Zombies—A Pop Culture Resource for Public Health Awareness

itting at his laboratory bench, a scientist adds mutation after mutation to a strand of rabies virus RNA, unaware that in a few short days, an outbreak of this very mutation would destroy society as we know it. It could be called “Zombie Rabies,” a moniker befitting of the next Hollywood blockbuster—or, in this case, a representation of the debate over whether a zombie apocalypse, manufactured by genetically modifying one or more diseases like rabies, could be more than just fiction. Fear of the unknown has long been a psychological driving force for curiosity, and the concept of a zombie apocalypse has become popular in modern society. This article explores the utility of zombies to capitalize on the benefits of spreading public health awareness through the use of relatable popular culture tools and scientific explanations for fictional phenomena.


History of Zombies in the Media
Zombie folklore made its appearance in the modern media in Das Cabinet des Dr. Caligari, a silent horror film directed by Robert Wiene, which debuted in Germany in 1921. The film's depiction of zombies paralleled Haitian lore: a sleepwalker under the control of another individual. The notion of a zombie was primarily defined by the control an individual had over another, and the main character in this film had the characteristic attributes of the early zombie: the unique lumbering gait, lack of higher cognitive ability, and obedience to another individual.
Drawing inspiration from Richard Matheson's 1954 novel I Am Legend, George A. Romero spawned the more modern manifestation of the undead zombie and the notion of a zombie apocalypse in The Night of the Living Dead. These zombies were a corporeal expression of strife, a mechanism to demonstrate rising social tension in response to a ruinous threat. Subsequent media have continued to use adaptations of Romero's zombie. The film adaptation for I Am Legend depicts humans who have undergone physiologic changes, developing intolerance for the sun and a unique form of communication while maintaining the ability to learn through mimicry and form social hierarchies. In the film 28 Days Later, infected humans transform into creatures characterized by preserved intellect and tremendously aggressive behavior. However, this expansion of aptitude is not uniform in modern media. Shaun of the Dead portrays zombies as very slow-moving, with incredible strength but no intelligence. They are fooled by normal humans who mimic their gait and groans.
Though most popular in film, zombies are present in other forms of media as well. They can also be found in print. Increasingly, however, these flesh-eating monsters have found themselves in video games, feasting upon unwary protagonists.
A brief look through the history of the zombie's evolution within media unearths their progressing ability to serve as a vehicle to reach greater audiences. Frank Darabont's awardwinning adaptation of The Walking Dead comic books has proven that zombies maintain thematic prominence even when serving as the backdrop to a character-driven television drama. These popular and varied manifestations of zombies elucidate the potential for a comprehensive dissemination of knowledge, from identifying traits indicating infection to explaining the significance of public health infrastructure. Zombies are a unique medium that allow for the audience's suspension of disbelief and for intellectual engagement.

Zombies and Parallels with Other Public Health Issues
Although zombies are certainly not the only favored supernatural creatures in modern times, they appear to be the best conduit to educate the layman about re-emerging infectious diseases, such as rabies. The interpretation of zombies has been diverse, but at its core, zombiism remains an existence in which the victim has been stripped of any higher consciousness or agency. The reimagining of zombiism as a virulent, incurable disease makes it an effective analogy for understanding of and interest in other infectious diseases.
Zombie popularity may be a perfect opportunity to increase awareness of rabies. The most prominent resemblance between those afflicted with rabies and zombiism begins at the mouth; both ailments are primarily transmitted through biting. While the pathogenesis for zombification is less consistent, rabies spreads through infected saliva entering the body. In addition, victims indicate infected status with increased production of fluid from the mouth; in the case of rabies, increased salivation occurs to improve chances of transmission. Rabies control in practice may be similar to hypothetical control of zombie outbreaks. For example, in 2008, Indonesian officials in Bali killed roughly 50,000 dogs in five days after an outbreak of rabies. This sparked a great deal of controversy, leading to the primary alternative of mass vaccination.
Additional physical characteristics of rabies and zombiism are similar. Once infected, victims display overall weakness and low-grade fever. In the case of zombiism, the advent of fever typically indicates the transition from human into zombie. When affected by rabies, human movement is irregular; muscle spasms and convulsions accompany numbness and loss of muscle function. May 2013 Shared characteristics are not limited to physical attributes. A person with rabies will experience several changes in mental state, such as increased anxiety, stress, restlessness, delirium, abnormal behavior, and even hallucinations. Zombies will also typically display a limited level of cognitive function, with aggressive behaviors strengthening as cognitive function declines.
The numerous parallels between zombies and rabies, as well as other infectious diseases that are a threat to public health, enable the use of a popular media creature to promote the prevention and control of a public health problem. Pending specific training in public health or medicine, the layperson may gain substantial interest and understanding of rabies with our comparison and utility of zombies. In the media, protagonists always find a way to fight back against the zombies and try to maintain their survival. The attack on infectious diseases is similar to this fight against a new menace, in that new ways will be discovered along with those already known to prevent, treat, and control infections.

