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Public health crises in popular media: how viral outbreak films affect the public’s health literacy
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  1. Evie Kendal
  1. Correspondence to Dr Evie Kendal, School of Medicine, Faculty of Health, Deakin University - Geelong Campus at Waurn Ponds, Geelong, Victoria 3217, Australia; evie.kendal{at}deakin.edu.au

Abstract

Infectious disease epidemics are widely recognised as a serious global threat. The need to educate the public regarding health and safety during an epidemic is particularly apparent when considering that behavioural changes can have a profound impact on disease spread. While there is a large body of literature focused on the opportunities and pitfalls of engaging mass news media during an epidemic, given the pervasiveness of popular film in modern society there is a relative lack of research regarding the potential role of fictional media in educating the public about epidemics. There is a growing collection of viral outbreak films that might serve as a source of information about epidemics for popular culture consumers that warrants critical examination. As such, this paper considers the motivating factors behind engaging preventive behaviours during a disease outbreak, and the role news and popular media may have in influencing these behaviours.

  • medical humanities
  • medical ethics/bioethics
  • film
  • public health

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Introduction

Infectious disease epidemics are widely recognised as a serious global threat.1 With increasing international travel and displacement of populations due to civil unrest and climate change, there is significant potential for diseases like influenza to spread rapidly across country borders. After the events of September 11 and the subsequent anthrax attack in the USA, a 2003 Gallup Poll discovered that 67% of Americans believed the USA would be attacked by an enemy using biological weapons within the decade.1 At a similar time a Harris Poll found that 68% of respondents thought epidemics such as Ebola and HIV/AIDS represented a ‘critical threat’ to the USA, with a further 29% seeing biological threats as ‘important’.2 Despite the fact there has been no substantial increase in bioterrorism since these events, nor any outbreak of Ebola on US soil, public fears have continued to influence government policies in related areas.3 Such beliefs have led to considerable opposition to immigrants and asylum seekers and restrictive travel policies aimed at preventing the flow of people, especially from low- and middle-income countries to developed countries. This plays into a narrative in which biosecurity is under threat from ‘outsiders’, both intentionally (through terrorism) and unintentionally (through disease spread facilitated by immigration and travel).

Throughout the Western world more generally, since the mid-1990s public policies regarding disease outbreaks have shifted from being purely health-focused to considering infectious diseases a security threat. According to Adam Kamradt-Scott,4 this ‘securitizing’ of infectious diseases in the West has particularly focused on viral pandemics, most notably influenza. In her book, Germ Wars, Melanie Armstrong5 draws an analogy between responses to potential viral pathogens and the fear of nuclear attack during the Cold War, noting that the current fear of infectious disease outbreaks is not new in society, but is manifesting differently due to a transformation of ‘human relations to disease’. She claims this has been caused by recent scientific failures to deal swiftly with outbreaks in the real world, including HIV, swine influenza and severe acute respiratory syndrome (SARS), and the increasing number of disease outbreaks and acts of bioterror depicted in fiction, naming television programmes like Alias (2001–2006) and 24 (2001–2014), and films like The Patriot (1998), as examples.5 However, fear is not the only thing that might be learnt through engaging with such fictional representations of disease threats, and this paper will explore the potential to use mass and popular media for educative benefit as well.

After disease outbreaks occur, the media is central in communicating information to the public regarding symptoms, preventive measures, treatment options, and when and where to seek help.6 The need to educate the public for health and safety is particularly apparent when considering that behavioural changes can have a profound impact during an epidemic. The 2009 H1N1 swine influenza outbreak in England is a good example of this, with population health being profoundly affected by the public’s willingness to adopt government recommendations to stay home when sick and seek remote healthcare instead of risking spreading infection to medical clinics.7 Practices like social distancing and voluntary self-quarantine are known to limit disease spread, and are among the only strategies available in the early stages of an outbreak, before pharmaceutical interventions, vaccinations or antiviral treatments have been developed or distributed.1 In a qualitative study by Teasdale and Yardley,7 general scepticism and distrust of the British government and media were found to be strong influences on citizen behaviour during the H1N1 epidemic, leading to a failure of self-diagnosis, quarantine and vaccination protocols. The authors concluded that health communication needed to consider public perceptions of the trustworthiness and safety of disease prevention strategies and information sources (p. 417).7

While there is a large body of literature focused on the opportunities and pitfalls of engaging mass news media during an epidemic, given the pervasiveness of popular film in modern society there is a relative lack of research regarding the potential role of fictional media in educating the public about epidemics. There is a growing collection of viral outbreak films that might serve as a source of information about epidemics for popular culture consumers that warrants critical examination. Given that viral epidemics are considered the ‘most feared’ communicable disease outbreaks by governments and citizens alike (p. 90),4 the failure of many members of the public to engage with simple disease avoidance strategies indicates the need for educational interventions that take into consideration public perceptions of disease risk. This paper explores the motivating factors behind engaging preventive behaviours during a disease outbreak, and the role news and popular media may have in influencing these behaviours, including through educating about disease risk and the role of epidemiologists, healthcare institutions and government authorities during a public health crisis.

