‘Covid is all about privilege’: Trump’s treatment underscores vast inequalities in access to care

As the symptoms of Covid-19 took hold, President Trump got an infusion of an experimental antibody cocktail and was whisked by helicopter to Walter Reed National Military Medical Center. When his oxygen levels dipped, he was quickly put on a steroid normally given to patients with severe cases of the disease. At every step of the way, the president has had a team of expert physicians carefully monitoring his care.

That experience is a world away from the stressful waiting game most patients wade through after a positive test.

They are told to stay home and monitor their symptoms. If they do become severely ill, there is only a remote chance they will get access to the antibody cocktail, which was developed by Regeneron Pharmaceuticals and is being tested in clinical trials. The company said Monday that the president was among fewer than 10 people who have gotten access to the drug through a compassionate use program.

“Covid is all about privilege. The more privilege you have, the more you can ignore some of the rules of Covid. Where one person would need to be in the hospital, another person can have the hospital come to them. That’s privilege,” said Lakshman Swamy, an ICU physician at Cambridge Health Alliance in Massachusetts.

If the president’s privileged treatment is understandable given his prominence, the contrast is no less stark for millions of Americans who have faced down Covid-19 in their homes or local hospitals, where barriers to cutting-edge care do not simply melt at the mere mention of their names or job titles.

“That’s the most heartbreaking thing about this virus,” Josh Barocas, an infectious disease physician at Boston Medical Center, a safety-net hospital that treats a largely underserved population. “A portion of the people who are severely symptomatic don’t have access to health care … and they are the population that is just being decimated by this.”

In many ways, it’s not a disparity that’s exclusive to Trump. High-profile individuals — in particular, professional athletes — have had frequent access to testing with fast-turnaround results. For much of the rest of the population, however, confirming a case of Covid-19 has meant waiting in line for a test, and waiting even longer for results.

Many patients are worried about losing their jobs because of a positive test, or afraid to go into the hospital because no one else will be available to care for their children if they’re admitted. So they stay home and try to ride it out.

For ordinary patients, there is no such thing as a precautionary hospitalization. Unlike the president, they would not be admitted based on concerns about what could happen if they are not in close proximity to doctors and state-of-the art equipment. They are only hospitalized if signs of severe infection emerge.

That’s a pragmatic limitation of the hospitals, which can only care for so many patients at a given time. But it also means that patients can’t get lifesaving care if their condition rapidly takes a turn for the worse, as was the case with a 53-year-old Black patient who recently sought care at a community health center in Ahoskie, N.C., a rural community in the northeastern corner of the state.

The patient, who had high blood pressure and diabetes, saw a doctor at the clinic on a recent Tuesday. He had a slightly elevated temperature, but reported no shortness of breath or other concerning symptoms that would have warranted a trip to the hospital. Still, his caregivers decided to watch him closely.

They called again on Tuesday afternoon, and spoke to the patient two more times at home on Wednesday. He reported feeling a little tired, but still no shortness of breath, the clearest signal to seek hospital care.

“We told him if he felt any different at any time to call us immediately,” said Kim Schwartz, chief executive of the Roanoke Chowan Community Health Center. “That afternoon he had a heart attack and died. He had a 100.4 temperature and nothing else. I could give you six or seven more cases like that I know personally.”

Data collected on Covid-19 cases have turned up significant disparities in who is infected — and who dies from an infection. State data analyzed by the nonprofit Kaiser Family Foundation revealed that the death rate is more than twice as high for Black patients, and nearly twice as high among patients identified as Native American or Alaska Natives. The data also show that people with lower incomes are much more likely to become seriously ill. About 35% of patients with household income under $15,000 became seriously ill, compared to just 16% of patients with income over $50,000.

“You have this pandemic where you literally see the numbers and faces in front of you that shows you that this disease impacts people differently, depending on what they look like and what jobs they work,” said Alison Bateman-House, an assistant professor of medical ethics at New York University’s Grossman School of Medicine.

Certainly, much of the president’s treatment protocol mirrors Covid-19 care in the wider population. Hospitalized patients are closely monitored for signs of deterioration, such as a drop in oxygen level. And many are now able to get access to the antiviral drug remdesivir, which was also used in Trump’s treatment.

But ordinary patients don’t necessarily get the everything-but the-kitchen sink care received by the president. In addition to remdesivir and the antibody cocktail, the president’s physicians have also said he was given the steroid dexamethasone after a temporary drop in his oxygen levels. It is unclear whether the president was actually sicker than his doctors had portrayed at that point. But for most patients, the steroid is only given if they are severely ill and already on a ventilator or otherwise receiving supplemental oxygen.

And getting access to Regeneron’s experimental drug, a cocktail of two monoclonal antibodies which has not yet been authorized by the FDA, is harder still. The only two ways to get it are through enrolling in a clinical trial — for which an individual would have to meet specific criteria — or applying for access through a compassionate use program. In that case, a doctor must apply for access based on a patient’s immediately life-threatening condition, a process that can typically take a week or more — when a patient isn’t the president.

Because it is not yet authorized, hospital pharmacies do not stock the therapy. So even in the rare circumstance that the drug company approves its use outside a clinical trial, it still takes one to two days to get it to the patient.

“If you think you have a patient that’s going to need the antibody cocktail, by the time the process is complete, it’s possible that you’ve missed your window,” said Barocas, the infectious disease doctor at Boston Medical Center. “And that’s likely why only 10 people have gotten it the way the president did.”

Bateman-House said the bigger problem is that the process itself is not based on need. “We know who gets access to investigational medicine is not a random cross section of the American population,” she said, adding that many patients do not even know there is a way to apply. “This particular case of Trump just makes it real for people.”

Helen Branswell contributed reporting.