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Contagion:  Public Health’s “Top Gun.”

Commentary by Eric Toner, Anita Cicero, Amesh Adalja, and Tom Inglesby

                  
 See also
: Video of Tom Inglesby 's comments on the importance of Contagion. Watch now.

               
Contagion
,
the just released film by director Steven Soderbergh, traces a flu-like virus as it jumps from animals to humans, creating a deadly pandemic. Contagion is unique in that it has earned acclaim from both movie critics and members of the scientific community, a group that often criticizes Hollywood for producing unrealistic movies about lethal viruses. While there were some scenes of social disintegration and violence that seemed unrealistic, the storyline actually follows rules of science and epidemic disease. As a result, Mr. Soderbergh has, in large part, met his goal of making Contagion “ultrarealistic” by seeking the very close counsel of scientists and public health leaders including Dr. W. Ian Lipkin of  Columbia University and Laurie Garrett of the Council on Foreign Relations.   

Given its vivid depiction of an epidemic catastrophe, Contagion should be mandatory viewing for those with the job of preparing the country for this crisis, as well as for members of the public who are invested in the success of such efforts. As a surrogate for a real pandemic, it could help lend energy to the country’s public health preparedness efforts.  

Contagion should give a much-needed shot in the arm to the public image of public health, just as Top Gun did for the military in 1986. In the year following that movie, Navy recruitment figures saw a spike of 16,000, and enlistment for naval aviators jumped 500%.1,2 It would be wonderful if this movie similarly motivates young people to seek careers in Public Health, but in any event, the movie powerfully demonstrates the rasion d’être of our public health infrastructure and shines an overdue spotlight on the national, state, and local heroes who devote their professional lives to detecting disease and protecting the public from outbreaks. With Gwyneth Paltrow as a compelling poster child for the need for strong public health capabilities, we should seize this moment to have a lively public dialogue about what we expect—and what we are willing to pay for—from our public health institutions.

The film makes visible a number of challenges we would confront in a real epidemic.

We Need the Ability to Rapidly Produce New Medicines and Vaccines

In Contagion, the pathogen is a virus for which there is no vaccine. In a future real epidemic as well, a new pathogen may not be susceptible to any known medicine or prevented by any known vaccine. The ability to rapidly determine which compounds (licensed or in development) may be active against a new pathogen will be essential. For a new pathogen, the research community must be able to rapidly screen compounds for efficacy and move to testing them in animals and humans as rapidly as possible. The systems to support such animal and clinical trials during a crisis have to be established ahead of time. Vaccine development would be of extraordinary importance in a new epidemic. It would be probably the single most important tool for stopping the spread of the disease.  

If an epidemic caused by a novel pathogen were to appear tomorrow, it would almost certainly take us longer to develop, test, and mass produce vaccine than the 6 months depicted in the movie. USG efforts to develop novel vaccines and medicines for infectious disease threats have been underfunded and have moved too slowly. Those efforts need to be reinvigorated, with clear priorities, explicit timelines, stated budget requirements, and plans to move products expeditiously through the pipeline. The country’s leading biopharma companies for the most part are not involved in the USG’s efforts to make vaccines and medicines for infectious disease threats. The USG must find ways to more effectively engage industry in this important undertaking. 

We Lack the Tools Necessary to Diagnose the Infected

In the movie, Matt Damon’s character helplessly asks a doctor about his wife’s death: “What happened to her?” The doctor has no answer. Contagion depicts the challenges in characterizing a novel pathogen and how important it is to do that quickly. The sooner we understand the virus, the faster we can set the wheels in motion to develop and tests vaccines, and take actions to slow or stop its spread. 

What the movie doesn’t show, but would also be of great importance once the pathogen is identified, is the need for diagnostic tests to differentiate the infected from the uninfected. If a test were available to reliably diagnose those who are infected and rule out infection in those who are well, then medical and public health authorities could focus and prioritize their attempts to provide medicines and vaccines. People could be reassured that their cough or fever was not the lethal virus. Without a diagnostic test, anyone with an off-normal symptom will presume that s/he is infected, and others in society will presume the same. This has terrible ramifications for keeping society functioning. Although some federal money has supported basic research for new diagnostic tools, the money doesn’t seem to stay around long enough to drive new diagnostics through the development pipeline, and especially diagnostics that don’t have immediate commercial appeal. This should change. 

We Need to Face the Facts: Large Scale Quarantines Don’t Work

In the movie, the Governor of Illinois declares a statewide quarantine. It’s one thing for a person with a contagious disease to be isolated alone in a hospital room. This happens now in U.S. hospitals, and it has been shown to prevent healthcare workers from catching contagious diseases. And it may also be reasonable to tell family members of a sick person to stay home. But large-scale quarantine of people in communities or cities is something entirely different.

There is no strong evidence that a large scale quarantine would be effective in containing the spread of a viral infection. By the time it could be implemented, it’s likely that a fast moving virus would have moved on to other communities, and infected people who were incubating and didn’t appear sick would have travelled to other places. And we know from actual outbreaks in the past, when people hear that quarantine is coming, they are likely to go underground or leave an area to avoid it. Losing track of sick people can make it even harder to control the spread of disease.

Quarantines also have serious adverse health, social, and economic effects. Confining those who actually may be well with those who are sick puts the well at risk. If large numbers of people are confined, economic activity would come to a halt. The government would be obliged to provide food, water, fuel, and medicines in the area of quarantine, which would be a major logistical undertaking. What is left unspoken is the prospect that force may be required to impose and maintain a mandatory quarantine.

Leaders who could someday be in the position to declare quarantine should ask their public health advisors to show them the evidence that quarantine works and the potential cost to society. 

Give our Public Health Officials a Fighting Chance to Fight Off the Next Pandemic

Many of the heroes in Contagion are public health officials and scientists. In a real epidemic, public health officials will help provide care to the sick; identify, track and predict the course of the outbreak; and communicate with the public about ways to slow the spread of disease. Scientists will study the virus to sort out its origins and how it spreads, and will develop and test vaccines and medicines.This important preparedness work is often done behind the scenes, and many are not aware of this public health mission. Out of the public eye, preparedness work is easy to forget, and budget cuts are a constant and serious threat to a public health workforce that has already been reduced in recent years. Further proposed cuts this year would diminish this workforce even more seriously.

We hope that Contagion does precipitate a Top Gun moment for public health, and that it wakes people up to the importance of the systems and people we have in place to respond to epidemics. Contagion makes crystal clear that the public health community is our front line of protection against new epidemics of the future and that we neglect the nation’s public health system at our own peril.  

References

  1. Richard D. Parker, "The Armed Forces Needs Another Top Gun" in U.S. Naval Institute Proceedings; Dec2005, Vol. 131 Issue 12, p58

  2. David Robb, "Operation Hollywood: How the Pentagon Shapes and Censors Movies” (2004).