Motivating preventive behaviours

During an outbreak, a number of preventive behaviours might be needed. These include using personal protective equipment (PPE), promoting hygiene practices, such as handwashing, receiving vaccinations or other prophylactic interventions, seeking treatment once infected, engaging in social distancing, restricting travel, and engaging isolation and quarantine measures.8 9 The latter three might be voluntary, such as when family members of a sick person choose to remain at home so as not to risk infecting others at school or work; or involuntary, as is the case when public buildings or airports are closed. According to Dr Stephen Redd, Director of the Office of Public Health Preparedness and Response at the Centers for Disease Control and Prevention (CDC), during an epidemic ‘voluntary self-isolation is a very important intervention’.10 As such, it is important to explore why some people choose to abide by such recommendations, even when they are not mandated by the State, while others do not, thereby potentially contributing to disease spread.

Behavioural change is one of the four pillars of the National Academy of Science’s Institute of Medicine recommendations for dealing with microbial threats to health.11 Protection Motivation Theory (PMT) is a framework in psychology that attempts to elucidate the motivations behind an individual’s health protective behaviour.1 PMT posits that the four elements that may motivate someone to alter their behaviour—to protect themselves from infection, for example—are their perceptions of the severity of the threat, their vulnerability to it, the efficacy of proposed protective behaviours and their ability to achieve these .1 In their meta-analysis of articles focused on PMT, Floyd et al 12 claim the theory contains an essential ‘cost-benefit component in which the individual weighs the cost of taking the precautionary action against the expected benefits’, noting that this first requires the individual to be made aware of the threat, the possible negative outcomes for themselves and various relevant ‘risk variables’ that impact personal susceptibility.

Given the statistics provided at the beginning of this paper, and the highly publicised outbreaks of SARS, avian influenza, swine influenza and Ebola over the past 15 years, it would be reasonable to assume most people are aware of the severity of the viral epidemic threat. 13 In fact, the strategic use of fear has proven to be an effective tool for promoting preventive behaviours among citizens aware of these outbreaks.14 As for the other three elements outlined in PMT, these can be captured by what researchers often refer to as the influence of perceived knowledge and risk perception. Importantly, such perceptions can be directly influenced by numerous sources, including both real and fictional depictions of medical science and disease. The CDC’s Porter Novelli HealthStyles survey consistently demonstrated the impact of popular media on the public’s health literacy, citing 67% of regular daytime drama viewers and 58% of regular prime-time drama viewers reporting learning something about a health condition from watching popular television in the 6 months prior to the survey, and a further 8% reporting learning from someone describing what they had viewed.15 In some cases audiences were motivated to seek medical attention or advice regarding what they had learnt, while in others possible misperceptions or inaccuracies went unchallenged.

Perceived knowledge

Perceived knowledge refers to what an individual thinks they know about a certain situation or topic, and might be quite different from their actual knowledge, objectively speaking (p. 69).6 According to Zhang et al,6 studies into perceived versus objective knowledge have found perceived knowledge to be a ‘better predictor of behavioral intention’. In other words, perception drives behaviour more readily than facts. Furthermore, most citizens are not sourcing their information from academic scholarship, but rather rely on the mass media to translate key findings into an accessible format.16 With regard to concerns about biosecurity and the threat of bioterrorism, Caduff notes that:

Newspaper stories, television reports, talk shows, computer games, thrillers, novels, tweets, blogs, and websites have contributed to the circulation and sedimentation of these alarming visions of vulnerability. Inspired, but not necessarily controlled, by experts, perceptions of biological threat are organizing reality as ‘fear and thrill’ for mass audiences, promoting a political imaginary of infinite reach that increasingly saturates public culture with uncertainty and anxiety.17

Such anxiety, and the actions it inspires, does not appear to be reduced by increasing scientific knowledge about disease outbreaks. In a recent study of health anxiety related to Ebola, researchers found that fear and engagement with preventive behaviours did not correlate with level of awareness or understanding of the true mechanisms of the virus or location of the epidemic.18 The preoccupation with infection among healthy individuals at very low risk of exposure was more to do with perceptions and how people felt about the media coverage of the 2014 African epidemic, than what they knew about Ebola. As such, merely improving the accuracy of available information about disease outbreaks is not sufficient to alter behaviour, public health professionals and other stakeholders also need to be able to alter public perceptions and attitudes. This is where popular media is in a unique position to contribute to public education, as engaging the emotions and promoting identification with characters is often a primary goal of fiction.19 As Angelo Volandes20 notes, ‘film offers a powerful and underutilised medium in which clinical vignettes come alive in their rich and textured details, both medical and non-medical’. As such, there is an opportunity to promote understanding about disease outbreaks and their impact on human populations through presenting stories of relatable characters and their struggles. As will be discussed later, the potential impact of fictional media for challenging or perpetuating scapegoating of certain minority groups during a public health crisis also warrants attention.

Risk perception

In his article ‘The plague of ideas’, Ralph Peters claims ‘ideas can now travel more swiftly than any human being–or disease’.21 One of the problems with this is that the ideas being circulated about epidemics are rarely communicated by researchers directly, potentially leading to public misinterpretation of disease risk.16 According to risk-theorist Francois Ewald,22 the concept of ‘risk’ is socially constructed, meaning the label is dependent on collective human judgement. Thus, it is unsurprising that public risk perception changes as circumstances change, including media coverage, official communications and personal experiences, with different risk management techniques also influencing how people perceive and judge a potential threat.23 Urquhart et al 23 note that risk perceptions will involve all of these elements, filtered through a lens of individual ‘values and meanings attached to whatever is under threat’. Unfortunately, throughout the history of human epidemics, this has often led to stigmatisation and scapegoating, particularly of migrants and refugees.

