Molnupiravir Hype Illustrates America’s Failure to Prioritize Prevention

Merck recently announced promising trial results for molnupiravir, a new oral antiviral for the treatment of COVID-19. While it’s encouraging that we may soon have a new weapon in our arsenal to fight the pandemic, the drug should not distract from the essential role of prevention. Time and time again during the pandemic, we’ve seen a de-emphasis on prevention and an outsized focused on treatment.

The COVID-19 pandemic has shown the value of robust public health systems and public health policies. Limiting the spread of highly contagious infectious diseases requires detection (data mining and interpretation), surveillance (testing and contact tracing), mitigation (social distancing and quarantines), prevention (vaccination and masking), treatment (therapeutics), and surge planning (improving medical infrastructure, providing PPE, workforce planning, etc.). A good public health plan minimizes the number of active cases, so people do not get sick and do not spread pathogens to others.

Yet, in several states, leaders have politicized and turned against proven public health measures while touting treatments as the holy grail. Take Florida for example. Gov. Ron DeSantis (R) has opposed mask mandates and even threatened to defund school districts that implemented mask mandates. He appointed a surgeon general — Joseph Ladapo, MD, PhD — who teamed up with the “demon sperm” doctor and said, “Vaccines are up to the person; there’s nothing special about them compared to any other preventive measure.” Both continue to downplay the benefits of mask wearing and vaccination — two of the most effective means of controlling this pandemic. At the same time, DeSantis is promoting monoclonal antibody treatment centers while continuing to neglect discussion of the important role of vaccination. I wouldn’t be shocked if as a next step he implements a ban on handwashing or subsidizes tobacco purchases for asthmatics.

We need to pause here. We need to point out this is not a public health plan. I don’t know what it is, but it is not a plan to help people in Florida deal with a pandemic. These ideas and policies are counter-productive and deserve derision.

Imagine a public health policy for polio that did not emphasize vaccines after one of the first effective polio vaccines — developed by Jonas Salk, MD — became available, but instead extolled the virtues of iron lungs, crutches, wheelchairs, and physical therapy. If that was the case, a public health meeting on polio in the 1950s chaired by DeSantis and Ladapo might have gone something like this:

Salk: This vaccine can prevent children from getting polio. We can administer the vaccine at schools and…

DeSantis: Slow down, Jonas, we have iron lungs AND crutches. Maybe we can create a vending machine with crutches so everyone has access.

Ladapo: Yeah, great idea. Vaccines are nothing special.

Salk: Are you guys pro-virus?

Luckily, conversations like these were not a reality — people in the 1950s did not complain that public health messaging emphasized the important role of the polio vaccine. My parents, who were young kids during that time, have complained about walking to school in heavy snow uphill both ways, but never complained once about a lack of crutches. When preventive measures like polio or COVID-19 vaccines are this effective on a large scale, political leaders and health providers must encourage as many people as possible to get vaccinated.

Beyond protecting people from getting sick, public health policies that emphasize vaccinations even limit healthcare costs. Keeping people from needing a hospital or ICU has obvious cost saving benefits. The numbers tell the story:

• About $30 to $40 for each dose of COVID-19 vaccine (with the benefit of limiting infection on a population-wide basis and high efficacy in preventing hospitalization or death in case of infection)
• $1,250 or more for each monoclonal antibody treatment (with no benefit of long-lasting immunity or community protection, 70% effective in preventing hospitalization and death in people with mild COVID-19)
• $700 for a full course of the new antiviral molnupiravir (no benefit of long-lasting immunity or community protection, 50% effective in preventing hospitalization or death)

Throw in the fact that overcrowded hospitals are postponing surgeries for people with cancer and are literally draining resources like clean water, and we can see that treatment-first policies are not only silly, but dangerous.

Public heath messaging must emphasize prevention over therapeutics, and most of the time, our patients are not upset about this. Our patients want our advice about diet, exercise, and smoking cessation — tools to keep them healthy — more than our opinion on which cardiac pacemakers and stents are most effective. Patients are fine with our efforts to convince them to get colonoscopies and avoid the need for chemotherapy and colostomy bags. No one wants to reach the point where those interventions are necessary.

Available COVID-19 treatments are a miracle for infected patients and should be widely available to people at an affordable cost — but they are a second line of defense. Vaccines are a miracle for everyone, they can help prevent people from being infected, and are widely available at no cost to the public. Keeping communities healthy by preventing illness should be a primary goal for any public health officer. Let’s keep encouraging each other to help our communities by wearing masks, washing hands, getting tested, and getting vaccinated.

Kenneth J. Stanley, MD, MBA, is board certified in family medicine and works as an emergency physician in rural Texas. He is also a volunteer for the Houston Health Department and a member of the Advisory Board for the Energy Industries Council.