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Home , Tyrant (Resident Evil), Zombie, Zombie apocalypse

—A Pop Culture Resource for Public Health Awareness Melissa Nasiruddin, Monique Halabi, Alexander Dao, Kyle Chen, and Brandon Brown

itting at his laboratory bench, a scientist adds muta- secreted by puffer fish that can trigger paralysis or death- Stion after mutation to a strand of virus RNA, like symptoms, could be primary ingredients. Which toxins unaware that in a few short days, an outbreak of this very are used in the powders specifically, however, is mutation would destroy society as we know it. It could be still a matter of contention among academics (4). Once the called “Zombie Rabies,” a moniker befitting of the next sorcerer has split the body and , he stores the ti-bon anj, Hollywood blockbuster—or, in this case, a representation the manifestation of awareness and memory, in a special of the debate over whether a zombie , manu- bottle. Inside the container, that part of the soul is known as factured by genetically modifying one or more diseases the zombi astral. With the zombi astral in his possession, like rabies, could be more than just . Fear of the the sorcerer retains complete control of the victim’s spiri- unknown has long been a psychological driving force for tually dead body, now known as the zombi cadavre. The curiosity, and the concept of a has be- zombi cadavre remains a slave to the will of the sorcerer come popular in modern society. This article explores the through continued poisoning or spell work (1). In fact, the utility of zombies to capitalize on the benefits of spreading only way a zombi can be freed from its slavery is if the spell public health awareness through the use of relatable popu- jar containing its ti-bon anj is broken, or if it ingests lar culture tools and scientific explanations for fictional or meat. The latter would usually cause the zombi to hunt phenomena. down and kill its master before finally returning to its fam- Although zombies are currently an integral part of our ily or its final rest as a corpse 1( ,2). , our morbid fascination with the walking Although most cultures would consider the zombie dead spans several centuries. Historians and anthropolo- to be a fictional creature, zombiism (i.e., being a zombie) gists trace the origin of zombies to the of several is rather common in , with instances of people being tribes in Africa, from Ghana to Nigeria (1,2). Dur- reported dead by loved ones, only to be spotted fully reani- ing the slave trade of the late 1500s through the 1800s, mated and wandering around town several weeks to several persons from these regions were spirited away from their years later. In Haitian and African culture, zombification is homes to till the plantations of the Caribbean and the Eu- a punishable offense on the same order of severity as mur- ropean colonies, bringing with them the voodoo culture of der (1). A person who has been zombified, or transformed and spells. Among some academics, zombies in the into a zombie, can have a blunt affect, dull gaze, and al- New World were thought to be wretched, half-dead crea- most stuporous behavior, characterized by a lumbering tures that reflected the bondage African-born and Caribbe- gait and simple, repetitive vocalizations and movements. an slaves suffered at the hands of their masters, working to Most medical evaluations would characterize victims of the point of exhaustion in the plantation fields while having zombification as having mental disorders such as catatonic little to no agency (2). To this day, voodoo is prominent in schizophrenia (1). The aforementioned traits have been in- western Africa, Haiti, New Orleans, and parts of the Carib- corporated into the current interpretation of zombies found bean Islands (1). in modern film and media. Haitian voodoo folklore recognizes a dual identity of zombis: one form of zombi is an ambulatory body without a History of Zombies in the Media living soul, and the other, lesser-known form is a soul wan- Zombie folklore made its appearance in modern media dering without a body (2). This severance of a body and its in Das Cabinet des Dr. Caligari, a silent direct- soul, known as zombification, is thought to occur when a ed by Robert Wiene, which debuted in Germany in 1921. sorcerer, or boko, performs a combination of dark magic The film’s depiction of zombies paralleled Haitian : a spells on a person to kill, enslave, or inflict illness upon sleepwalker under the control of another individual. The him (3). Bokos may also use poisonous powders in which notion of a zombie was primarily defined by the control an frog or toad venom and , a powerful neurotoxin individual had over another, and the main character in this film had the characteristic attributes of the early zombie: Author affiliation: University of California, Irvine, California, USA the unique lumbering gait, lack of higher cognitive ability, DOI: http://dx.doi.org/10.3201/eid1905.AD1905 and obedience to another individual.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 5, May 2013 809 ANOTHER DIMENSION