A number of patterns arise when considering common anxieties about infectious disease outbreaks. Caduff summarises these effectively:

They are anxieties about a borderless world and a shrinking planet, where viruses are said to know no borders. They are anxieties about industrialization, urbanization, deforestation, and an unprecedented destruction of the environment.…They are anxieties about migrant and refugee populations and the revenge of terrible afflictions, such as smallpox or tuberculosis.…Fatal strains of deadly disease are carried across national borders; the next pandemic seems no more than a plane ride away (p. 113).17

These concerns were cast in sharp relief with the panic surrounding the 2014 Ebola outbreak, illustrating a conflict between the ideals of global health and the obligations of states to protect national public health.24 Sinha and Parmet24 state it is ‘cliché to note that infectious diseases that arise in the developing world can travel to the developed world’, claiming that instead of inspiring solidarity with poorer nations, this has led to a perception that ‘those who live in the developing world are dangerous vectors of contagion needing to be kept at bay’. The public reaction to the Ebola outbreak was not unique, with these authors tracing discriminatory travel bans, immigration restrictions and public scapegoating of vulnerable populations in various historic outbreaks. This includes the HIV/AIDS crisis of the 1980s, which led to the USA prohibiting HIV-positive people from immigrating to the country, a ban that was only lifted in 2009 (p. 231).24 In both this and the more recent Ebola outbreak, Sinha and Parmet claim public officials tried to communicate accurate risk assessments to the public, who were demanding travel bans that public health scientists believed would be counterproductive in the fight to arrest the spread of disease, as it would ‘deter health workers from traveling to Africa, where help was desperately needed to stem the epidemic’ (p. 240).24 William Millard25 notes that during the Ebola outbreak, the desire to close the border against a perceived army of microbial invaders was pervasive, despite the fact the risk to the USA was ‘statistically almost negligible’. Thus risk and risk perception were not in accordance.

Comparing the national responses with the SARS epidemic of 2003, the USA engaged with more coercive controls, such as restricting freedom of movement and travel, while the UK promoted voluntary self-quarantine measures and education programmes to prevent disease spread (p. 6).13 In Canada the identities of hospital workers infected with SARS were protected, but this led to a public perception that all such employees were an infection risk, with many healthcare professionals reporting they were stigmatised and avoided.26 This is despite research showing that Canadian citizens consider healthcare professionals to hold some moral obligation to treat the sick in a pandemic scenario, within the limits of personal safety.27 Public officials in Toronto are also on record blaming the outbreak on federal immigration policy, exposing a racial bias to risk communication.27 These examples effectively demonstrate that when faced with the same real threat, perceptions of risk may greatly influence policy decisions and public behaviour.

Trust of healthcare institutions

The final factor influencing engagement with preventive behaviours to be considered here is the need for public trust in the sources of information promoting behavioural changes. A Market and Opinion Research Institute (MORI) poll in 2004 found that while 92% of respondents trusted doctors to be honest about disease risk, only 23% trusted government officials and 20% trusted journalists.28 While admitting there certainly are ‘scoundrels’ in media reporting, as in any profession, Laurie Garret29 claims that most journalists are scrupulous and strive to provide accurate information in a timely fashion, despite increasing productivity demands. Feeding into doubts about truth-telling among government representatives are rival politicians’ statements accusing the government in power of concealing information about epidemics from the public. An example can be seen in Senator Rand Paul’s accusations against the Obama administration during the Ebola outbreak of 2014, in which he claimed the virus was ‘more contagious’ than the public were being led to believe (p. 238).24 Beyond promoting misunderstandings about disease transmission, such distrust in government health officials has led to significant losses of life in some countries. Suspicion that the local government and hospital workers were deliberately killing patients with Nipah virus in Bangladesh in 2004 led to families avoiding seeking care for symptoms of infection.30 Parveen et al found that a lack of transparency about the disease, its treatment or diagnosis ‘in the context of failure of biomedical treatment’ served to alienate residents and sabotage health communication of preventive measures (p. 734).30 Since the lives of affected individuals were not saved by the medical interventions on offer at the local hospital, a conspiracy started that doctors were giving the infected lethal injections as a form of quarantine for the community (pp. 732–3).30 Similar concerns have arisen in low- and middle-income countries receiving medical aid from developed countries, especially when there is the perception that the true motivation behind the assistance being granted is self-interested protection of the population back home. As will be seen in the analysis of popular media sources later in this paper, such conspiracies are rampant in viral outbreak films, in which trust in institutions is frequently seen to be misplaced.

While governments may not be widely trusted, research indicates that certain governmental and non-governmental organisations are well-respected sources of accurate health information during an epidemic, such as the WHO and other United Nations departments, as well as the CDC. A study in China found that almost 75% of respondents trusted the CDC to efficiently and accurately detect dengue fever outbreaks, with over 86% reporting confidence in laboratory support for rapid diagnosis.31 Given the need to motivate citizens in an epidemic to engage in preventive measures to control disease spread, maintaining the credibility of the WHO and CDC is paramount.32 As such, any news or popular media portraying such organisations in a negative light may have flow-on effects for risk communication and the potential impact of health promotion messages.

