This thematic review analyzes four key areas of public health and preventive medicine practice portrayed by the film 'Contagion': infectious disease transmission dynamics, the role of public health physicians, the interface between clinical practice and public health, and the role of social media in health promotion. The findings presented here promote an understanding of how the film represents these topics and illustrates the potential benefits to public health as a discipline arising from popular media depictions
Jin Hee Kim
Dalla Lana School of Public Health, University of Toronto
College of Medicine, University of Saskatchewan
Lawrence C. Loh
Dalla Lana School of Public Health, University of Toronto, and Director of Programs at The 53rd Week Ltd
Popular Media, Outbreaks, and Parallels with Key Themes in Contagion
The film Contagion, which depicts fictional events surrounding the emergence of a novel virus and its rapid worldwide spread, opened on September 9, 2011 to great fanfare, widespread advertising, and media frenzy. On opening weekend, a broad viewership in North America contributed $22.4 million in revenue to propel the movie to the number one spot at the box office.
Numerous television interviews with moviegoers demonstrated that the movie had achieved some traction in guiding people through the work of public health in outbreak and emergency situations. Other disciplines portrayed in film and television have resulted in altered public perception and expectations of real-life professionals working in those areas, such as the “CSI effect” on forensic scientists., A broad-reaching release such as Contagion similarly provided and opportunity for increased public knowledge and awareness of public health and preventive medicine practice, while also stereotyping and distorting nascent impressions of the discipline and its activities. It is thus worthwhile for public health physicians to reflect on this depiction of their specialty to identify potential changes in public perception.
This thematic review analyzes four key areas of public health and preventive medicine practice portrayed by Contagion: infectious disease transmission dynamics, the role of public health physicians, the interface between clinical practice and public health, and the role of social media in health promotion. The findings presented here promote an understanding of how the film represents these topics and illustrates the potential benefits to public health as a discipline arising from popular media depictions.
THEME 1: INFECTIOUS DISEASE DYNAMICS
“On day one, there were two people, and then four, and then 16…In three months, it’s a billion – that’s where we’re headed.”
– Jude Law (as health blogger Alan Krumwiede)
“Stop touching your face!”
– Kate Winslet (as CDC Epidemic Intelligence Service Officer Dr. Erin Mears)
While principles of infectious disease epidemiology by necessity underlie the story of any real or fictional epidemic, cinematic portrayals of outbreaks rarely mention the technical details., Characters in Contagion, however, make explicit reference to terms and concepts used in the public health practice of communicable disease control. These filmmaking decisions drive the plot and characterize the epidemic, while also providing information on infectious diseases and their control.
The basic reproductive number “R0” is prominently referenced in the film’s dialogue, which correctly identifies it as the number of new infections transmitted by a single infected individual. Early in the MEV-1 epidemic, Dr. Mears (Kate Winslet) explains to local health officials that ascertaining the R0 for the infection is critical to predicting its potential spread. Less overtly, Mears highlights the components of the R0 for any infection: frequency of personal contacts within a population, probability of transmission during contacts, and the duration of the infectious period.
By describing these concepts, the film lays the groundwork for viewers to connect these themes to the mitigation measures later introduced, including: quarantine (lowering contact rate) and vaccine development (lowering the probability of transmission). While reviews drew parallels to other films addressing communicable disease control such as Blindness and Outbreak, which also employed quarantine and other measures as plot devices, Contagion was unique in that it further explored why these strategies work (or fail).
Contagion also focuses on the most universal and evidence-based approach to reducing transmission: hand hygiene. The emphasis of this control measure occurs alongside the perhaps more glamorous strategies of vaccine experimentation and novel cures. This is entirely realistic and educational; in the event of a novel respiratory outbreak, hand hygiene would be the chief infection control strategy messaged to the public. When Dr. Mears scolds her support staff in the film (“Stop touching your face!”) and various Centers for Disease Control (CDC) staff are seen fastidiously applying alcohol gels to their hands, they are communicating a valuable public health message to audiences, a message as memorable as the dramatic symptoms of MEV-1.
Popular media assessment of the potential impact of these realistic portrayal of disease transmission was mixed, with some outlets pointing out that existing hand hygiene messages are already largely ignored and that the message that “other loved ones” are actually potential disease carriers would not be well-received.  However, other outlets were more optimistic, highlighting the newfound awareness of celebrities from the movie, and suggesting that Contagion was “a 105-minute public service announcement with a simple message: Wash your hands. Often.” 
THEME 2: ROLE OF THE PUBLIC HEALTH PHYSICIANS
“I’d rather the news story be that we overreacted than have people dying
because we didn’t do enough.”
– Laurence Fishburne (as Dr. Ellis Cheever)
The film addresses the role of the public health physician early on, as Dr. Ellis Cheever (Laurence Fishburne) passes one of the service staff in the CDC parking lot. The staff member wonders if his son may have attention deficit disorder, and requests Dr. Cheever’s advice. Cheever responds “I’m not that kind of doctor,” and promises to refer the child on to a colleague.
As the outbreak investigation ramps up, two physician epidemiologists lead field investigations, demonstrating the role of public health physicians as experts in data analysis, risk communication, and knowledge transfer. One scene also captures the highly political nature of the job, with resistant local officials voicing economic concerns and referencing public outcry over the perceived pandemic influenza H1N1 overreaction.
Contagion also illustrates the critical balance between population health protection and personal privacy. Dr. Mears takes an exposure history from the husband of the index case, and during the interview, inadvertently divulges that the index case had an extramarital dalliance prior to her untimely death.
