The photo is startling and heart-wrenching. One woman lies in the middle of the floor, a translucent blue poncho draped over her tank top, her face pressed against the carpet. Another woman is on the floor nearby, curled up with her back to the wall. “Moaning, crying, unable to move,” the accompanying Reddit post says, describing sick people waiting hours to receive an experimental treatment. The picture was taken in mid-August, in a library in downtown Jacksonville, Florida, where COVID-19 patients waited for monoclonal antibody treatments.
And from Tampa, a video shows car after car lined up as people waited for the same treatment at a pop-up site in the middle of an otherwise empty field—even as plentiful vaccination sites in the area offered walk-in shots.
What is this treatment, and why are people lining up for it instead of vaccines? The answer to the latter, at least, isn’t just about the science. As with so much else in the pandemic, it’s about politics.
Monoclonal antibodies, or mAbs, flood the immune system with lab-made antibodies that are especially good at neutralizing the virus. For patients in the early stages of the disease, mAbs help keep the illness mild. According to early research, they are 70 percent effective at preventing hospitalization among those who receive treatment soon after a positive test, and they’re 80 percent effective at keeping people who were exposed to the virus from being hospitalized. “And if you do go to the hospital, [they] decrease your risk of dying from the virus,” Sunil Joshi, an allergist and immunologist and president of the Duval County Medical Society Foundation, told me. “So there are some huge benefits to it.”
At a briefing on Aug. 24, Anthony Fauci, the president’s chief medical adviser, said the highly effective treatment hasn’t received enough attention. “We want people out there, including physicians as well as potential patients, to realize the advantage of this very effective way of treating early infection,” Fauci said.
Quick action is key. Once a person is sick enough to be hospitalized, it may be too late for the treatment to work. “The earlier, the better,” Sam Lai, a professor of pharmacoengineering and molecular pharmaceutics at the University of North Carolina who also runs a startup working on inhaled monoclonal antibodies, told me. “If you have symptoms, get tested ASAP.” In places like Florida’s pop-up clinics, a positive test—or close contact with someone who has tested positive—is a requirement for the treatment.
Usually, the antibodies are given through hourlong intravenous infusions. They can also be administered as four shots under the skin, spaced over a few minutes, as the Florida clinics are doing it—but that is only recommended if infusions aren’t possible. Whether you receive an infusion or shots, you then have to wait for an hour to make sure you have no adverse reactions. And that’s all after waiting for an appointment or as a walk-in for a few hours. “No matter how you slice it, it’s still going to take two or three hours per person,” Lai said.
The treatment from Regeneron, a biotechnology company, is free for Americans as part of a $450 million deal with the U.S. government, although patients may be responsible for the costs of infusion. Regeneron’s cocktail itself costs about $1,250 a dose. (The COVID vaccines, which the government also pays for, are about $20 each.) Other mAbs from Eli Lilly, GlaxoSmithKline, and Vir Biotechnology have also received emergency use authorizations, but the government has not purchased these treatments to make them available for free.
About half of Regeneron’s antibody treatments have gone to Florida, Texas, Mississippi, and Alabama, which have had huge spikes in cases in recent weeks. Florida and Texas, led by governors who have frequently downplayed vaccinations and masks for all, have opened pop-up clinics and infusion sites.
In Florida, as COVID cases skyrocketed in July and August, hospitals were coming to a breaking point. State authorities unveiled a hasty plan: They would offer monoclonal antibodies at a handful of impromptu clinics in the hardest-hit areas.
The decision came so quickly that local authorities had only days to set up pop-up clinics in abandoned lots and public buildings. In Jacksonville, where 1 in 4 tests were coming back positive, officials raced to convert the lower level of the library into an impromptu clinic. They weren’t ready for the steady stream of patients who soon arrived seeking relief from COVID symptoms, and they didn’t even have time to find chairs for people waiting in line for hours—which is why several of the patients on the first day were seen lying on the ground.
“The role of monoclonal antibodies in this pandemic is increasing each day as we learn how to use them and set up more facilities for delivering them,” Arturo Casadevall, a molecular microbiologist and immunologist at the Johns Hopkins Bloomberg School of Public Health, told me in an email. “I think [that role] will increase in this pandemic as the logistical problems in delivering them to patients are solved and there is greater appreciation of their usefulness by both the public and physicians.”
That widespread appreciation is relatively new. For months, the medicine sat on shelves. This was partly because many practitioners and patients weren’t aware that it was available. And it was partly because it was so difficult to create IV infusion sites for COVID-positive patients, and the backup option of giving the treatment as shots was only approved in June. Before the pandemic, infusion centers usually served patients with cancer or autoimmune diseases. “There’s just no way any doctor can justify bringing a COVID patient to the very same facility as people who have compromised immune systems,” Lai said. Hospitals have been overwhelmed, making it difficult to offer infusions there. “There is just not the infrastructure that’s set up to dose them, and you really need a herculean effort,” Lai said.
The treatment is also not for everyone. It’s only approved for those ages 12 and up and for those who are at higher risk of developing severe illness or dying because of their age or because of conditions like diabetes, obesity, and heart disease. There’s scant evidence on how well monoclonal antibodies prevent long-term symptoms, like those associated with long COVID. And, crucially, the protection offered by these antibodies is temporary. They only work as long as they stay in your system, usually a few weeks.
“The vaccine provides more long-lasting immunity,” Joshi said. “If you rely just on the monoclonal antibody treatment, there is no long-term protection.” In a few months, he said, “you’re going to be back in the same boat, potentially.” (There is not yet clear evidence as to whether a patient with COVID who receives mAbs will have the same immunity from infection as a patient whose immune system fights off COVID without assistance. And not everyone who fights off COVID develops immunity to it.) Not to mention that for the needle-averse, vaccination is better than an hourlong infusion or four injections.
So why are people lining up for shots of the treatment and not shots to prevent COVID in the first place? There will always be some people who don’t believe they will get sick—people who think they are protected because they had COVID before or who think it’s just a mild illness. But it also has to do with leadership. Florida Gov. Ron DeSantis has frequently praised monoclonal antibodies in speeches and on Twitter, where he has promoted the treatment 36 times in the past month. In comparison, he’s tweeted about vaccines once in that time—and only for the elderly. Similarly, Florida’s COVID-19 informational website strongly focuses on mAbs, with vaccines given less prominence.
The treatment is not an alternative to vaccination; it should be a complementary part of fighting the pandemic, as it can also help those suffering from breakthrough cases, like the person who took the viral library photo. But only half of Floridians are vaccinated, and the vast majority of hospitalizations and deaths from COVID are among those not yet vaccinated, making both early treatment and prevention through measures like vaccination urgent.
In Northeast Florida, cases are slowly beginning to drop, but Joshi is worried about another surge if there’s not an increase in vaccination. “We should be in a situation where people are not requiring hospitalization, and that’s why vaccinations are so important,” he said. “The more and more people that get vaccinated, the less and less that we’re going have to deal with this over the next 12 months.”
But treatment options are important for those with breakthrough cases and those who are not yet vaccinated, experts agreed, alongside other preventative measures to slow the spread of the virus. “You really need these treatments to close the gaps and fill whatever holes that the vaccines are not covering,” Lai said. “Let’s just find a way to get through this and make sure everybody is protected.”