Molnupiravir: another Covid-19 treatment, another opportunity to recognize inequity

The Covid-19 pandemic has disproportionately affected communities of color and those with lower socioeconomic means, two groups that overlap to a significant extent in the U.S. Merck’s submission of molnupiravir, its oral antiviral drug, to the Food and Drug Administration for emergency use authorization will only heighten inequities wrought by the pandemic.

Merck and others have touted this drug as a game-changer. Although the data from randomized controlled trials have not been made available for review, the press release claims that a five day course of molnupiravir is associated with a 6.8% absolute reduction in hospitalization or death in patients with moderate Covid-19 not requiring hospitalization when the drug is taken within five days of the onset of symptoms. Assuming this information is accurate, early use of molnupiravir may lead to significant reductions in hospitalizations and deaths.

We would applaud that advance if all communities were to equally reap the benefits of the drug. But that isn’t likely to happen.

Approximately 33 million U.S. adults under age 65 lack health insurance. Those in racial and ethnic minority groups are more likely to be uninsured than white Americans. And about 25% of Americans don’t have a primary care provider. These numbers are important.

For molnupiravir to be effective, it apparently must be taken within five days of symptom onset. This requires that an individual:

• recognize they have symptoms indicative of Covid-19
• secure a Covid test
• get the test results back in a timely manner
• make an appointment with a doctor
• get a prescription from the doctor for molnupiravir
• buy the medication

As health care workers, we have access to excellent insurance programs and yet we would struggle to complete all of these steps within five days of noticing Covid symptoms. The barriers would be even higher for people of color and those with low incomes.

Data from Sutter Health show lower Covid-19 testing in outpatient settings for Black people in comparison to white, Asian, and Hispanic people, suggesting issues with access to getting Covid tests. Delays in getting a test, being informed of the result, and making an appointment with a doctor will all be harder among those with marginal or no insurance.

The rollout of earlier Covid-19 medications provides an illustrative example. Remdesivir, an intravenously administered antiviral that needs to be given early in the course of the disease and that can be administered only in the hospital, was given to Black cancer patients with Covid-19 — a high-risk group — half as often as it was given to white patients. Its distribution was also uneven: safety-net public hospitals, which tend to serve racial and ethnic minorities as well as those with lower incomes, waited for supplies of remdesivir while smaller, private hospitals, which tend to serve higher-income populations, had earlier access. The evidence base for these new anti-Covid medications has also been inequitable: the majority of those in typical early studies were white.

For individuals who are not sick enough to be hospitalized with Covid-19, using emergency departments or outpatient care clinics for access to molnupiravir is not the solution to these inequities. An emergency visit would incur large charges to the un- and underinsured and stress an already near-capacity hospital system. Already overburdened community-based clinics can often not accommodate urgent appointments, especially for those who are not already established patients at the clinic.

Even if a patient without insurance was able to navigate the first five steps listed earlier, buying the medication would be difficult, as a course of molnupiravir costs $700. Inequities in access to necessary medications are well documented, and while the country’s goal should be pharmacoequity — ensuring that all individuals have access to the medications they need — we are far from accomplishing it. The cost would escalate quickly if Covid-19 spread to family members, presenting some families with the choice between improving their odds against Covid-19 and incurring debt or bankruptcy.

The federal government could provide the medication for free, as it has done with monoclonal antibody therapy, and has in fact already ordered 1.7 million courses of molnupiravir. But here, too, there are inequities between racial/ethnic groups, with white patients being far more likely to get monoclonal antibody infusions. Many of those who receive monoclonal antibodies are referred by their primary doctor to an emergency department or an infusion center, which limits access to this therapy to those who have primary care doctors. So simply eliminating cost won’t fix the problem.

Removing one barrier to treatment is inadequate; all must be removed.

Throughout the pandemic, the U.S. has been caught in endless loops of compounding inequities. With every new resource, though, we have the opportunity to recognize them earlier and do better moving forward.

Anand Swaminathan is an emergency physician at St. Joseph’s University Medical Center in Paterson, N.J. Utibe Essien is a general internist and assistant professor of medicine at the University of Pittsburgh School of Medicine. Esther Choo is an emergency medicine physician and professor of emergency medicine at Oregon Health & Science University and cofounder of Equity Quotient.