Thursday, December 1, 2011

Dining With Doctors: Perspectives on the Movie Contagion

Four ECBC microbiologists gathered after hours recently to view Contagion and offer their perspectives on the film’s portrayal of a lethal, fictional pandemic. The R&T Connection was invited to listen in on the discussion. Spoiler Alert: If you’re intending to watch the movie, you may want to delay reading this discussion.
Participants included Peter Emanuel, Ph.D., BioSciences division chief; Mary Wade, Ph.D., BioDefense branch chief; Calvin Chue, Ph.D.; and Jennifer Sekowski, Ph.D.
Emanuel: To start, it struck me that the film Contagion was drawing on events from the 2009/2010 H1N1 pandemic. I remember being at the White House Office of Science & Technology Policy when the president's Science Advisor was called over to help determine our path forward. It started in April and by summer we were meeting daily - sometimes late into the night. The government spent a lot of money on a vaccine, closed schools, and the public health officials did a lot of messaging about social distancing and vaccine safety. When the vaccine took longer than promised to manufacture and the H1N1 turned out to be less deadly than expected, the public perception was that the federal government had wasted money. This movie showed what could have happened if the H1N1 virus had been as deadly as it appeared in April 2009. Back in April, all we knew was that it was spreading fast in Mexico and we learned soon after that it was targeting young people.
Sekowski: Typically, flu infects people that are over 65 years of age. Young people tend to be the least demographically infected. The last time that happened was in 1918 with the Spanish flu pandemic. That killed somewhere between 50 and 100 million people.
Emanuel: Yes, I liked that scene where Kate Winslet talks about the infectivity calculation. I remember we were desperate to get data to accurately calculate that value. WHO [World Health Organization] and CDC [Centers for Disease Control] had little data from Mexico early on and we knew later about the preference for young people. Then there was an outbreak at a grade school in New York City and that created a high emotional tempo. In the real world, these events slowly roll out over weeks, but in a movie the director paces them so months can pass in a matter of minutes. It’s easy to play Monday night quarterback but, had we waited until a few months into the spread of H1N1, and the virus had proved deadly, that hesitation would have been a disaster.
Wade: In the movie, Dr. Ellis Cheever from the Centers for Disease Control and Prevention [played by Laurence Fishburne] stated that he would rather be overprotective than make a mistake and risk the lives of millions of people.
Emanuel: Yes, I was so glad that he said that. That’s what HHS [Health and Human Services] Secretary Sebelius said as well. The media tends to want to over-sensationalize perceived missteps of the government, but we felt with H1N1 that we needed to take extreme care and prepare for the worst.
Wade: One thing that I thought was inaccurate about the movie is that researchers seemed to be working alone whereas we would be working in teams. Dr. Cheever and the epidemiologist, for example, were working alone rather than with a partner in the labs.
Sekowski: Yes, the labs were very quiet. There was one post-doc and one PI [principal investigator].
Chue: A real CDC lab could have 60 people.
Emanuel: Yes, they showed the character Ian Sussman working alone when he disobeyed CDC orders to destroy his samples. He sent the other scientist home and worked alone on the infected samples. Hollywood makes that kind of reckless behavior okay because Sussman solved the problem. But what if he hadn’t solved the problem?
Sekowski: He could have infected himself.
Emanuel: He was working in the middle of New York City –
Sekowski: – which wasn’t infected at the time –
Wade: – in a university lab, all alone, in the middle of the night, with a virus that had no known cure and high infectivity. From a security perspective, it was disturbing that Hollywood trivialized that as scientific bravado. That’s both a safety and security violation.
Emanuel: It’s interesting that in the end only the Laurence Fishburne character is punished with a congressional inquiry [for warning his wife], while others who significantly violated rules were given a pass. It’s also interesting that Hollywood tends to portray government scientists as either lone wolfs or dunderheads, but that’s a whole different conversation.
Wade: Speaking of characters who broke the rules, was the assumption that the vaccine clinical trial in humans occurs when CDC scientist Dr. Ally Hextall secretly injects herself with the live virus, then tests herself by visiting her father, who is severely ill with the virus?
