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05/03/2016

BioethicsTV: Containment Fails to Go Viral

by Craig Klugman, Ph.D.

The CW network began airing a “limited” series (what used to be called a mini-series) drama about a bio-terrorism outbreak in the city of Atlanta. Similar to the far superior film Contagion, this television show explores how lives change and the tough decisions that are made in an epidemic.

Containment demonstrates many of the real tools public health has for controlling an epidemic of little known origin and lacking cure or vaccine: closing public places, compulsory leave at businesses, cordon sanitaire, curfews, sanitation, isolation, price controls, quarantine, screening, surveillance, testing, and travel restrictions.

Like all good ethics, I’ll begin with some definitions: Although there are several definitions for these terms, for our purposes here, quarantine is separating exposed persons who are symptom free. Isolation is separating the infected, or those with symptoms.

The other definition that you will need is information about our fictional pathogen. The disease in this show is an aggressive, fast-acting, genetically-modified form of the flu with hemorrhagic characteristics and a 16 to 48-hour incubation period. The virus is passed through contact with bodily fluids (especially sputum, saliva, and sweat). It is also fatal 100% of the time.

When patients start appearing at a hospital (yes, there is apparently only one), the hospital is quarantined (meaning that a group of visiting school kids on a field trip have to move in) and public health officials immediately set up a cordon around central Atlanta. The government quickly builds a cordon fence with the idea of separating those who could have been in geographic proximity to a sick person. By quarantining the potentially infected from everyone else, spread of the disease should be contained.

After the cordon is established, all symptomatic patients are identified and placed into isolation in the hospital (where they all die). This process is known as “contact tracing” to track asymptomatic, exposed individuals and isolate them. The idea is that if the potentially exposed are separated from the exposed and the unexposed, then the last group will be protected from exposure. But this assumes that we can isolate all of the exposed. In the case of this show, it also assumes that there is only one patient zero.

When a house full of sick young adults is later discovered (they were partying since their parents are all outside the cordon and school is canceled), everyone realizes that the isolation of the hospital has failed. A red mark is painted onto the house where the kids were found, warning others to stay away because the house may contain sick people or virus particles. Outside the cordon, walls of cargo containers replace the cordon fence so that no one gets in or out: Those inside the cordon are on their own. The problem that this scenario creates is that healthy, unexposed people are now trapped with the sick, infected, and dead. As the leader of the containment effort hints, it’s better that all of the people in the cordon die from exposure than the virus gets a foothold outside the cordon. While potentially effective, such a perspective violates most theories of ethics both medical, philosophical, and public health oriented. The viewer is repeatedly told that the loss of these lives is nothing compared to the loss of all humanity if this virus is to get out.

From an individualistic perspective, putting these innocent people in harm’s way (close contact with the infected and no way to “escape”) is unethical. In the U.S. we do not practice medicine where one life is sacrificed for the good of another. From a public health standpoint where the goal is to minimize morbidity and mortality, the idea of a cordon makes sense—your protect the many by harming the few. This was seen in the Ebola epidemic where workers returning from West Africa were asked to maintain social distancing (and in some states forcibly quarantined) during the incubation period. But, like the governor-demanded quarantines for the returning health workers, this cordon is not backed by scientific evidence. Abandoning these people to a lord of the flies scenario (which is seen in a brief flash forward) is antithetical to the goals of crisis management. As this show is staged, we are supposed to think that the cordon is a bad thing.

Within the cordon, the show makes use of “social distancing” keeping people a certain distance apart even if their movement is not restricted. Thus, the viewer is told over and over again, that people must remain “4 to 6 feet apart.” There is no shaking of hands, hugging, or even supportive touch (hand on the shoulder). This precaution is apparently enough of a distance that bodily fluids can’t move from one person to another (despite the explosive fluids that are purged from the bodies). One inconsistency in the show is that if social distancing is sufficient to prevent transmission, then why put up a cordon wall? Isn’t the wall overkill? We also see that when an infected patient sneezes on the lone police person inside the cordon (who is also apparently acting as hospital orderly), his riot gear faceplate is quickly covered with gore. Whether he will get sick is not yet known.

The cordon has the effect of cutting off families (thus, why this is a drama). Outside the cordon we find the public officials acting to prevent spread of the disease. These are the decision-makers, the political players, and the media darlings. Inside the cordon are the potentially sick, the symptomatic sick, the traditional heroes, and the innocent. Another way to view this is that outside the cordon are those with resources and means, and those inside represent those who lack resources.

This show raises a number of public health ethics issues that are worth exploring. For example, consider the first patients who are locked in basement isolation rooms in the hospital. Each is basically left to die. Although the cordon was put into place quickly and without notice in the middle of the day, this is a very understaffed hospital. Granted, several of the health care personal are in the second round of deaths (those who treated the first patients). However, except for a couple of autopsies and some images of people coughing up blood onto biohazard faceplates, the patients are left to themselves in these rooms. They are essentially left to die in unpleasant basement rooms. This is fairly shocking. As someone who has been working on crisis managements plans for the last few years, I know that these plans, at the very least, provide for palliation, a service that is not in evidence in this show.

In fact, the show quickly stigmatizes those with the virus. Remember that this virus is genetically engineered as a bioterrorism agent and yet the patients are treated as if getting the virus is their own fault. Consider the initial patients—a family of Syrian refugees whose cousin brought this virus into the country. The second group is a cast of teenagers crashing in a house for a multi-day party. A third group are health care providers who assisted the others. Though these first responders are not blamed for their disease, they are treated as poorly as those who are viewed as responsible.

Another concern I had was that the first responders and medical personnel are not wearing biohazard suits, most likely because the virus is not airborne (at least not yet, that could be an interesting plot twist). But given the plethora of bodily fluids that are coughed and sneezed onto the visors and thin coverings, it seems like they might want to adapt stronger biohazard suits. Very quickly the care providers could become a vector for the virus to pass to new people. The large number of health care providers who die in the early rounds of death suggest better personal protection equipment (PPE) would be advisable: Consider the cop who seems to only wear his one police uniform and riot face shield.

From a different perspective, it is important to maintain civil order in such a crisis. For example, the show demonstrates the need for price controls. In the second episode, a shop owner (whose daughter is a prominent character and has been exposed to the virus) raises her prices because she is the only shop around and can charge whatever she wants. The problem with the cordon and nothing in or out is what happens when even she runs out of goods. We are given a glimpse of this future in the opening minutes of the pilot (which we are told is episode 13) where a riot has people willing to kill each other for boxes of MREs (i.e. food).

At the end of episode 2, the police officer in the cordon is asked to help dispose of the bodies that are piling up. This is one of the most wrenching tasks that needs to be done in an epidemic, but also one of the most important to protect lives and to maintain civil order. The bodies of the dead could still harbor dangerous pathogens that threaten to infect others. Contingencies for disposing of bodies are always included in crisis management plans.

The limited series so far calls for a total of 13 episodes. Though there is buzz on the internet of future possible seasons. If I were looking for television to teach about epidemics, I would certainly be using Outbreak or Contagion because they are shorter and better done. But for entertainment purposes, this may fill some space while other shows end their seasons.

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