As with vaccines, equity becomes issue with COVID-19 medicines

Under pressure from a virus that has killed nearly 900,000 Americans, researchers have developed a range of life-saving treatments that reduce the risk of serious illness from COVID-19 by up to 89%. But there aren’t nearly enough of the new drugs to go around. And if recent pandemic history is any indication, the patients who get them are likely whiter, wealthier, and healthier than those who aren’t.

States, counties and health systems are struggling to allocate their limited supplies without exacerbating existing inequalities. Some try to prevent this by taking into account the race and ethnicity of the patients – and in doing so stir up controversy. The Biden administration has provided little guidance.

For the record:

12:45 p.m. February 8, 2022An earlier version of this story states that California created the Healthy Places Index to measure a community’s socioeconomic well-being. This index was developed by the Public Health Alliance of Southern California and adapted by state officials to create their own health equity metric.

4:22 p.m. February 4, 2022In an earlier version of this story, JP Unfortunately’s last name was misspelled as Lieder.

A little over a year ago, the launch of vaccines raised similar concerns: that high demand and tight supplies would keep low-income communities and people of color waiting — and dying — to get vaccinated. Although federal government experts urged steps to improve equity, these calls were largely ignored by the states’ initial distribution efforts.

“It’s pretty clear that we haven’t learned that lesson,” said Harald Schmidt, a professor of medical ethics and health policy at the University of Pennsylvania. The federal government can recommend and pay for measures designed to make access to health care fairer for everyone. But if states don’t choose to adopt them, the market will decide who gets them first, and the outcome will rarely be fair, he added.

The new drugs are as hard to get as they are difficult to pronounce. Paxlovid and molnupiravir are antiviral drugs for patients with newly discovered coronavirus infection who are at high risk of becoming seriously ill or dying. Sotrovimab is a monoclonal antibody therapy for the same patient population. Evusheld is another monoclonal antibody infusion that helps fight off infection in patients who don’t get much immunity from the vaccine or for those who can’t take a vaccine.

They all trickle out of a government pipeline in quantities far below demand.

In the first four weeks of the year, in which 20.5 million new infections were reported, the federal government distributed enough Paxlovid and molnupiravir to treat just under 1 million patients. States have received just over 200,000 courses of sotrovimab, the only monoclonal antibody effective against the Omicron variant. And fewer than 300,000 doses of Evusheld have started reaching hospitals to protect a vulnerable population that numbers between 10 million and 17 million.

“It doesn’t even scratch the surface” of the need, said JP Leider, a University of Minnesota ethicist who helped develop a lottery system for the state’s COVID-19 drug shortage.

President Biden has promised that larger shipments of all drugs will come. Meanwhile, Washington has reserved a fraction of each drug’s supply — about 15% — to ship directly to a network of 1,368 federally-qualified health centers serving poor and underserved communities across the country.

But the bulk of the drugs will be given out to states to allocate at their discretion, Leider said. And many states and counties are handing them out in a way that effectively gives dibs to the medically-eligible patients who walk in the door first.

This allows many doses to be diverted from those patients who are most at risk of serious illness or death from COVID-19 to better-off patients who are not, Schmidt said.

The pandemic has eased a hard fact about medical care in the United States: In a first-come, first-served system, the wealthier, better-insured, and better-educated will quickly come out on top. Poorer, socially vulnerable patients – including a disproportionate number of blacks – will be slow in coming.

The result can be counted in deaths. Americans living in the bottom third of the nation’s socioeconomic ladder are 48% more likely to die from COVID-19 than those in the top third. And people of color are much more likely to fall into this bottom third than white people.

The Federal Centers for Disease Control and Prevention estimates that Black Americans, Latinos, Native Americans and Alaska Natives are about twice as likely to die from COVID-19 as their white peers in any age group. Only Asian Americans fared better than whites, with a 10% lower risk of death.

The use of monoclonal antibodies in newly infected patients to fight off a severe case of COVID-19 is a good example of a system that discriminates against people of color. A January report by the CDC COVID-19 Response Team found that over a 10-month period ending in August, Latinos who tested positive for coronavirus infection were more likely to have the antibodies to 58% lower than similar non-Hispanic Americans. In addition, newly infected black people were 22% less likely to receive the treatment than their white counterparts, the report found.

Once patients were sick enough to be hospitalized, racial and ethnic differences in the use of COVID-19 treatments all but disappeared. To the report’s authors, this suggested that Latinos, Blacks and Native Americans face barriers that are not as prevalent for white Americans. Many lack a family doctor to recommend and prescribe therapy, the time and transportation to get it, and medical insurance to fully cover it.

Even when antibody treatment is offered, a lack of trust in the medical establishment — borne by historical injustice and often personal experience of bias — prompts many people of color to make a pass.

A system that forces disadvantaged patients to compete with the wealthy for access to scarce medicines “is a terrible strategy,” said Dr COVID-19 drug allocation.

For example, many states have chosen to only sell the highly potent and sought-after drug Paxlovid at retail pharmacies, rather than making it widely available in hospitals and clinics. The result was free manipulation in favor of people who not only know about the drug in advance, but also have direct access to doctors – who are required to prescribe it – and have the means to track down a pharmacy that has it in stock.

“The rich and well-connected will win the race,” White said. It is “the poster child for an unfair system”.

But many efforts to make access more equitable have sparked a backlash. New York City faces a legal challenge because of its policies on healthcare systems, which include race and ethnicity, among many other risk factors. Legal action is also being threatened against Minnesota, which briefly used a similar system. The state ended this policy in January in favor of a lottery that takes into account a broad measure of patients’ socioeconomic status.

California developed its own broad measure of a community’s socioeconomic well-being to make COVID-19 vaccine distribution more equitable when demand far outstripped supply. This health equity metric, inherited from a measure called the Healthy Places Index, now governs the distribution of coveted COVID-19 drugs.

It makes no reference to race or ethnicity. Instead, it focuses on factors such as housing density, poverty, level of education, environmental factors, and access to supermarkets and healthcare in specific neighborhoods.

State allocations of the antibody sotrovimab are based on where new cases and new hospital admissions are highest, a spokesman for the California Department of Health said.

The lack of an explicit reference to race and ethnicity in the state’s health equity metric is no coincidence, Schmidt said: It’s helped California stay away from a third rail in American politics.

Former President Trump has been fueling those passions in recent weeks. “The left is now rationing life-saving therapeutics on the basis of race,” he told his supporters at a rally in Florence, Arizona last month. And in New York, he demanded, “If you’re white, you have to stand at the end of the line to get medical care.”

Watch LA Times Today at 7:00 p.m. on Spectrum News 1 on Channel 1 or stream live on the Spectrum News app. Viewers from Palos Verdes Peninsula and Orange County can watch on Cox Systems on Channel 99. As with vaccines, equity becomes issue with COVID-19 medicines

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