Media relations also figure prominently in the movie. One scene involves Dr. Cheever at a press conference, providing an overview of the outbreak and discussing control measures such as hand hygiene. He also responds to insinuations that the MEV-1 outbreak is “another H1N1 overreaction.” A later television interview has a different outcome; Dr. Cheever’s reluctance to provide the number of deaths results in a media catastrophe when the conspiracy theorist Alan Krumwiede (Jude Law) correctly accuses him of preferentially informing loved ones on the severity of the outbreak prior to the public announcement.
Contagion generally portrays the physicians as selfless and caring, but with human failings. In one dramatic field hospital scene, a dying Dr. Mears offers her jacket to a neighbouring patient suffering from rigors. In contrast, Dr. Cheever’s decision to divulge confidential information reveals his fallibility. When confronted, he states: “I did it because I have loved ones, and I would do it again in a heartbeat.” A later scene shows him immunizing his service staff’s son in lieu of taking the immunization himself. Portraying such intensely personal conflicts allows the audience to find common ground with public health physicians, who often do not share a similar connection to individuals as those in traditional clinical practice.
THEME 3: INTERFACE BETWEEN CLINICAL PRACTICE AND PUBLIC HEALTH
Public health is often challenged to demonstrate its relevance to the people it serves. Some of the most common opportunities for public health to market its relevance arise through specific educational and clinical occurrences. Contagion provides no shortage of memorable scenes exploring such avenues.
As one of the top ten greatest public health achievements, identified by the CDCvaccines represent a significant point of linkage between individual patients and public health. The movie follows the chain of vaccine development from bench research to administration to individual patients, demonstrating to viewers the role of public health in research and policy. Similarly, popular scepticism and the anti-vaccine movement are other clinical considerations with significant connections to public health practice that are heavily explored by the movie.
Another interface between public health and clinical practice is the role of government agencies in disasters and emergencies. Patients do not often consider who administers a health care system until it begins to fail. Contagion cinematically reinforces this link through scenes involving overcrowded waiting rooms and field hospitals, mass graves, and immunization centres.
Communicable diseases – both the common and the rare – represent another intersection of public health priorities and individual patient care. The film strengthens this point with references to a wide spectrum of diseases which require public health action. The fear of an unknown disease weighs heavily throughout the film, thrusting public health officials into action, but some scenes focus on the medical care of MEV-1 patients and reference societal perceptions about the common cold. As much as public health needs to be informed by medical care of the ill, the control of communicable diseases provide tangible opportunities for the field to connect with the minds of individual patients.
Public health generally fares poorly at promoting its work. Contagion reminds us to be aware of the linkages between certain everyday clinical interventions and public health. At the same time, scenes from the movie depicting these linkages will also draw public attention to the public health basis of these activities. Overall effects on audience perception remain to be seen, and public health physicians should consider how to take advantage of potential changes in the population’s interest and understanding.
THEME 4: SOCIAL MEDIA AND PUBLIC HEALTH
“If I could throw your computer into jail I would.”
– Enrico Colantoni (as U.S. government agent Dennis French)
Another theme front and centre in Contagion is social media as a platform for magnifying and hastening the spread of sensational messages. Rejected by mainstream print media, blogger Krumwiede amasses an online following to whom he promotes an alternative treatment (Forsythia) while spreading dire warnings about the vaccine. The viewer inevitably links his activities with a riot in a community pharmacy over Forsythia rationing. In another example of online information spread, Facebook is identified as having propagated Dr. Cheever’s breach of confidence, resulting in widespread revelation and legal consequences.
Contagion illustrates the internet’s ubiquity and the rise of social media, while linking these phenomena to the personal contexts in which they exist – Krumwiede is depicted as exploiting his newfound influence to acquire investor interest in his activities, while news arising from Cheever’s breach spreads out of control online. Both examples demonstrate the power of social media to reach the masses and potentiate action or behaviour change; both also show the unpredictable and uncontrollable nature of such communications.
While the movie depicted the reliance of public health officials on traditional media outlets, a rapidly changing event of such magnitude is precisely the kind that requires the instantaneous information transfer that social media facilitates. Many public health organizations function on outdated information technology systems, with social media websites frequently excluded from communications plans and even blocked to employee access. In many ways, it reflects a denial that such technologies are increasingly integral to today’s society, with this shift in mass communications reflecting possible changes in the populations they serve.
As social media and information technology continues to evolve, public health institutions will need to find ways to engage their communities through these new modalities and remain attentive to emerging research on online behaviours. In Contagion, a government official’s retort to Krumwiede, “If I could throw your computer into jail I would,” is especially telling – attempts to control the technology rather than trying to understand the technology’s users are probably misguided and likely to fail.
Overall, Contagion explores key public health concepts, achievements and messages in the midst of a novel outbreak, and portrays dilemmas faced by public health physicians who straddle the worlds of population and clinical medicine. Contagion promotes an understanding of modern public health practice in a world of dense connectivity and rapid advances in telecommunications. More than tools for modern living, these developments are changing the way we interact in our social environments.
Many of the themes identified in Contagion have been observed in recent outbreaks of notable scale, including the 2015 Ebola outbreak in West Africa and the 2016 Zika virus outbreak in Latin America, current as of this publication. During Ebola in particular, themes around social media information and misinformation was demonstrated by YouTube videos that ranged from comedy to detailing conspiracy theories; health behaviour messaging and the role of public health physicians was observed in press releases and communications (e.g. to encourage changes to burial practices in West Africa); and linkages between front line services and public health were made real in preparations and responses to suspect Ebola cases both in West Africa and in high income settings.
During novel outbreaks, public health physicians would thus do well to recall Contagion, and use elements of the movie’s themes together with evidence-based strategies to consider potential responses, inform public health efforts, and engage the public.
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