Revisiting “Contagion” During a Real Pandemic

March 24, 2020 (originally posted September 23, 2011)
Raymond A. Zilinskas

This article is part of World War “V”: The COVID-19 Pandemic, a collection of all CNS COVID-19-related articles.

The following article was written by Dr. Raymond A. Zilinksas, the former Director of the Chemical and Biological Weapons Nonproliferation Program at CNS. In 2011, he wrote a review of the film, Contagion, which bears a passing—yet nevertheless unsettling—resemblance to the current novel coronavirus pandemic. As one of the world’s foremost experts on infectious diseases, Dr. Zilinskas discussed what that popular movie got right in terms of epidemiology, virology, and our response to and prevention of viral outbreaks.  –CNS

Contagion: A Movie Pandemic Versus the Reality of Public Health

Can anyone resist seeing a film that simultaneously aims to be beguiling and horribly scary—and offers lessons in epidemiology and virology? I certainly could not. Never having been a film reviewer, I nonetheless want to discuss the new film Contagion from the viewpoint of someone who has for many years attempted to do his best to prevent infectious diseases of whatever etiology, nature or laboratory, from damaging our society.

Caution: major spoilers ahead.

Nature is very good at creating ever-changing threats and challenges of microbial origin that cause casualties ranging from a few people to multiple millions. Hollywood, too, is adept at creating deadly viruses—of the imaginary variety. Yet Contagion deals with a very real possibility: a global pandemic. So it is appropriate to ask whether the movie is realistic in terms of how the disease emerges, develops into a pandemic, and is, for the want of a better word, contained.

More than a dozen scientific experts helped director Steven Soderbergh make the film as realistic as possible, according to the New York Times. In fact, the movie’s fictional pandemic virus, MEV-1, is based on the very real Nipah virus, according to W. Ian Lipkin, an epidemiologist and virologist at Columbia University who was a lead technical consultant for the film. The Nipah virus suddenly and surprisingly jumped from pigs to humans in Malaysia in 1999, causing more than 100 deaths before it was controlled by quarantine.[1]

Though the Nipah outbreak may have influenced the script writers, the course of the fictional pandemic in Contagion more closely resembles that of another real-life emerging infectious disease: severe acute respiratory syndrome (SARS), which was first reported in Guangdong Province, China, in February 2003 and within a few months affected populations throughout the world. The SARS outbreak, I believe, is indicative of how future pandemics are likely to commence, develop, and, hopefully, be controlled. How does Contagion‘s MEV-1 compare?

Both SARS and the fictional MEV-1 first emerged in a remote location in China, both were carried to Hong Kong by infected persons, and both spread globally from Hong Kong via air travelers. Further, both SARS and MEV-1 viruses are spread person-to-person via airborne droplets produced by sneezes or coughs, as well as by viruses deposited on “fomites”—e.g., doorknobs, peanuts, shared utensils, and so on. The symptoms presented by Contagion‘s disease victims differ a bit from those of SARS sufferers. For MEV-1, the symptoms are cough, headache, malaise, fever, and, as a prelude to death, frothing around the mouth; SARS sufferers present with high fever, body aches, headache, mild respiratory symptoms, and, eventually, dry cough. The mortality rate for MEV-1 is 25 percent; for SARS, about 10 percent. The difference in scale between Contagion‘s fake disease and the non-fictional SARS is striking: MEV-1 leads to a pandemic that kills millions worldwide; SARS is estimated by the Centers for Disease Control and Prevention (CDC) to have sickened 8,098 people, killing 774 of them, by the end of 2003. But like MEV-1, SARS generated huge problems for health delivery and public health systems around the world; in addition, it disrupted air travel and international trade. (Unlike MEV-1, there was no military response to SARS and no collapse of civil society in the most affected areas.)

The Pandemic Plot Line

The Emhoffs—Mitch (Matt Damon), Beth (Gwyneth Paltrow), Mitch’s teenage daughter Jory, and Beth’s son Clark—are an ordinary family caught up in an extraordinary situation. We first meet Beth as she is returning home from a business trip to Hong Kong, where she was unknowingly infected by the MEV-1 virus. Coughing and tired, Beth transmits the virus to people who happen to be nearby (including an ex-lover she meets during a layover in Chicago). Once home in Minneapolis, her health declines precipitously. Four days after she contracts the virus, Beth has seizures, froths at the mouth, and dies, but not before fatally infecting her young son Clark, who further spreads the virus at his elementary school. During Beth’s autopsy (just six days after she was infected) a pathologist observes highly suspicious signs of encephalitis and sends samples of brain tissue to the CDC in Atlanta. As a precautionary measure, Mitch is placed in isolation in the hospital; his daughter Jory arrives from an out-of-state visit with her mother.