Discussion
Within the past couple of years, we have seen zombies gain traction not just in media, but also in the field of public health. Zombies entered the health circuit in mid-2011 when, after the Tohoku Earthquake in Japan in early March of that year, the Centers for Disease Control and Prevention (CDC) opened up a disaster forum on the microblogging site Twitter. In it, the CDC asked members of the general public what sorts of emergencies they were prepared for and what tactics they were using to ensure disaster preparedness. Several persons showed interest in preparing for a catastrophic zombie attack. These responses were most likely meant to be facetious, but they demonstrated the prominence of zombies in popular culture and their utility for drawing attention to public health issues. As a result, Dr. Ali S. Khan and his colleagues wrote a column on the Public Health Matters blog of the CDC Web site. They used zombies as a hook to draw readers into an article detailing how best to prepare for a zombie apocalypse and, by extension, any kind of disaster, be it natural or manmade.
The popularity of the CDC's tongue-in-cheek zombie apocalypse article prompted other organizations to create their own, shedding light not only on disaster preparedness but also the ethics of zombie killing. Among them is an op-ed piece written by Daniel O'Connor of Johns Hopkins University's Berman Institute of Bioethics. In the article, O'Connor outlined several bioethical guidelines to consider if one found oneself in a community that had a zombie infestation. Some of the guidelines explain the threshold at which a person can no longer be considered a human, and when and how to kill a zombie in a morally acceptable manner. Other guidelines underscored the importance of minimizing the risk-benefit ratio for as many people as possible when devising antizombie strategies, as well as the importance of community engagement. The most effective strategies incorporate the diverse voices of the community rather than relying solely on the judgment of the military, politicians, and health experts. Many of these bioethical guidelines come into play when promoting public health intervention strategies for several other diseases and health concerns, but O'Connor's article also subtly underscores the frailty of such guidelines in the face of disasters that threaten to destabilize health infrastructure. The article points toward a glaring need to ensure that the standards of public health are maintained even in the event of an apocalyptic pandemic event.
There has been speculation on whether a virus akin to rabies could become a threat similar to that of zombification. Authors of a National Geographic article titled "Zombie Virus" Possible via Rabies-Flu Hybrid? shed some light on what they believe to be an irrational fear of such a predicament. First, there is a mechanistic barrier to creating the perfect zombie virus from the rabies virus. Contrary to the immediate onset of zombification, the onset of rabies within the body is about 10 days to one year for incubation. In addition, there is a genetic barrier to induce the symptoms exhibited in zombification within the genetic code of other viruses; it is scientifically unheard of for two viruses to borrow traits or fuse. Despite the availability of cutting-edge genetic engineering that could combine the airborne potential from influenza, personality changes from measles, fever and delirium from encephalitis, and internal bleeding/necrosis from the Ebola virus with that of the rabies virus, little certainty exists that such a virus could be viable in vivo and still leave its host alive.
If a cocktail of deadly virus could not even mimic the traits of a zombie, is there any other microorganism out there that could? In fact, this answer is closer than one would expect. Simple misfolding of proteins in the brain can lead to the creation of a whole family of these anomalies, called prions. Prions can ultimately lead to brain disease, which may result in personality changes, loss of cognitive function, and muscle twitching, all highly characteristic of a potential zombie. Fortunately, current scientific evidence reveals prions as incapable of causing widespread epidemics.
The government might also be a barrier to zombie outbreak, by isolating and controlling the source of such infections from circulating worldwide. Still, some may argue that governmental response to a zombie apocalypse may lead to discrimination against zombies as a minority population. When we are dealing with disease outbreaks beyond our understanding, we must first develop a capable society that can effectively deal with outbreak control and civic problems before mentioning any possibility of a cure. For now, we can at least rest in peace without worrying that a zombie epidemic is just around the corner.

Conclusions
Zombies can be used as a powerful tool for increasing awareness of issues of public health significance. The popularity of the CDC piece on preparing for a zombie apocalypse has been instrumental in teaching how to prepare for disasters. We propose continuing these efforts, building on the popularity of zombies to increase public health awareness in the general public, and explore additional issues that may have not been considered in the past. These issues can be explored by taking advantage of various forms of media, including one, distributing informational pamphlets, books, and other printed media explaining the similarities between zombie infestations and less known outbreaks and how to protect oneself and others; two, creating satirical or dramatic public service announcements to promote defensive community strategies against infectious disease outbreaks by using zombiism as an analogy; three, using interactive games, computer programs, and smartphone applications to enable the public to safely experience the natural progression of real epidemics on different levels, and with and without intervention strategies such as vaccination, quarantine, or extermination; and four, facilitating the creation of clubs, societies, blogs, and even magazine articles across age ranges, academic institutions, and internet interest groups to share the excitement of applying what we can learn about zombies to more applicable avenues of life, such as public health and epidemiology. We must also consider the possibility that zombies could very well be replaced by other popular culture icons in the future. To that end, we must continue to adapt and use these pop culture tools to increase interest in and awareness of notable public health issues affecting the world.
I'm Reginald Tucker, for Emerging Infectious Diseases, and I've been reading an abridged version of Zombies-A Pop Culture Resource for Public Health Awareness. You can read the entire article online in the May 2013 issue of Emerging Infectious Diseases at cdc.gov/eid. If you'd like to comment on this podcast, send an email to eideditor@cdc.gov.
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