The role of media

As noted in the introduction, there is significant scholarly interest in the role mainstream news media plays during an epidemic, with experts in risk communication suggesting healthcare providers and governments should strategically plan for media involvement in public health crises.33 The two forms of media of interest in this paper are news and popular culture, especially fictional films.

News media reporting

It has long been recognised that the media is an important source of health knowledge for most citizens, and that narrative framing can impact how an individual perceives the seriousness of a health threat and their personal susceptibility to the danger being reported.34 Media attention surrounding the claim the measles-mumps-rubella (MMR) vaccine was associated with the development of autism, for example, is known to have led to a significant decline in vaccine uptake, which has continued long after the claim was debunked.35 Had this claim remained in the academic literature, rather than the mainstream press, it is unlikely such an effect would have been seen. In a study of parental attitudes towards the MMR vaccine, Petts and Niemeyer36 found that ‘media reporting was frequently portrayed as a catalyst of concern and worry not only about whether to have MMR but whether previous decisions had been wise’. Despite numerous studies demonstrating the safety of the MMR vaccine, public concern has remained almost two decades after the initial scandal (p.691).35 In the case of the Ebola outbreak, Millard claims mainstream media turned the virus into ‘the movie star of pathogens…publicized and mythologized out of all proportion to its knowable characteristics’ (p. A15).25 In this instance, the media’s communication of risk was exaggerated and often scientifically inaccurate, leading to mistaken beliefs about personal risk among citizens who were safe from exposure.37

According to Benjamin Beit-Hallahmi,38 another common inaccuracy seen in media reporting of disease outbreaks is the likelihood of contracting an infectious disease if involved in the handling and disposal of human remains. While admitting that such professionals are at some risk if the disease of interest is ‘highly infectious’, he notes that ‘actual cases of contagion are rare’.38 Their rarity makes them more interesting for news reporters and thus more likely to attract media attention, but this in itself may influence risk perception among the public. With respect to the fear of decomposing bodies in general, Beit-Hallahmi38 notes that ‘the concerns expressed in the media are totally unfounded’, even in cases where a mass mortality event has led to significant public exposure to human corpses, such as after a natural disaster. However, according to PMT, such media representations could impact the adoption of preventive behaviours, by influencing individuals’ perceptions of risk severity and personal vulnerability. As Floyd et al note, ‘the perceived effectiveness (or response efficacy) of taking precautionary action is regarded as an important variable’ in PMT (p. 408).12 As such, regular exposure to cases where protective behaviours have failed to produce results is problematic from an educational perspective, exposing a key challenge in news reporting of disease outbreaks. On the one hand a sensational story is more likely to succeed in the goal of making audiences aware there is a threat, which, as noted previously, is a prerequisite for adopting protective behaviours. However, according to PMT, such reporting will simultaneously undermine the perceived effectiveness of adopting the very same protective behaviours, thus having a net negative effect on uptake.

Although there is significant potential for sensationalised or inaccurate information to be seized by journalists, Garrett’s article claims that mainstream media can also form a bridge of trust between a ‘government and the public it serves’, with news media journalists often the first voices citizens hear in a public health emergency (p. 91).29 Garrett29 notes journalists’ ability to ‘get there first’ and drive the narrative is often lamented by scientists, providing the 1995 Ebola outbreak as a prime example, in which scientists and media personnel were driven to fistfights and the rights of patients and their families were violated in pursuit of a good story. With reference to political campaign reporting, McCombs and Shaw39 claim mass media can force some aspects of news into focus while deprioritising others, in other words, engage an agenda-setting function (p. 177).39 Bernard Cohen is frequently cited as an illustration of this point: ‘The press may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about’.29 40 As public health requires cooperation between healthcare professionals, government officials and services, and the citizenry, it is important to remember mass media represents a significant information source for many people, and may even be the sole provider of health updates for some.39 As such, the representation of epidemics in news media is important; as Robert Entman41 notes, the frame used to explore a particular news event ‘determines whether most people notice and how they understand and remember a problem, as well as how they evaluate and choose to act upon it’. Hilton and Hunt42 include interpretations of disease risk and health behaviours as possible targets for the influence of such framing. Given the goal of communicating vital protective behaviours to vulnerable members of the public during an epidemic, this suggests framing can be considered a health intervention in itself, one that relies on accurate and timely news reporting.

Popular culture

Mainstream news media is not the only type of media that can communicate health information to the public, with popular culture and social media also playing a significant role. Even when the primary purpose is to entertain, the potential for popular media sources, such as television, to educate audiences has been noted by health promotion professionals.43 Social media posts are now used to track epidemics in real time,44 and has even been implicated in the spread of psychogenic illnesses itself, with young people ‘contracting’ symptoms they read about online.45 Real epidemics have inspired music, including the polio-pop movement of the 1940s and 1950s in America, and various forms of art.46 The latter is perhaps most disturbingly exemplified by the ‘Ebola-chan’ images that were widely circulated during the recent Ebola outbreak.47 Originally shared to a Japanese illustrator’s social media platform, the manga-style anthropomorphised virus went through various iterations, with its dissemination promoted by internet groups such as 4chan (p. 347).47 Marcus and Singer claim this internet meme came to influence how patients and healthcare workers affected by Ebola were perceived and treated, and caused significant distress to viewers who felt particularly threatened by the outbreak (p. 344).47 Real epidemics have also influenced plotlines within fictional novels and films, from Katherine Anne Porter’s short story, Pale Horse, Pale Rider (1939), to Stephenie Meyer’s Twilight Saga (2005–2008), and the recent British television series Downton Abbey (2010–), all of which make reference to the Spanish influenza pandemic of 1918.48