The next day, local media report that teachers and students at Clark’s school are becoming ill and dying. The school is closed. Mitch, still disease-free by Day 12, is believed to be immune to the virus, so he returns home with Jory. It is clear a horrible pandemic is under way. Since he has a natural immunity, Mitch is able to move around freely, but Jory is susceptible to MEV-1. Their existence becomes increasingly difficult as civil society collapses; grocery stores, pharmacies, and banks are looted, hospitals and schools close, and thugs roam the streets. When Mitch and Jory attempt to flee to Wisconsin, National Guard soldiers turn them back at the border because quarantine has been imposed. They return home, where they are trapped for the next 126 or so days.

Contagion‘s treatment of the Emhoffs’ ordeal is at times adequate; however, the specifics (or lack thereof) were puzzling. Where, for example, do Mitch and Jory get food for more than four months after supplies run out, and how is it that their utilities seem to work without interruption?

Though the Emhoffs’ travails make up a significant part of the film, Contagion does not really tackle the myriad aspects of society as a whole responding to a public health catastrophe—this is fiction, after all, not a documentary. Instead, the movie focuses on the activities of a few CDC and World Health Organization (WHO) professionals. There are two categories of public health professionals: investigators and researchers. Investigators travel to sites affected by the disease and have two general responsibilities: to determine how the outbreak began by identifying the index case (the first victim of the disease), and to gather data on secondary, tertiary, and subsequent cases in order to characterize the outbreak. They also work with local and state public health officials to stop the spread of the disease and try to make sure disease victims are sheltered and treated; in the movie, the investigators also end up being responsible for vaccine distribution. Ellis Cheever (Laurence Fishburne) is a department head at the CDC who oversees the work of field investigator Erin Mears (Kate Winslet). The CDC researchers are Ally Hextall (Jennifer Ehle) and David Eisenberg (Demetri Martin), and their main responsibility is to develop a vaccine against MEV-1. Lenoara Orantes (Marion Cotillard) is a WHO investigator stationed in Geneva, but the scope of her investigative work is international.

Five days after Beth is infected, the WHO and CDC receive the first indications of a serious outbreak, and Orantes briefs WHO personnel on outbreaks in several cities. The following day, Cheever briefs Mears on events in Minneapolis and dispatches her to the city to investigate. Mears contacts local officials and warns them that a serious outbreak is in the offing. She notes that the CDC does not yet know the disease’s R-naught (R₀), a real-life measure of how many new victims a disease carrier is likely to infect—the higher the R₀, the more contagious the disease. (For example, the R₀ for influenza is typically 3 or 4, while the measles R₀ is close to 10.) Also on Day 6, virus samples are sent to a famous researcher in San Francisco named Ian Sussman (Elliot Gould, playing a fictionalized version of Lipkin), and Hextall and Eisenberg start studying samples at a CDC laboratory in Atlanta. The next day, Hextall briefs Cheever on the virus’s characteristics, including that it is entirely unique, having DNA from bats and pigs, and is exceedingly dangerous to humans in terms of infectivity and virulence. Cheever orders that given the extreme danger the virus poses, it can only be researched inside Biosafety Level-4 (BSL-4) laboratories and that Sussman must therefore destroy the samples he has.

On Day 8, the CDC estimates that 85,000—256,000 people worldwide are infected with MEV-1. Orantes arrives in Hong Kong, and after a thorough investigation, concludes that Beth is the index case. The story jumps ahead now to Day 12, by which time Sussman, who defied Cheever’s order, has grown the MEV-1 virus in culture, which means the CDC can develop it into vaccines, a process that Hextall begins.

Back in Minneapolis, Mears assesses what looks like the inside of an enormous, empty stadium and tells a state health official how hospital beds should be arranged inside it. Hinting at the scale of the unfolding disaster, she congratulates her colleague on securing the facility, then tells him to “find me three more.” Two days later, Mears develops a telltale cough, dies on Day 18, and is buried in a mass grave in Minneapolis. Modeling used by the WHO shows accelerated spread of the pandemic from large cities. Estimates of victims are in the millions.

