To Dr. Adit Ginde, it’s a now-familiar conundrum.
Ginde is an emergency medicine physician with UCHealth. One of his responsibilities involves working with the clinics that provide monoclonal antibody treatments to people infected with the coronavirus. And many of the patients he sees in that role have not been vaccinated against the virus.
He knows their arguments for why — the vaccines were developed really quickly, they might say; they didn’t want to take something synthetic that interacts with their immune system. But the same things could be said about the monoclonal antibodies being infused into their bodies.
When it came to the vaccines, the patients were skeptical of the scientific and regulatory processes that created them. Once infected, they were eager to get a treatment developed under the same processes.
“From my standpoint,” he said, “it’s not logical to have that approach.”
And yet this dynamic — on display in some of the most high-profile coronavirus cases in the country recently — is now crucial to Colorado’s plan to knock back the current surge of COVID hospitalizations in the state.
The number of people hospitalized with COVID in Colorado took another worrying jump Wednesday, to more than 1,500 patients. When combined with patients in the hospital for other reasons, there are now only about 75 intensive care beds available statewide, according to the Colorado Department of Public Health and Environment.
“Right now,” Scott Bookman, CDPHE’s COVID-19 incident commander, said Wednesday, “we’re in a dangerous spot.”
The Polis administration is working to create more capacity in the Colorado hospitals. But also central to its plan is to keep people out of the hospital to begin with. That means expanding the availability of monoclonal antibody treatments, which Ginde, who worked on clinical trials of the therapies at UCHealth, said are 70% to 80% effective at preventing hospitalization.
The key to the treatment is speed. They are only effective before patients get very sick, which means people who test positive for COVID need to move with determination in order to secure a treatment slot. Once people need oxygen or need to be admitted to the hospital, it’s too late. The vast majority of those being hospitalized right now — 82%, according to CDPHE — are unvaccinated.
So, will enough people in Colorado who have rejected the vaccines embrace monoclonal antibodies to make a difference? There’s reason for hope.
A tale of two COVID advances
While COVID vaccines have become the subject of remarkable political polarization, monoclonal antibodies have not. Red state governors who are generally skeptical of COVID precautions heartily endorse the treatment. In two recent high-profile cases, people who refused vaccination — the radio host Dennis Prager and NFL quarterback Aaron Rodgers — received monoclonal antibodies following their infections, according to reports.
It’s a sign of the lack of polarization around monoclonals, as doctors sometimes call them in shorthand, that there is little polling about attitudes toward them. But a CNBC poll released in September found that the unvaccinated generally favor them. When asked, 83% of unvaccinated respondents said they had no plan to get vaccinated. But only 33% said they would reject antibody therapies if infected.
Ginde said the unvaccinated patients he sees frequently have a common reason for their change in thinking about COVID therapies.
“There’s often regret that they didn’t get vaccinated in the first place,” he said. “There’s definitely a strong sentiment, when they are feeling as bad as they are, that they wish they had made different decisions.”
But there may also be deeper psychological forces at work.
Prevention vs. treatment
In some ways, there is very little difference between the COVID vaccines and the COVID monoclonal antibody treatments.
The vaccines stimulate the body’s immune system to produce antibodies that will attack the coronavirus’s spike protein when called upon. Monoclonal antibodies are essentially synthetic versions of the antibodies people would already have on board if they had been vaccinated. Given early enough in an infection, they meaningfully increase the number of virus fighters that the body can send into battle.
Both the COVID vaccines and the monoclonal antibodies build upon decades of work by researchers. They were developed under the guidance of Operation Warp Speed, the federal program intended to zip products to market as fast as possible. They were backed by large pharmaceutical companies. They both even had clinical trials at UCHealth.
And they both work, with few and rare serious side effects.
“I would say from a clinical trial standpoint they are equivalent,” Ginde said. “They’re both effective.”
Their crucial difference, from a psychological perspective, is when they are given.
The vaccines are administered when people are healthy. This means some people may have a low tolerance for risk with vaccines. The thinking goes: Why take something that might have a side effect when I’m already healthy?
Meanwhile, at this preventative stage, the risk of getting sick is only a hypothetical. Ginde said he sees this with his patients. They weren’t weighing the risk of a rare vaccine side effect against the much more common risk of serious health problems from COVID. Plan A for them was to not get COVID to begin with.
But, once infected, people may shift into a more aggressive treatment mindset.
“People start to feel more desperation about what they are willing to accept,” Ginde said.
And so the rare risks that used to weigh so heavily in their consideration now seem smaller.
Advocating a “vaccine-first” strategy
This risk calculation flip-flop is well known among researchers who study vaccine hesitancy, and it predates COVID.
Jennifer Reich, a University of Colorado Denver sociology professor, has written about how parents who reject vaccines for their kids and disapprove of pharmaceuticals in general will still seek out prescription medications when their children are sick. This isn’t evidence of hypocrisy, Reich argues. Instead, she said, it shows how people’s health care decisions fit within intertwined “individual, interactional and institutional contexts.”
There’s also an element of trust. In September, Reich wrote a piece for The Washington Post asking how people who refuse scientifically proven vaccines could turn around and embrace unproven treatments like the antiparasitic drug ivermectin.
The answer, she argued, is that government endorsement of the vaccines led people who are suspicious of government to reject them and turn toward “rogue” treatments advocated by sources they trust specifically because those sources hold themselves as being outside the mainstream.
“For people who are suspicious of mainstream scientific thought, information that appears to come from other sources often seems independent, insightful and brave,” she wrote.
In this sense, the lack of polarization around monoclonal antibodies — and, until now, the lack of a big government push to use them — worked to the treatment’s advantage.
“I do wonder about the perception of independent thinking that goes into this,” Reich wrote in an email to The Colorado Sun. “Some may believe vaccines are pushed by the government and this feels like an individual choice.”
Though Ginde, the UCHealth doctor, understands the dynamics at work, he finds them somewhat exasperating. Vaccines and monoclonal antibodies aren’t an either/or, he said. They should be part of a coherent, “vaccine-first” virus-fighting strategy: Vaccines preventing people from getting sick and monoclonals helping to speed recovery in the case of a breakthrough infection.
Though he is enthusiastic about the expansion of monoclonal antibody treatments in Colorado, Ginde said there still isn’t enough for everyone who needs it to have access. In that situation, he said, choosing to be unvaccinated is not a risk worth taking.
“It is really rolling the dice,” he said, “with one’s own health and the health of those around you.”