Sekowski: Yes, and the film glosses over that a bit. She visits her father, doesn’t get ill, and assumes that the vaccine is effective.
Emanuel: Yes, she injects herself with one dose, waits just a couple hours to let the vaccine take effect, catches an episode of Dancing with the Stars, and then goes to kiss her sick dad. That must have been some adjuvant [an agent included in vaccines to boost the immune system]. Okay, I’m joking. But the timeframe was very compressed and this is not a realistic scene.
Chue: Well, the Jude Law character does get in trouble too, but it was for insider trading, right? I think Jude Law [who plays a freelance blogger who falsely claims to have discovered a homeopathic cure] was supposed to epitomize the counter culture who distrusts the government and science. A big part of that is the lack of scientific knowledge. If you don’t understand something, you distrust it.
Sekowski: This is how conspiracy theories start.
Emanuel: In terms of realism, I believe the labs and the lobby were actually shot at the CDC. However, most of the office shots were from a different location. You can tell that because the skyline was different from what you would see at the CDC. You would see Emory University.
Chue: The movie is fairly realistic in part because of Dr. Ian Lipkin, the Columbia University Mailman School of Public Health infectious disease expert who served as the movie’s technical adviser, and Stuart Nichol, chief of the Viral Special Pathogens Branch of the Centers for Disease Control and Prevention, who also served as a consultant for the film.
Emanuel: The Obama administration wrote two reports on H1N1 that made a series of recommendations. Those recommendations were addressed in the movie. One was the ability to more rapidly isolate the seed stock.
Sekowski: You know, I was impressed that the movie addressed the fact that they were having difficulty growing and isolating the virus. That was a detail that I didn’t expect the film makers to pick up.
Emanuel: The second recommendation was the need to rapidly manufacture the vaccine. There is a massive initiative currently called the MCMI [medical countermeasures initiative] to build a rapid, flexible and agile capability to make vaccines in a fraction of the time we currently need. Without getting into too many details, I was glad the film recognized these two recommendations: to rapidly isolate seed stock and make vaccines.
Sekowski: They also looked at the need to set up PODs [points of distribution] to vaccinate hundreds of millions of people. The birthday lottery idea was very accurate. The big ethical issue that emerged with H1N1 was who gets the vaccine first? Who are the prioritized groups? The film didn’t gloss over this issue, unlike in the film Outbreak, in which everyone magically is vaccinated and survives. In Contagion, Gwyneth Paltrow and Kate Winslet end up in body bags. [Paltrow plays Beth Emhoff, the person who spreads the disease from Hong Kong to Chicago and back home to Minneapolis. Winslet plays Dr. Erin Mears, a CDC epidemic intelligence service officer.]
Chue: Outbreak was the feel-good version.
Wade: Another element that seems unrealistic is shown in the end scenes when we see that an infected bat that drops a piece of fruit activates the spread of this virus, which they termed MEV-1. That happened too quickly.
Emanuel: I think they were just trying to demonstrate how a pandemic might start.
Sekowski: It was an artistic interpretation of recombination, which does not happen in 30 seconds. Bat eats fruit, pig eats fruit, boom … Contagion!
Emanuel: The movie assumes that we have a scientific capability to rapidly characterize a new pathogen, identify therapeutic targets, and translate that into an effective countermeasure in one fluid pipeline. The fact is that this capability is still in its infancy. Because Hollywood required the concept to complete their story line, they portrayed it as a robust capability. We really don’t have a diagnostic pipeline like this – we have the beginnings of that, but it’s being impacted by programmatic cuts.
Chue: An example of the ultimate failure of the system is HIV. It’s not super infectious. Scientists all thought that if we throw enough money at it, we’ll cure it. But here it is 30 years later, and we haven’t developed a cure. It’s still at the basic research step, we don’t have a workable vaccine, and we still don’t really understand the virus. Nature doesn’t necessarily cooperate with us.
