The Power of Paxlovid

First, a programming note: This is my last newsletter before starting a book leave. I’ll be back in late January. Until then, other Times journalists will be writing The Morning, and I look forward to reading their work along with all of you.

A worrisome pattern has emerged with Paxlovid and other drugs that reduce the severity of Covid: Many people who would benefit most are not receiving the treatments, likely causing hundreds of unnecessary deaths every day in the U.S.

There seem to be two main explanations for the drugs’ underuse. The first is that the public discussion of them has tended to focus on caveats and concerns, rather than on the overwhelming evidence that they reduce the risk of hospitalization and death. The second explanation is that many Americans, especially Republicans, still do not take Covid seriously.

Today’s newsletter will dig into both issues.

“A large chunk of deaths are preventable right now with Paxlovid alone,” Dr. Ashish Jha, the White House Covid response coordinator, told me. He predicted that if every American 50 and above with Covid received a course of either Paxlovid or a treatment known as monoclonal antibodies, daily deaths might fall to about 50 per day, from about 400 per day in recent months.

Dr. Rebecca Wang, an infectious disease specialist at Dartmouth Hitchcock Medical Center, has said: “Never really in recent history for a respiratory virus can I think of an anti-viral medication being as effective, demonstrated in scientific literature, as what Paxlovid has shown.”

Dr. Robert Wachter, the chair of the medicine department at the University of California, San Francisco, told me that he thought the underuse of Paxlovid was already associated with thousands of preventable deaths in the U.S. “The public doesn’t seem to understand that the evidence around hospitalization and deaths is really powerful,” Wachter said.

Bad-news bias

By now, you have surely heard about the downsides and shortcomings of Paxlovid.

The drug can produce a metallic taste in the mouth. (One member of my family described it as among the worst tastes she had ever experienced.) Some research has also found that the drug might not cause a statistically significant reduction in hospitalization among younger adults. Most prominently, people who take Paxlovid can endure “rebound” Covid — as both President Biden and Jill Biden did — in which symptoms return after the five-day course of pills has ended.

All of this is true. It also does not change the big picture. Covid is a deadly virus, especially for older people, and Paxlovid reduces Covid’s severity. It does so by inhibiting the virus’s replication inside the human body, the same process that has made H.I.V. treatments so effective.

With Paxlovid, both randomized trials and data from electronic health records have pointed to its effectiveness. Some research finds an effect across all age groups, while other research finds one only among older patients. But that is not surprising. The Covid death rate for people under 50 is already so close to zero that reducing it in a statistically significant way is difficult.

“I think almost everybody benefits from Paxlovid,” Jha said. “For some people, the benefit is tiny. For others, the benefit is massive.” (People who can’t take Paxlovid because it interacts dangerously with another drug they’re taking can usually take monoclonal antibodies.)

A recent analysis of about 568,000 patients by Epic Research found that 0.016 percent of Covid patients over 50 who received Paxlovid died. The death rate for patients who did not get the drug was more than four times higher, or 0.070 percent. And yet the Epic data showed that only about 25 percent of patients eligible to receive Paxlovid actually did, even though the drug is widely available and free for patients.

Perhaps the most shocking statistic about Paxlovid’s underuse — and Jha used the word “shocking” when describing it to me — is that a smaller share of 80-year-olds with Covid in the U.S. is now receiving the drug than 45-year-olds with Covid, according to data he has seen. Many doctors are evidently worried about side effects or rebound cases among their more vulnerable patients.

Even in rebound cases, however, symptoms tend to be milder than they would have been without Paxlovid. After Dr. Anthony Fauci, another White House adviser, who’s 81, contracted Covid in June and then took Paxlovid, he experienced a rebound — and also believed that the drug kept him out of the hospital.

“Medicine is about weighing costs and benefits,” Wachter said. “The recommendation should be clear and unambiguous for people at high risk: The benefits of the drug outweigh the downsides.”

Red Covid

When I last wrote about “red Covid” — the concentration of Covid deaths in conservative communities because of vaccine skepticism — almost eight months ago, I explained why the partisan gap could eventually shrink: Republican communities might have built up more natural immunity through previous infections, and treatments like Paxlovid were becoming more widely available.

This spring and summer, the gap did narrow somewhat. But it has begun growing again in the past two months, according to an analysis by my colleague Ashley Wu.

One possible explanation is that Paxlovid takeup rates appear to be lower in Republican areas, even though they are the very places where the drug could do the most good, because of lower vaccination rates. Government data shows that of the 20 states with the least Paxlovid use between late August and late September (per 100 diagnosed cases of Covid), 18 were won by Donald Trump in 2020.

The shunning of Paxlovid seems to be part of a pattern in which Republican voters have wrongly dismissed Covid as little different from the flu. That mistake has had tragic consequences. A new study by three Yale University researchers found that the wide partisan gap in Covid deaths remained even after controlling for other factors, like age.

