People infected with COVID-19 were captured in a photo this week lying on the floor in pain while waiting for antibody infusions at a treatment site set up inside the library in Jacksonville, Florida.
The image has become a vivid illustration of the huge demand for the once-neglected COVID-19 drugs in the states hit hardest by a summer surge of infections being driven by the highly contagious delta variant.
"They were moaning and obviously in a lot of pain. They were miserable," said Louie Lopez, who shot the photograph as he waited for more than two hours to receive the treatment.
Antibody treatments remain one of a handful of therapies that can blunt the worst effects of COVID-19, and they are the only option available to people with mild-to-moderate cases who aren't yet in the hospital.
They have risen in demand in states seeing a spike in infections, including Florida, Louisiana and Texas, where hospitalizations among the unvaccinated are overwhelming the health care system.
White House officials reported recently that federal shipments of the drugs increased five-fold last month to nearly 110,000 doses, with the vast majority going to states with low vaccination rates.
"They are safe, they are free, they keep people out of the hospital and help keep them alive," said Dr. Marcella Nunez-Smith, a senior adviser to the White House's COVID-19 response team.
The main drug in use is Regeneron's dual-antibody cocktail, which has been purchased in mass quantities by the U.S. government. It's the same drug former President Donald Trump received when he was hospitalized with COVID-19 last October.
The drugs are laboratory-made versions of virus-blocking antibodies that help fight off infections. The treatments help the patient by supplying concentrated doses of one or two antibodies.
The drugs are only recommended for people at the highest risk of progressing to severe COVID-19, but regulators have slowly broadened who can qualify. The list of conditions now includes older age, obesity, diabetes, heart disease, pregnancy and more than a half-dozen other issues.
With expanded eligibility and skyrocketing caseloads across the country, more people are getting the treatments.
Texas Gov. Greg Abbott, who this week tested positive for the virus and is himself receiving the treatments, said five state-run COVID-19 antibody infusion centers opened last week and that another four would open by Monday. At least 140 providers across Texas are offering the antibodies treatment, his office said.
In Florida, where more than 20,000 people a day on average are testing positive for the virus, the rising demand created a scene at the Jacksonville center that resembled an overwhelmed emergency room.
At one point, Lopez said staff brought out paper hospital gowns and covered a woman on the floor. It took more than half an hour for staff to bring out enough wheelchairs for people to sit in.
"They poured them into the wheelchairs," he said. "They were just so sick."
After the photo was published Wednesday, Florida health officials said they had increased the number of wheelchairs at the facility. They also said it is open seven days a week and has plenty of cots, as well as ambulances on standby to transfer the sickest patients to the hospital.
Florida Gov. Ron DeSantis said during a news conference Friday that the woman in the photo is fine and feeling great after the treatment.
"None of our sites are having a capacity issue," said Weesam Khoury, spokesperson for the Florida Department of Health. "We have the resources and if we need more we can quickly get them."
But she cautioned, "This is a site where people are going to be very ill."
That's why state health officials are urging patients who test positive for COVID to get the antibody treatment immediately instead of waiting until they are extremely sick, which many patients are doing.
Florida over the past week has set up about a dozen monoclonal antibody clinics typically serving 300 patients per day, with an online portal for appointments, and plans to stand up more, as DeSantis has traveled around the state to promote them.
Getting the drugs involves a number of steps.
A positive test for COVID-19 is required, which must be reviewed by a physician or health professional. They then decide whether to recommend an antibody treatment for the patient, which usually means scheduling an appointment at a local administration site.
To be effective, the drugs are supposed to be given within 10 days of initial symptoms. That's the timeframe in which they have been shown to cut rates of hospitalization and death by roughly 70%.
Medical experts agreed that the drugs should not be seen as the first line of defense against the virus or a substitute for wearing a mask and getting vaccinated.
"I see the monoclonal antibodies as a short-term bridge to get us to the point where enough people are fully vaccinated," said Dr. James Cutrell of the University of Texas Southwestern Medical Center in Dallas. "We definitely need to keep vaccinating as many people as possible."
Joyce Wachsmuth, of Eau Claire, Wisconsin, and her husband were infected with COVID-19 in January. A breast cancer survivor, she had never felt so much pain.
"I actually thought to myself if 10 days of this is what COVID people go thru, I don't know if I want to live," she said.
When doctors at the local Mayo Clinic told the 67-year-old that she and her 70-year-old husband were prime candidates for experimental drug treatment, she jumped at the opportunity.
She said she felt relief just two hours after the one-hour, drip treatment.
"It did wonders. It kept us off the hospital and off the ventilators," said Wachsmuth, who has since been vaccinated.
The federal government has been distributing monoclonal antibody drugs to the states since last winter but the treatments were underused due to lack of awareness from physicians, low interest among the public and the logistics of setting up areas to give them to patients via IV infusion.
Also, persistent testing delays meant many people didn't even get their results for seven days or longer, and clinics were focused on the upcoming vaccines or managing the winter surge of cases.
Since then, many cities have set up alternative locations to administer the drugs and offer vaccines. The treatments are free for most patients, largely because the federal government has been actively involved in securing and distributing them.
"There was less urgency at that time — the important thing was to get people vaccinated to crush the curve," said Dr. Arturo Casadevall of Johns Hopkins University. "But the delta variant has changed the equation."