In addition, epidemics of fictional viruses feature in various stories, particularly within the horror genre. As Lauri Mullens49 notes, regardless of the genre, the representation of epidemics ‘can never be ideologically neutral’, as they necessarily ‘carry the baggage of the metaphors through which they are understood’. This is particularly important when considering the implications of depicting viral outbreaks in terms of a zombie apocalypse, due to the dehumanising effect of turning the infected into brainless monsters. Anijar et al claim that the proliferation of postapocalyptic narratives from the 20th century continued to be spurred on by the September 11 terrorist attacks in the USA in 2001, leading to a ‘wide array of cataclysmic visions’ (p. 136).2 This included a new wave of bioterrorism stories and inspired the recasting of traditional zombie horror films into epidemic-focused films. This trend has been capitalised on by health promotion campaigns, including the CDC’s award-winning ‘Zombie Preparedness’ media release, focused on educating the public on the importance of preventive behaviours during a disease outbreak.50 2Risk communication specialist, Jody Lanard, says of the campaign:

…zombies are hot in the U.S. So for heaven’s sake, let zombie movies carry the message. A movie about a disaster is a good teachable moment – a surrogate for a real disaster, which is an even better teachable moment. If the movie is gripping, the audience imagines itself in the scary situation, and temporarily becomes very interested in what they can do about it if it happened to them in real life.51

Zombie narratives have also been used to educate healthcare professionals on disease prevention methods, as seen in a 2011 article in the Journal of Clinical Nursing, which advises nurses on best practices for avoiding ‘Solanum infection’, the zombifying virus from The Zombie Survival Guide.52 The pedagogical value of popular culture for improving health knowledge and literacy among the public and health professionals is thus being coupled with an opportunity to work through certain anxieties regarding epidemics, in a non-threatening, fictional space. Mullens claims this performs a vital function in instructing audiences on the ‘appropriate’ relationship between citizens and the ‘institutions of medicine and public health’, as well as communicating some real facts about health conditions and risk (p. 5).49 While many of the plot points in a disease outbreak film may be entirely fictional, the depiction of the horrors of a mass mortality event, the need to instigate disease control measures, and the importance of investigating transmission and trying to establish ‘patient zero’ are all genuine concerns (p. 118).49

One need not look far to see evidence of the real-world impact of representations of fictional viral outbreaks. Richard Preston’s The Cobra Event (1997) famously motivated President Bill Clinton to consider the threat of a real-life bioterrorist attack, with Preston testifying before the Senate about the risk of biological weapons (p. 75).11 According to Nicholas King, Preston’s earlier non-fiction piece The Hot Zone (1995)—inspiration for the fictional film Outbreak (1995)—can be considered ‘patient zero’ for the viral outbreak paranoia and panic that gripped the USA at the time (p. 73).11 The more recent blockbuster film, Contagion (2011), is similarly implicated in perpetuating what Priscilla Wald53 classifies as the common ‘outbreak narrative’, in which a pathogen is introduced into the developed world via contact with migrants and visitors from low- and middle-income countries. Regarding this narrative trope, Sinha and Parmet claim:

Although the outbreak narrative and scientists’ warnings about EIDs [emerging infectious diseases] served to draw attention to the very real threat of infectious epidemics, they also reinforced the colonial tendency to see the non-Western world as a source of lurking danger, in addition to ancient tendencies to associate diseases with ‘the other’ (p. 235).24

These authors argue that as a result of the pervasive nature of this ‘othering’ in response to disease threat, responses to real-world outbreaks, such as Ebola and HIV, have led to public outcries to close borders and limit interactions with low- and middle-income countries, thereby further disadvantaging affected individuals in poorer nations and perpetuating misconceptions of disease transmission methods.24 As othering involves establishing one’s own group identity in opposition to that of another group,54 it makes sense that in a time of universal vulnerability, such as a pandemic, such behaviours would be displayed.

Returning to the outbreak narrative more generally, in her book Contagious, Wald notes that fictional films like Outbreak ‘did more than reflect and convey the lessons of science; they also supplied some of the most common points of reference, which influenced social transformation and disease emergence in their own right’ (p. 31).53 This film explores how military and civilian responses to a disease threat might cause global panic and contribute to disease spread. Wald goes on to claim that despite Garrett’s defence that the majority of media reporting on disease outbreaks was rapid, accurate and informative, that ‘embellishments accrued, circulating (like microbes) until they became conventions’, including drawing comparisons between the real diseases being reported and fictional outbreaks from popular films (p. 33).53

One of the more vocal critics of Hollywood’s treatment of viral epidemics is Dr Stephen Morse, an epidemiologist from Columbia University who served as a scientific consultant for the film Outbreak. Noting a key fact about Ebola transmission is the need for sustained close contact with an infected individual (thereby leading to a much lower reproduction number for this virus compared with others like smallpox, pertussis or rubella, and somewhat lower than influenza, SARS or HIV), Morse claims public confusion about how contagious Ebola really is ‘is partially attributable’ to the film Outbreak (p. A17).25 While the ‘Motaba virus’ of the movie is not literally Ebola, the similarities of the two haemorrhagic fevers are such that facts about the one may be conflated with fictions about the other in the minds of lay audiences. Most notably for Morse, this includes that Motaba somehow ‘magically’ mutates to become airborne, something American audiences then believed could happen to Ebola.25 As will be demonstrated in the next section, such mutations are common for fictional viruses, potentially impacting audience beliefs about virus mutation patterns in nature.