A few days later, the CDC learns that in Africa MEV-1 has mutated, giving rise to an even deadlier strain that is killing hundreds of thousands of people. Contagion shows scenes from around the world of empty streets, abandoned airports, and panicked people surrounding closed hospitals; back at the CDC, Hextall and Eisenberg have developed a candidate vaccine and begin to test it on rhesus monkeys.

By Day 29, civil authorities in Minneapolis run out of food to distribute to the local population. At the CDC lab, one of the monkeys shows signs that the trial vaccine is working, but Hextall tells Cheever it will take months to test, approve, and then synthesize large amounts of a vaccine. Ignoring protocol, Hextall injects herself with the unproven vaccine and goes to visit her sick father in the hospital. Time passes, and newscasters report that a vaccine has been found, but caution that it will be at least 90 days before the FDA approves and then manufactures the first batch. After that, it will take months before people worldwide can be vaccinated.

On Day 133, a limited amount of vaccine becomes available. To make the distribution as fair as possible, the CDC holds a televised lottery based on birthdates. Just two days later, incidents of anarchy have decreased drastically, and the pandemic is fading.

But how did the pandemic begin? A flashback shows a construction crew from Beth’s company bulldozing trees in a forest in China, bats flying out of the falling trees. One bat grabs a piece of banana, then perches on a beam in a pigpen, dropping the saliva-covered fruit, which a pig gobbles up. The pig is sold and slaughtered for food. Inside a casino restaurant’s kitchen, a chef prepares the carcass with his bare hands, stuffing something inside its mouth. Without washing his hands and still wearing his bloody apron, the chef enters the dining room and poses for a photo, holding hands with Beth. The virus’s path—from bat, to pig, to Beth, and beyond—is revealed.

Reality versus Contagion: Details Matter

There is much to appreciate about Contagion from a public health perspective. When the movie’s CDC scientists explain the nature and course of the virus, we understand; the mechanisms of person-to-person infection clearly described, and visual models demonstrating the spread of MEV-1 by day and then week are realistic and appropriately frightening. The movie depicts, graphically, the panic that grows worldwide in a way that I think reflects what actually would happen in a real-life situation. The movie dramatically portrays how a vicious pandemic could shred society: health systems are overloaded, food supplies runs out, and transportation systems collapse. All of these effects are plausible. Yet far from everything in Contagion is believable: officials take nonsensical decisions, the uses of biomedical science are unrealistic, and the portrayal of public health operations is incomplete.

Any film that deals with a complex event in only 102 minutes must by necessity compress the action and blur the details. Yet for me, the lack of precision made the film less gripping and more senseless than it might otherwise have been.

For example, the speed at which MEV-1 spreads is implausible. Just five days after the index case is infected, the WHO is already aware of a budding pandemic, and at Day 8 the CDC estimates as many as 267,000 people are infected worldwide. For a real-life comparison, SARS was first detected in Guangdong Province, China, on November 16, 2002—but not identified; nearly three months later, on February 13, 2003, it was reported to the WHO. An infected individual from Guangdong arrived at the Metropole Hotel in Hong Kong on February 22 and died about ten days later; a foreign traveler left the Metropole on February 23 and arrived by air in Hanoi, Vietnam, on the same day. Another hotel visitor left on February 24 and flew into Toronto the same day. The Hanoi case was reported to the WHO on February 28, and WHO headquarters was placed on heightened alert; a third case was diagnosed in Singapore on March 1. Yet it was not until March 22 that the WHO issued a worldwide alert about SARS; by that date, fewer than 100 people outside Guangdong had contracted SARS.

Another real-life example, influenza A(H1N1)—the so-called swine flu—spread internationally at about the same rate as SARS. Believed to have started in northern Mexico, the first case was diagnosed there on March 18, 2009, and the first US case was diagnosed on April 21. The WHO declared a public health emergency on April 25; two days later, Canada had its first case. By May 1, there were an estimated 331 cases in eleven countries. Compared to actual recent pandemics, MEV-1 spread worldwide in an impossibly short time. In a more realistic time frame, public health and other officials would have more time to prevent the disorder pictured in Contagion.

