain the virus, Raimondo was forced to shut down most of the state’s economy for the past six weeks. That led to nearly 200,000 unemployment claims being filed in less than two months, likely sending the jobless rate as high as it has been in nearly a century.

As of April 25, 19.8 percent of Rhode Island’s civilian workforce had filed an unemployment claim, according to a study from the Tax Foundation. Only Vermont (24.8 percent), West Virginia (23.3 percent), and Nevada (20.2 percent) posted higher jobless rates. Michigan was tied with Rhode Island at 19.8 percent.

While millions of people throughout the country have lost their jobs since the middle of March, experts say Rhode Island has suffered more than most because of its high reliance on service industry jobs.

Edinaldo Tebaldi, a professor of economics at Bryant University, said employment in Rhode Island has become “more concentrated in sectors that are sensitive to demand-shocks,” like leisure and hospitality, retail, and transportation.

“Productivity is key for business sustainability and resilience,” Tebaldi said. “In Rhode Island, labor productivity is low across key industries, making businesses more sensitive to the challenges and less capable of continuing to operate because of the pandemic.”

If there is any good news, it’s the virus has not hit Rhode Island as hard as some of the initial projections suggested it might. At one point, state leaders thought Rhode Island would need between 2,200 and 4,400 hospital beds by now. As of last week, there were fewer than 400 people with the virus in the hospital.

Raimondo credits residents for adhering to social distancing regulations that allow gatherings of no more than five people and the early decision to close schools as some of the key reasons that the virus hasn’t overwhelmed the health care system.

She’s so confident that the number of cases has stabilized that she’s moving quicker than governors in neighboring states to roll back some of the restrictions. While Massachusetts Governor Charlie Baker has ordered nonessential businesses to remain closed until at least May 18, Raimondo has said she intends to lift her stay-at-home order by Saturday. A phased-in reopening of the economy will follow, one that could take months.

Raimondo said she fully expects Rhode Island’s beaches to open this summer, but she has warned that other annual traditions will have to wait. That means no Newport Jazz Festival, or Fourth of July parade in Bristol, or any gatherings of more than 100 people.

While those pastimes will return someday, some believe other rituals may never return.

“I don’t know if masks are part of the forever normal,” McDonald said. “But I think the handshake is done."

Dan McGowan can be reached at dan.mcgowan@globe.com. Follow him @danmcgowan.