Viral outbreak films

As noted in earlier sections, disease outbreaks caused by viruses are typically feared more than those caused by other contagions. Kamradt-Scott suggests this is partially due to familiarity with viral infections, including influenza and HIV, and the increased visibility of such infections through global health warnings and national pandemic planning strategies (p. 94).4 In order to explore dominant narrative tropes in viral outbreak films, a sample was selected using the dedicated Wikipedia page ‘Films about viral outbreaks’, cross-referenced where necessary with the Internet Movie Database entry for apocalyptic/epidemic/pandemic/disaster films.55 56 These databases were used solely on the grounds that they are the most likely sources to be searched by a lay member of the public seeking a film on this topic. Furthermore, the lack of comprehensive indexing of films containing viral pandemic plots made drawing a systematic sample impractical. Films were included if they were released in the English language between 1995 and 2015.i This yielded a sample of 20 feature-length films (or franchises) for analysis, of which only Fedz (2013) was not obtainable as it was not released in Australia. Films were reviewed in their entirety and simply coded for content that included references to preventive behaviours, viral mutations, travel implications, the presence of a conspiracy theory subplot, and whether or not an epidemiologist or virologist was included as a major or minor character in the story. While many of the sample texts are based on graphic novels or books, to ensure comparability only the films are included here. The results of this review are summarised in table 1, followed by a discussion of some key similarities that emerged across the sample.

Table 1

Summary of viral outbreak films

Inaccuracies and misinformation

The Transparent Communication in Epidemics (TELL ME) project developers have noted that a major impediment to effective communication during an epidemic is a lack of understanding of the ‘urban myths’ the public have consumed about public health crises.57 One source of such myths is popular media, where a lot of scientific inaccuracies can be found. As can be seen in table 1, although it is common to have medical scientists and doctors as characters in viral outbreak films, epidemiologists and virologists are only specifically mentioned in seven of the sample films, and constitute main characters in only four. As these professionals are likely to be very influential in a real-world viral outbreak, this represents a lost opportunity to educate audiences on their function. Previous studies have also demonstrated that recruitment and choice of specialties within medical schools are heavily influenced by televisual and filmic representations of medical professionals.58 As such, the field of public health medicine could stand to benefit from more accurate representations of epidemiology in general, and the role of epidemiologists in particular. Weaver and Wilson59 note health educators often seem concerned about the impact of inaccurate fictional accounts of medicine and medical professions on health education, or ‘how the fictional world of medicine intrudes on and influences the real one’. The unrealistic success rates for cardiopulmonary resuscitation and unusual frequency of trauma admissions in fictional hospitals are typical examples cited in scholarship, and are believed to be potential causes of misperceptions among both medical students and patients regarding these issues.60 From a pedagogical perspective, these examples indicate students and the public are gleaning perceived knowledge from these sources, despite their primary purpose being entertainment. That a subgenre of medical drama exists in which the key specialists within the relevant field are almost entirely absent sends a mixed message to audiences regarding the efficacy of these specialists, including students of health professions. As will be discussed later, there are also inaccuracies regarding virus behaviours that are common in viral outbreak films perpetuating the ‘urban myths’ TELL ME are concerned about. In terms of PMT, the promotion of misinformation impedes accurate identification of real threats, thus minimising the likelihood of an appropriate protective behaviour being pursued.

Similar to the above, another feature viral outbreak films have in common with the rest of medically focused drama is the lack of central nurse characters, with Planet Terror the only example examined that contains a significant nurse figure. This film follows a band of survivors of a bioterror attack that left most citizens suffering a zombie-like infection. Writing for the Journal of Nursing Scholarship, McGillis Hall and Kashin61 note the absence of realistic representations of nursing staff in news and popular media covering epidemics is concerning, as it fails to recognise the vital role such healthcare workers provide in such crises. Given the fact nursing staff are likely to spend the most time with infected patients, their absence in the so-called ‘epidemiology of representation’62 of disease outbreaks is particularly jarring. Further, in the case reviewed here, the nurse character is actually responsible for torturing patients and promoting disease spread, rather than contributing to disease prevention. Thus, an opportunity to educate audiences on the vital role nurses play in epidemic responses is lost and replaced with a clichéd horror trope of medical mutilation.