Emanuel: Mary [Wade], you’re in charge of a rapid characterization pipeline and you really work with Dr. Ian Sussman (Dr. Ian Lipkin in real life). You might be called upon in a situation like this. You built this capability and at the very moment that you were about to become operational, your budget was reduced 50 percent and you had to let people go. How do you build this intellectual capability with shifting funding?
Sekowski: That’s a good point. You can’t just invent experts when you need them. You need to build the capability, build the expertise, be a well-oiled machine well before a pandemic would occur. It’s expensive, but a rapid response capability is worth the money.
Wade:  You can’t make this capability on demand. On another note, I’m not sure that the movie really addressed the role of the local hospitals and local health departments. They would generally be involved first before the CDC. The response in general was minimized – from the local response to the number of people in the lab.
Chue: Supportive care is another issue. It’s odd that the nursing staff would unexpectedly be on strike and stay on strike during a major crisis.
Sekowski: The mortality rate in Contagion was 25% at its worst, so supportive care was obviously effective, but the movie made it appear as though everyone were dying.
Wade: They seemed to just store everyone in a gym or stadium.
Emanuel: The number of respirators in this country is really limited, as is our ability to conduct massive supportive care. If large numbers of people were to get sick, the quality of care would drop dramatically, except for the very wealthy. That part was realistic.
Chue: There are ways we could mitigate that, such as by having a surge capacity, training additional personnel and identifying pre-equipped sites like convention centers and stadiums to be available to hold beds. Volunteers could help set everything up. We have some sites identified on a local level but not on a national level.
Emanuel [laughing]: In Harford County, the mall is always used for the drills. If that is where they pick, then I have dibs on a spot I staked out in the men’s department at Macy’s.
Sekowski: The time course that the movie implied for the development of the pathogen was completely unrealistic.
Emanuel: I think it was entirely plausible, but certain aspects were simplified for the sake of the movie, including the time course. A natural outbreak that gets out of control is far more likely than an overt biowarfare attack.
Chue: There have always been emerging diseases. The problem is that global travel allows emerging diseases to spread much more rapidly.
Sekowski: A natural outbreak that jumps species as in Contagion from the bat to the pig to the human is entirely possible.
Emanuel: I wouldn't be surprised if we see this during our lifetime.
Chue: Farming practices in Southeast Asia would facilitate this kind of outbreak. Here we have feed lots and separation of animals. It’s usually small farmers with a chicken house above the pigs.
Emanuel: If you’re trying to feed 6-7 billion people, you’re cramped for space and you’re commingling your animal stocks, you’re going to see this happen. With the globalization of travel and commerce, you’re going to see some kind of massive pandemic within the next 20 years. H1N1 didn’t manifest itself in the way we feared, thank goodness. The tipping point is a fine line between overreaction and devastation.
Wade: In the movie, Gwyneth Paltrow was patient zero – she contracted the virus after shaking hands with the chef after he handled the raw pork and didn’t wash his hands. The chef died too, along with everyone Paltrow came into contact with at the casino.
Chue: A good question is what is ECBC doing to help avoid this kind of situation? We are a rapid response pipeline. In real life, the CDC could be on the phone with us almost immediately, and we would be shipping samples back and forth.
Wade: The rapid characterization pipeline that allowed Paltrow to point at a screen and say, “Here’s what happened” is exactly what ECBC’s BioDefense team is doing. The problem is that without consistent funding to support our scientists, we can’t fully realize the capability portrayed in the film.
Sekowski: You’re setting up the expectation with the public that we have this capability. It is possible, but only with stable, dedicated funding.
Emanuel: The filmmakers are creating the expectation that the politicians aren’t fulfilling. This is easily fixed. We’re so close.
Sekowski: We have the technology, the expertise, and the infrastructure. But we need the support to maintain the capability.
Chue: ECBC is a complete lifecycle pipeline for unknown characterization. Edgewood is in a strategic location; no other base that does this kind of work can receive samples by major highway, water way, rail line, fixed and rotary aircraft. We’re the only military base in the country that can do this.
Emanuel: We can take any sample, prepare it, sequence, analyze and characterize it. We can receive mixed samples that others can't. Still it’s frustrating because we’re ready to contribute, but we’re limited because of the lack of consistent funding.

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