Another of the movie’s flaws is its portrayal of how public health officials operate when addressing an international catastrophe. In Contagion, just one senior CDC executive, one field investigator, and two scientists bear the brunt of responding to MEV-1; the situation at WHO is even more circumscribed. Of course, dozens of worried-looking diplomats attend meetings and public servants look at maps showing the spread of the MEV-1, but these extraneous characters never actually do anything (to be fair, no film could portray the work of so many individuals). During a real pandemic, the CDC would interact intensely with other federal agencies, with local and state health departments, and with national and intergovernmental agencies.

The method Contagion depicts for the allocation of the MEV-1 vaccine—distribution via a birthdate-based lottery—is also very odd when compared with realistic practices. No explanation is given regarding why this method was chosen and by whom (given the scale of the pandemic, was this really the most equitable way?). Further, there is no mention of how much vaccine is actually available, which means that viewers have no way to know how long the distribution process will take (though some television news footage suggests it will be months). When the first lot is drawn on Day 133 and it is not Jory’s birthdate, she laments that it will be 144 days before she can escape the confines of her house. How she came up with this figure is unexplained; the viewer is left in the dark whether she actually has a one in 364 probability to be selected the next day, a one in 363 probability then day after, and so on. In 2009, when the CDC had to address a similar situation with the distribution of limited supplies of influenza A(H1N1) vaccine, it selected a method that made sense and was widely accepted by the public: it gave preference to those most susceptible to infection and those who might suffer grave consequences from infection, such as pregnant women; the second-level preference was given to first responders, nurses, and doctors, and so on. Contagion‘s solution is more dramatic but less plausible.

How the rest of the world fares in Contagion with their vaccinations is given only the barest of mentions. What of the strain that mutated in Africa and became more deadly? Is the vaccine effective against it? We never find out.

The research and development that led to the MEV-1 vaccine is also unsatisfactory and unrealistic. No vaccine to counter either Nipah virus or SARS exists. Yet in Contagion, it took just twenty-three days for the intrepid Hextall to discover a vaccine that works on one monkey. Even more unrealistic is that this momentous feat is achieved by just two researchers, with help from a third. For a film that supposedly received sage counseling from a team of a dozen scientists, this is really fictionalized science. And it is made worse when Hextall injects herself with the unproven vaccine and visits her father. She tells him not to worry as she is testing a vaccine she developed. For anyone who knows anything about vaccine R&D, this makes absolutely no sense. First, just because a vaccine works on a single monkey does not mean that it will work automatically on humans. Second, it always takes time for the vaccine to stimulate the immunological defense system to produce an adequate level of antibody to defend against the pathogen. So between not knowing if the vaccine is effective and visiting a highly infectious individual, Hextall displays either the height of carelessness or ignorance—or both. Real-life CDC scientists are unlikely to behave so recklessly.

According to Contagion, on Day 135 the situation had markedly improved worldwide, as looting and anarchy slow and mortality rates decline. How this can possibly happen just two days after the MEV-1 vaccine has been released is left to viewers’ imaginations.

The filmmakers “were determined to make a movie … that didn’t distort reality but did convey the risks that we all face from emerging infectious diseases,” according to Lipkin, who also says it is necessary to “prepare ourselves” for (assumedly) future outbreaks. He makes the case for two worthy goals: increased funding and resources for the US public health system, and increased cooperation among agencies at the local, federal, and international levels.

Contagion vividly presents a worst-case scenario of a pandemic and the havoc it can wreak, but its portrayal of public health and emergency response systems is at best sketchy—even superficial—and, at times, questionable. Nevertheless, Contagion has educational value: it dramatizes many ethical, practical, and sociological questions that can usefully be raised and discussed in public health and medical school classes and meetings, and the movie also gives a rough idea of what the general public could expect from the public health and medical communities times of extreme crisis. In the final analysis, I found Contagion‘s portrayal of a global pandemic caused by a virulent pathogen rather gripping, but I was disappointed by its questionable depiction of vaccinology, lack of international public health developments, and shallow treatment of public health practices.

Raymond A. Zilinskasis Director of the Chemical and Biological Weapons Nonproliferation Program at the James Martin Center for Nonproliferation Studies. He thanks Dr. Robert Melton, a retired public health officer, who reviewed an earlier version of this article.