The hygiene practices used to prevent the fictional diseases portrayed in the sample films range from routine handwashing and disinfection of potentially contaminated fomites, to incineration of human remains, sterilisation of diseased crops and even culling of infected humans. Although it is likely audiences will be able to recognise the latter is used solely for dramatic effect, Dr Morse notes the same cannot be said for the myth that a virus can spontaneously mutate to become airborne. He notes: ‘Nature can do things we’ve never expected…but there is no virus in history that we know of that’s ever mutated to change its route of transmission’(p. A17).25 Nevertheless, in 10 of the samples chosen, viral mutation is a major plot point, including shifting from bloodborne to airborne transmission, as seen in Outbreak, I am Legend and The Crazies. The latter two focus on how small groups of survivors of an outbreak may be forced to relocate and radically alter their behaviours in order to survive in a post-outbreak world in which infection risk is everywhere. In these films protective behaviours adopted during early phases of the outbreak become meaningless following the implausible mutation of the viral agent. As mentioned earlier in this paper, common concerns regarding HIV and Ebola have focused on the false belief these agents are likely to mutate and become significantly more infectious, a belief sometimes attributed to the influence of films like Outbreak.25

Risk communication

Returning to PMT, there is the potential for risk communication in popular media to influence perceptions of disease vulnerability and the efficacy of preventive behaviours among audience members. The first element to consider is whether the viral outbreak occurred as a result of human agency. In 11 of the sample films, either the virus or its release was a result of deliberate human action, ranging from bioterrorist attacks to liberating experimental animals from a laboratory. In many cases a hubristic scientist or corrupt pharmaceutical research company is to blame for creating an uncontrollable biological hazard, such as the development of the cancer-curing Krippin virus in I am Legend, the regenerative T-virus manufactured by the Umbrella corporation of Resident Evil, and the Alzheimer’s cures, ALZ-112 and ALZ-113, which inadvertently brought on the Simian Flu Pandemic in Rise of the Planet of the Apes. In only three cases does the viral agent responsible for the epidemic specifically arise in nature, with the virus in Infected resulting from certain combinations of Lyme disease strains, the flesh-eating virus of Cabin Fever infecting animals and humans through the water supply, and the MEV-1 virus of Contagion arising due to random genetic mixing of existing bat and pig viruses. In each of these films, characters are infected through natural means, but the first two follow a standard horror formula in which the infected then proceed to hunt down the uninfected, while the third is a more realistic drama depicting a global response to a pandemic.

Whether audiences’ concerns regarding the threat of biological weapons caused Hollywood’s obsession with anthropogenic viral development and release, or if it was the other way around, is impossible to say, but whatever the case such representations could serve to fuel the panic regarding bioterrorism. Armstrong claims engagement with such ‘imagined futures’ causes fears that can be easily exploited to legitimise extensive political intervention under the guise of promoting biosecurity and public health (p. 28).5 She notes that thanks to the influence of fictional media, such fears have become less about what these pathogens can do to the human body naturally, and more about what scientists and terrorists can manipulate them to do in the form of a weapon (p. 5).5 Regarding the horror narratives listed above, there is also a fascination with what infected humans might be driven to do as a result of their disease, such as turning violent or deliberately attempting to infect others. Thus, human agency and its removal are both key dramatic elements.

Another clear pattern that emerges when considering the above films is the presence of racialised or gendered scapegoating. In almost every example the first victim to perish from infection is a woman or a member of an ethnic minority, with ‘patient zero’ often coming from a disadvantaged segment of modern society, such as a member of the homeless community or a refugee. There is also a tendency to conflate stigmatised behaviours, such as alcoholism, sexual infidelity, sex work and homosexuality with increased disease transmission risk. Mullens notes that throughout history women and racial minorities have borne the brunt of blame and stigma for supposedly causing disease outbreaks, especially those associated with female sexuality or migration (p. 72).49 The former can be seen in fiction through the acts of infidelity that facilitate the rapid spread of infection in Cabin Fever, Planet Terror and Contagion, or the targeting of sex workers in Planet Terror, Blindness and Infected. In Contagion, it is the secrecy surrounding one infected woman’s extramarital affair that makes tracing the origin of the mutated virus before it spreads impossible. Thus, unsanctioned female sexuality is directly blamed for countless deaths, as referenced in various internet memes connected with the film, including a screenshot of a mass grave with the text ‘this is all Gwyneth’s fault’ superimposed on the scene.63 Likewise, in the real world, diseases like syphilis were predominantly blamed on women,63 especially sex workers, while the hypersexualised image of Ebola-chan embodies the supposed threat of female sexuality (p. 347).47 With regard to migrant and refugee populations, the virus in Outbreak is known to have originated in Africa, while those depicted in Planet Terror, The Crazies, Contagion and World War Z are thought to have originated in Asia. These racial groups are further accused of being the source of disease outbreaks in Blindness, Carriers and Quarantine, despite a lack of evidence to support this. In most of these films, the outbreak is unexpected and its impacts vary from causing zombie-like behaviours, as in Planet Terror, The Crazies, World War Z and Quarantine, or simply causing disease symptoms and/or death, as in Contagion and Blindness, the latter of which depicts the sociopolitical response to a sudden epidemic of blindness. Even when little is known about the true cause of the epidemic in these films, scapegoating is actively present. In the real world, S Harris Ali notes that situations of ‘moral panic’ often invoke racial paranoia, which was partly responsible for the stigmatisation of the Asian community in Toronto during the SARS outbreak in 2003 (p. 53).26 The same drive also promoted the travel restrictions enforced during the recent Ebola outbreak, a policy that would be supportable in the fictional cases above, since, as is often the case in reality, trans-border and airline travel is implicated in the majority of the outbreaks.

