An Epidemiologist on 'Contagion': This Will Almost Certainly Occur

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Despite some disappointments, Contagion hits much more than it misses. The science is uncannily true, with rare exceptions.

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When I came of age in medicine -- I'm a public health physician, scientist, and student of emerging infectious diseases -- infectious disease threats seemed to be on the wane. New vaccines, a seemingly endless stream of new antibiotics, antiviral agents, and improvements in public health and sanitation meant that, at least in the developed world, infectious pathogens were behind us. Medical leaders spoke seriously of the "conquest of infectious diseases."

It wasn't long, of course, before that folly was exposed. HIV; a mysterious pneumonia killing American Legion members in Philadelphia; Ebola, Marburg, and Hantaviruses; SARS; anthrax by mail -- these and others reminded us not to drop our guard.

When public health, like public security, is doing its job well, nothing happens, and this invisibility undermines its support.

Nor did the old diseases ever really go away. The forces that tend to drive the emergence of new diseases -- rapid global travel and migration of human and animal populations, a complex and interconnected worldwide food chain, to name only two -- have only accelerated.

Contagion hits these points with near-documentary accuracy and precision. Like SARS, the fictional pathogen in the film begins in Asia and travels rapidly by plane to other parts of the world. Effectively intertwining different individual and public health perspectives starting with Gwyneth Paltrow's opening cough, the film shows us both the worried ill and the worried well in her family members and co-workers.

Of particular interest to me were the viewpoints of the public health officials (Laurence Fishburne's CDC official, Kate Winslet's EIS officer, Marion Cotillard's WHO epidemiologist) faced suddenly with a clearly worrisome situation and working to hold back panic and deal with the uncertainty that is inherent at the start -- and to some extent throughout -- any outbreak. Was this a false alarm? Bioterrorism? What was causing it? How fast would it spread? How was it spread? At the beginning of the SARS outbreak, in 2003, it was not even clear if the agent was bacterial or viral. Reports from Mexico at the beginning of the 2009 H1N1 pandemic pegged the mortality rate at four percent -- staggeringly high for influenza. The need to make decisions in the face of so many unknowns is perhaps the most difficult aspect of public health (medicine too).

Other perspectives include the research scientist (Dr. Ally Hextail), sympathetically and beautifully portrayed by Jennifer Ehle, working tirelessly to develop the vaccine. Another virologist, the rumpled academic played by Elliott Gould (named Ian Sussman no doubt as a paean to real-life Columbia scientist Ian Lipkin, who writes today about being a consultant on the film) ignores rules and makes a breakthrough.

Despite -- or maybe because of -- how close the story was to my own work life, it seemed less entertaining and dramatic than it might have. Ticking off important teaching points like bullets in a slide presentation (human-wildlife interface -- check; handwashing -- check; deforestation -- check; conflict between professional and personal roles -- check; R0, an epidemiology 101 concept -- check) the film tries to cover too much, and at times does so at the expense of depth. Of course, cinematic license is a necessity if an audience is to want to actually see the movie, but too often single individuals serve as proxies for many. (Even in the animal roles: I chuckled when a single surviving monkey represented the success of a vaccine candidate). The filmmakers gave short shrift, I think, to the role of state and local public health specialists, who in reality would be the front line of the battle. Some might question the degree of social disruption depicted in Contagion, but one doesn't have to look much further than the aftermath of Katrina (definite, conscious echoes here) to believe it.

Finally, a disappointment to me was that the lone representative of the unofficial sector. Jude Law's blogger, (Alan Krumwiede) though at times ambiguous, turns out to be a nefarious opportunist. In real life, this sector includes organizations ranging from Medecins sans Frontieres, HealthMap, Flutrackers, to the news media, parent and provider groups, and others who play important and responsible roles. I direct an organization, the Program for Monitoring Emerging Diseases (ProMED), that detects outbreaks rapidly through careful analysis of unofficial sources and reports them widely and transparently. Our efforts led to the early recognition of the SARS outbreak, ahead of official notifications.

Despite these disappointments, Contagion hits much more often than it misses. The science is uncannily true, with rare exceptions. An epidemic like the one described in the film will almost certainly occur, though we can't predict the details. The notion that an agent like Nipah virus, a pathogen shared by bats, pigs, and humans and presumably the model for the virus in the movie, will break out of its niche and cause widespread disease is very believable.

It is easy to forget about public health and the threat of emerging infectious diseases. Despite millions of cases and hundreds of thousands of deaths worldwide, many saw the H1N1 pandemic as a dud. When public health, like public security, is doing its job well, nothing happens, and this invisibility undermines its support. At a time when public health expenditures can, in all seriousness, be called "discretionary" by politicians arguing for deficit reduction at the expense of public health, we need to be anything but complacent.

Image: Warner Bros.

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Dr. Larry Madoff is director of the Division of Epidemiology and Immunization at the Massachusetts Department of Public Health (MDPH) and professor of medicine at the University of Massachusetts Medical School. More

Dr. Larry Madoff is director of the Division of Epidemiology and Immunization at the Massachusetts Department of Public Health (MDPH) and professor of medicine at the University of Massachusetts Medical School. He is an attending physician in the Division of Infectious Diseases and Immunology at University of Massachusetts Memorial Medical Center and Associate Director of Infection Control.

He is a graduate of Yale College and Tufts University School of Medicine. He trained in Internal Medicine at New York Hospital-Cornell and received his Infectious Disease Fellowship training at the Brigham and Women's Hospital, Beth Israel Hospital, and the Dana-Farber Cancer Center program at Harvard Medical School. From 1989 until 2008, he was on the faculty of Harvard Medical School where he performed research on bacterial pathogenesis and vaccine design at the Channing Laboratory. He was an attending physician on the infectious disease service at Brigham and Women's Hospital and director of the Global Travel Health Clinic there.

Since 2002, Dr. Madoff has served as editor of ProMED (the program for Monitoring Emerging Diseases), an Internet-based emerging disease surveillance system with over 55,000 subscribers. He is a fellow of the American College of Physicians and the Infectious Disease Society of America and a member of the American Society of Microbiology, the Massachusetts Infection Disease Society, and the Massachusetts Medical Society.
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