With flu season now officially underway across the country, according to The Centers for Disease Control, it is appropriate to reflect on the notion that Hollywood's Academy Awards made no mention recently of the movie Contagion, just as PBS ended season two of its acclaimed series Downton Abbey with the penultimate episode about the 1918 Spanish Flu.
All three of these developments carry a potentially dangerous public health message.
While the CDC offers reassurance that this year's flu will be mild, the box office failure of Contagion -- despite an all-star cast and an impressive list of expert consultants -- suggests that moviegoers were unwilling to confront a plausibly worst-case scenario of a deadly pandemic. By contrast, Downton Abbey, which attracted more than 9 million viewers each week , dramatized the deadliest epidemic in the history of the world by fitting it neatly within the plot lines without compromising the elegance that is so attractive to devoted fans.
As a public health researcher who studies epidemic preparedness and a fan of Downton Abbey, I was especially nervous when the teaser announced that the the program would feature a visit of the Spanish Flu to the Crawley estate.
I did not look forward to viewing how the disease would change life at Downton and alter the appearance of the attractive people living there. What would the family members and servants do to avoid contracting the highly contagious virus from an ill household member? Would the servants' love of their lords and ladies compel them to minister at their bedside thus overcoming the natural fear of illness and possibly death? Would the beautiful actors cover their beautifully made up faces with crude masks to minimize the spread of the droplets from coughing? Would they forego their elegant clothes? Could the house remain spotless and the silver polished if the servants took sick?
I was also curious about the portrayal of medical care. The one doctor remaining in the area after Downton's conversion from a wounded soldier's infirmary did not impress me with his medical competence. Having seriously misdiagnosed the paralysis of Downton heir Matthew Crawley and the self-destructive depression of a wounded soldier, he appeared to be unqualifiedly self-assured, inflexible and snobbish. If he remained healthy as the epidemic spread, he would undoubtedly be overwhelmed by needy patients. Certainly, he would respond immediately to the aristocratic members of the Crawley family, but would he also minister as carefully to their servants and village folk?
As it turned out, I needn't have worried. About the only realistic facts associated with this portrayal were that the disease was an unpredictable respiratory illness, and that, unlike most influenza, the largest number of deaths inexplicably occurred among the healthy young adult age group. Hence Lavinia Catherine Swire, fiancée of the designated male heir, died while the Countess and butler recovered.
While there were reports of other maids being sick, there was no mention of their suffering. Life at Downton was only nominally disrupted; the wedding was reluctantly postponed perhaps in part because there might be a shortage of healthy servants to attend to their guests. Alas, the wedding became a moot issue when the prospective bride suddenly succumbed to the disease. She died looking gorgeous even if pale and gasping for breath as she spoke to her fiancé. He sat by her side holding her hand while others stood nearby -- all apparently oblivious to the possibility of infection.
Ironically, the Countess, who in one scene appeared to be near death, did not look quite so lovely. She was seen bleeding from the nose and appearing to vomit. Contrary to expectations, however, she pulled through and none of her attendants got sick. Similarly, the doctor made a point of visiting the servants who were ill.
Thus, the show, whose storylines revolved around social class distinctions, made no reference to the particular difficulties experienced by the poor and working classes in accessing medical services, receiving help during their suffering, and avoiding destitution when they had no income because illness kept them from working.
There was still drama aplenty in the script, but it came primarily from the viewers' fear for the characters rather than the fear of the characters for the disease. This too was unreal. In his monumental book on The Great Influenza, John Barry writes: "There was terror afoot in 1918, real terror. The randomness of death brought that terror home. So did its speed."
He further explains,
The public could trust nothing and so they knew nothing. So a terror seeped into the society that prevented one woman from caring for her sister, that prevented volunteers from bringing food to families too ill to feed themselves and who starved to death because of it, that prevented trained nurses from responding to the most urgent calls for their services. The fear, not the disease, threatened to break society apart.
The Downton Abbey episode stands in sharp contrast to the docudrama presented in the 2011 movie Contagion. The fictional, but credible and frightening, film version of a future pandemic did not attract a large audience.
This is likely due in large part to the general public's unwillingness to confront the reality of what a serious disease threat could look like. The movie premiered soon after the 2009 worldwide H1N1 pandemic proved far less deadly than experts had feared. Claiming fewer lives and causing minimal disruption, many Americans concluded that the government had overhyped the danger. A majority of adults refused to believe the government's claim that the vaccine developed during the second wave of the virus was safe and effective in preventing the spread of the disease. Ignoring the movie version for many likely meant not having to worry about the continuing danger.
Certainly, art need not imitate life even when a story's plot depends upon a major historical event. The British television drama sought to entertain effectively allowing us to ignore the realities of the disease that ravaged the world in the early 20th century. PBS frequently presents excellent informative and educational programming about current issues, although few of these attract a viewership as large as Downton Abbey. It is ironic, if not surprising, that Hollywood, whose primarily goal is to entertain, could not attract a large audience to a realistic movie that educated viewers about a potentially serious threat to modern society.
From the perspective of the viruses, not much has changed from the time of Downton Abbey to the near future of Contagion. Medical care and medicine have indeed advanced, but the increase in world travel and human contact will tax our capacity to treat those suffering from an unknown virus for which we have no vaccine and possibly no wholly effective treatment.
We have no way of assuring that the present income gap will not make it more difficult for the poor, the unemployed, and those in medically underserved communities to access medical care and support services. That we have thus far been lucky does not mean that every contagious disease will be mild or containable. In a crisis we cannot expect that all the planning will work as expected.
Americans understandably preferred the pure fiction of Downton Abbey as they were reluctant to find reality of Contagion entertaining. We must hope, however, that if life imitates art and confronts us with a novel deadly pandemic, we will do more than sit back and watch for a happy ending.
Leslie Gerwin is Associate Director, Program in Law and Public Affairs, Princeton University; she teaches Public Health Law and Policy as an Adjunct Professor of Law at the Benjamin N. Cardozo School of Law.
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