Impact on adopting protective behaviours

In terms of the efficacy of preventive behaviours, by far the most common method used in the sample films was some sort of isolation or quarantine, which appeared in every film except 12 Monkeys, an interesting example in which disease prevention is attempted through time travel to thwart the bioterrorists’ plans, rather than intervention during or following the outbreak. However, I am Legend is the only example that does not demonstrate a breach of quarantine leading to further infections, possibly owing to the fact the majority of the film is focused on a single character’s plight to avoid infection long enough to perfect a cure to the disease. Overall, these films are unlikely to inspire much confidence in the value of voluntary or mandated quarantine. Social distancing methods, such as encouraging people to avoid congregating in large groups and shutting down public buildings, is often seen to be similarly ineffective due to poor compliance. In light of the importance of such measures in real-world epidemics, and the potential for films to influence perceived knowledge of the efficacy of such interventions, this represents a significant area of concern. By depicting the failure of such measures as a foregone conclusion, these films may foster an attitude of hopelessness towards such protective behaviours, causing an imbalance in the cost–benefit analysis Floyd et al 12 noted was imperative to PMT.

Beyond quarantine attempts, dedicated health information campaigns and surveillance are only seen in 28 Weeks Later, Maggie and Contagion, each of which contains sustained plot points focused on avoiding infection, in the first two from zombies and in the latter from a natural viral infection. Interestingly, Maggie also considers in detail the end-of-life care needs of a zombie and the conflicting duties families may have to protect other members from infection, including siblings. At least 15 of the sample films actively show PPE use, and 7 films attempt to synthesise a vaccine or cure for the virus, often through scientifically or ethically dubious means. The most dramatic failures of PPE to protect the uninfected occur in Outbreak, when a lead character suffers a needlestick injury and is exposed, and Carriers, when a character drops her face mask just before a sick girl coughs blood on her face. Risking infection to protect a loved one is a common theme, with abandonment of PPE or breaching quarantine often depicted as a heroic act. The most problematic example of this can be seen in 28 Weeks Later when two children break quarantine protocols to save their infected mother, who then brings a highly virulent strain of the Rage virus into the established safe zone. Across the board these films depict preventive measures as being largely pointless, with quarantine requirements further feeding into a variety of conspiracies that also call into question the motivations and effectiveness of authorities and institutions involved in public health efforts.

Institutional conspiracies

Perhaps the most concerning element of the fictional representation of viral outbreaks is the prevalence of conspiracy plots in the narratives. With the military and government officials often seen to be withholding information from the public, and misusing their positions to evacuate or obtain vaccines for at-risk family members, trust in health institutions is understandably low in these films. Many of the conspiracy theories mentioned in these stories turn out to be false, but those involving hospital staff euthanising the infected are particularly disturbing. The Bangladeshi Nipah virus and British H1N1 outbreak examples discussed earlier in this paper demonstrate that when a community mistrusts the government or health authorities, risk communication and disease prevention can be challenging. The Ebola-chan meme and its relationship with 4chan further exemplifies the potential for conspiracy theories to promote distrust of healthcare workers (p. 345).47 In several of the sample films the true origin of the outbreak is never determined and a cure is still being sought by the time the narrative ends, thereby leading to ambiguity and a lack of narrative closure that can promote suspicion. Members of the CDC are also frequently at the centre of these conspiracies, ranging from providing untested vaccines to culling quarantined patients. A particularly tragic self-fulfilling prophecy can be seen in Contagion, when Chinese villagers kidnap a WHO epidemiologist to ransom for vaccines they believe the government will not prioritise them for otherwise, leading to the government trading them fake vaccines they then believe will protect them and their children. Such negative representations of health institutions may be damaging in the real world, when cooperation with authorities is often paramount for the prevention of disease spread. As noted earlier in this paper, the perceived trustworthiness of institutional information sources during an outbreak forms part of the wider risk perception component in PMT, and thus the public’s response to health protective advice.

Future directions

There are a number of other patterns in these viral outbreak films that could be explored in further studies on this topic. These include the frequency with which the viruses are anthropomorphised or described as if they have some form of agency. There is also a significant fixation on sources and reservoirs of infection, such as fomites and water supplies, demonstrated through close-ups and lingering camera focuses on random objects. The prevalence of total social collapse in the face of an epidemic is also worthy of further examination.

Conclusion

Given the need to communicate effectively with the public during an epidemic regarding appropriate preventive behaviours to engage to avoid infection, the impact of news and popular media in informing (or often misinforming) citizens on what to do in the event of a public health crisis warrants critical examination. Using a sample of viral outbreak films, this paper has demonstrated there is a real risk of audiences adopting inaccurate beliefs about disease transmission and developing a sense of mistrust of health and government institutions. With fictional representations impacting how infected individuals and countries are treated in the real world, future studies in this area might need to focus on educational opportunities to correct the misconceptions and stigmatisation these films can engender, especially in the light of the ethical obligations developed countries have to protect the health of those living in low- and middle-income countries during an outbreak of infectious disease.

References

Footnotes

  • i Four entries were excluded for misclassification: Dreamcatcher (2003) is about alien parasites and not viral infection, I am Omega (2007) is a parody film of a much older film, and Fatal Contact: Bird Flu in America (2006) and Virus (1995) were both direct-to-television specials.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.