Solutions

Jha told me that the Biden administration was committed to increasing the use of Paxlovid and monoclonal antibodies nationwide. “We are going to go after this problem hard,” he said. “We have got to fix it, and we’ve got to fix it in weeks.”

What might make a difference?

Persuading more doctors of Paxlovid’s benefits would probably have the biggest impact. Wachter thinks that accelerating research about rebound Covid — including whether a longer course of Paxlovid would help — could also increase use, given the fear around the issue. He added that he was surprised that government, academic and private researchers had still not learned more about what causes a rebound and how to prevent it.

In coming months, this newsletter will follow up and see whether this country can do a better job of using a widely available treatment to save lives.

THE LATEST NEWS

Politics

• Biden pardoned thousands of people convicted of marijuana possession under federal law.

• A judge blocked much of New York’s new gun law. The state plans to appeal.

• The Justice Department believes that Trump still hasn’t returned all of the documents taken from the White House.

• Senator Ben Sasse, a Nebraska Republican, plans to resign to become the University of Florida’s president.

• The roughly 200 U.S. newspapers owned by Alden Global Capital will stop endorsing major political candidates.

War in Ukraine

• Some supporters of Russia’s war have criticized its military leaders, saying they were unprepared.

• Biden delivered a blunt and unusual warning, saying that threats from Vladimir Putin could devolve into a nuclear conflict.

Other Big Stories

• The victims of the shooting at a Thai day care center included a pregnant teacher and a 3-year-old known as Stamp who loved racing toy cars.

• Nobel Prizes: Human rights advocates in Belarus, Russia and Ukraine won the Peace Prize. Yesterday, the French writer Annie Ernaux won for literature.

Opinions

An unpublished 1990s book manuscript by Barack Obama offers a blueprint for saving American democracy, Timothy Shenk argues.

If Elon Musk’s takeover bid destroys Twitter, good riddance, Michelle Goldberg says.

Barry Bonds is the true home run king, and baseball has a selective memory about cheaters, gamblers and racists, Kevin Blackistone writes in The Washington Post.

MORNING READS

The best and bulkiest: Fat Bear Week is in full swing.

Modern Love: To find love, rub this statue.

A Morning listen: Why did Musk change his mind about buying Twitter?

Advice from Wirecutter: Read this before you buy a stove, oven or dryer.

Lives Lived: Judy Tenuta, a standup comic who anointed herself “The Love Goddess,” became famous in the 1980s with her off-kilter jokes and accordion playing. She died at 72.

SPORTS NEWS FROM THE ATHLETIC

An ugly win: In a sloppy game that many couldn’t bear to watch, Indianapolis beat Denver 12-9 in an overtime field-goal fest yesterday.

M.L.B. playoffs: The first pitch is set for noon Eastern today in Cleveland. The Athletic picked its World Series winner: The Houston Astros.

ARTS AND IDEAS

Joan Didion’s legacy

A sense of place was a hallmark of Joan Didion’s writing, and her subjects included California, where she was born, and New York, where she lived for decades (returning after she famously left). An exhibition opening at the Hammer Museum in Los Angeles next week aims to capture her writing’s geographic sweep.

The exhibition, which Didion blessed before her death last year, features materials curated by the New Yorker critic Hilton Als, a friend of Didion’s. “She talks about loving that kind of drift, that feeling of drifting,” Als told The Times’s Adam Nagourney.

PLAY, WATCH, EAT

What to Cook

Don’t skip the toppings on this peanut-butter fudge.

What to Watch

In “Amsterdam,” Christian Bale and Margot Robbie “charm and seduce,” our critic writes.

What to Read

Matthew F. Delmont’s “Half American” is about African Americans and World War II.

Late Night

Stephen Colbert discussed Biden’s marijuana pardons.

The News Quiz

How well did you follow the headlines this week?

Now Time to Play

The pangram from yesterday’s Spelling Bee was paranormal. Here is today’s puzzle.

Here’s today’s Mini Crossword, and a clue: Water color (four letters).

And here’s today’s Wordle. After, use our bot to get better.

Thanks for spending part of your morning with The Times. See you tomorrow. — David

P.S. David Scull, a Times photo editor who worked on this newsletter, died last week. We miss him deeply.

Correction: Yesterday’s newsletter misidentified Chicago’s N.W.S.L. team as the Fire. It is the Red Stars.

Here’s today’s front page.

“The Daily” is about nuclear weapons.

Kitty Bennett, Matthew Cullen, Lauren Hard, Lauren Jackson, Claire Moses, Ian Prasad Philbrick and Ashley Wu contributed to The Morning. You can reach the team at themorning@nytimes.com.

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