Drawing inspiration from ’s 1954 the end of the film. None of these interpretations are neces- novel , George A. Romero spawned the more sarily out of step with the use of zombie movies as a useful modern film manifestation of the undead zombie and the public health messaging tool. notion of a zombie apocalypse in The Night of the Liv- Though most popular in film, zombies are present in ing Dead. These zombies were the corporeal expression of other forms of media as well. They can be found in print, strife, a mechanism to demonstrate rising social tension in with novelizations such as Zombies for Zombies: Advice response to a ruinous threat. Subsequent media have con- and Etiquette for the and the popular comic tinued to use adaptations of Romero’s zombie. The film ad- book series Marvel Zombies. Increasingly, however, these aptation for I Am Legend depicts humans who have under- flesh-eating have found themselves in- video gone physiologic changes, developing intolerance for the games, feasting upon unwary protagonists since the in- sun and a unique form of communication while maintain- troduction of Zombie Zombie in 1984 (5). Zombies have ing the ability to learn through mimicry and form social hi- since spread to the more general population in games such erarchies. In the film , infected humans trans- as Plants versus Zombies and , available on form into creatures characterized by preserved intellect and several different platforms of accessible . tremendously aggressive behavior. However, this expan- A brief look through the history of the zombie’s evolu- sion of aptitude is not uniform in modern media: Shaun tion within media unearths their progressing ability to serve of the Dead portrays zombies as very slow-moving, with as a vehicle to reach greater audiences. Frank Darabont’s incredible strength but no intelligence—they are fooled by award-winning television adaptation of The Walking Dead normal humans who mimic their gait and groans. In addi- comic books has proven that zombies maintain thematic tion, Juan of the Dead includes zombies dismissed by the prominence even when serving as the backdrop to a char- Castro government as dissidents, and depicts acter-driven television drama. In his critically acclaimed zombies as human protectors once they begin to transform novel World War Z: An Oral History of the Zombie War, back into humans. revolves around the explores social issues surrounding zombie zombie siege of a noninfected gated community and sees apocalypse, such as the efficacy of government. These the leader of the zombies gain class consciousness toward popular and varied manifestations of zombies elucidate the potential for a comprehensive dissemination of knowledge, Table. A comparison of zombies folklore and rabies epidemiology* from identifying traits indicating infection to explaining the Characteristics Zombies Rabies significance of public health infrastructure. Zombies are a Susceptibility Human infection Requires environment unique medium that allow for the audience’s suspension of requires fictional with infected animals, apocalyptic such as dogs or bats disbelief and for intellectual engagement. environment Cause virus, other Mononegavirales Zombies and Parallels with Other viruses, unknown pathogens Public Health Issues Virus Bites and scratches; Bites; saliva infected Although zombies are certainly not the only favored transmission unknown pathogen; with rabies virus; supernatural creatures in modern times, they appear to be spread human to spread animal to the best conduit to educate the layman about reemerging human; 100% human effectiveness infectious diseases such as rabies. The current popular inter- Virulence Victims die Victims die and pretation of , for instance, has shifted away from and become stay dead the classic grotesque undead creature that voluntarily dines “walking dead” Symptoms Fever, chills, loss of Delirium, anxiety, on the vein and sires new progeny and instead has hair and pigmentation, stress, hallucinations, embraced the idea of vampirism as the paragon of human hobbling gait muscle spasms, existence, alive or undead. The interpretation of zombies convulsions Control methods Avoiding bites from Avoiding bites from has been diverse, but at its core, zombiism remains an ex- existing zombies; dogs and bats; istence in which the victim has been stripped of any higher intervention includes postexposure consciousness or agency. The reimagining of zombiism as a destroying brain prophylaxis virulent, incurable disease makes it an effective analogy for of zombies Exposure in popular culture understanding of and interest in other infectious diseases. Nonscientific Movies, books, Movies, books, Zombie popularity may be a perfect opportunity to media television shows television shows increase awareness of rabies. The most prominent resem- Scientific Zombie websites, Academic journals, media CDC, Nature global health blance between those afflicted with rabies and zombiism websites, NIH, begins at the mouth; both ailments are primarily trans- CDC, Nature mitted through biting (Table). While the pathogenesis for *CDC, Centers for Disease Control and Prevention; NIH, National Institutes of Health. zombification is less consistent, rabies spreads through

810 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 5, May 2013 Zombies—A Resource for Public Health Awareness infected saliva entering the body (6). 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 (6). Rabies con- trol in practice may be similar to hypothetical control of zombie outbreaks. For example, in 2006, Chinese officials in the Yunnan province killed roughly 50,000 dogs in 5 days after an outbreak of rabies (7). This event sparked a great deal of controversy, and circumstances surrounding a similar rabies outbreak among dogs in Bali, Indonesia, in 2008 led to the primary alternative of mass vaccination. If a zombie apocalypse were to occur, surviving humans might not have the capacity for mass vaccination. The sole option may be to kill the undead for human survival; however, the ethics of destroying something that was once human might Figure. Comparison of physical characteristics of zombies and of be called into question. an animal with rabies. Additional physical characteristics of rabies and zom- biism are similar (Figure). Once infected, victims display overall weakness and low-grade fever (6,8). In the case of menace, in that new ways will be discovered along with zombiism, the advent of fever typically indicates the tran- those already known to prevent, treat, and control infec- sition from human into zombie. When affected by rabies, tions. The use of the zombie analogy can provide food for human movement is irregular; muscle spasms and convul- thought, thus providing inspiration for persons to be pre- sions accompany numbness and loss of muscle function pared for and prevent infectious disease outbreaks. (6). Although their physical ability varies in media, the zombies we are familiar with generally have a distinctive, Zombie Psychology hobbling gait. Rabies causes difficulty swallowing because Zombies may inspire fear within those who witness drinking causes spasms of the voice box; zombies largely them in popular culture, and this fear can be compared with lack the ability to produce any sound other than a deep the same emotions that people might experience when they groan, although they have been capable of speaking the encounter the unknown. Some of the fears brought on by word “brains” in classic zombie cinema. zombies include fear of brain dysfunction, fear of death, Shared characteristics are not limited to physical attri- and feelings of hopelessness. Zombies, in turn, make these butes. A person with rabies will experience several changes fears into something concrete, something we can reflect in mental state, such as increased anxiety, stress, restless- upon from a safe distance, as opposed to more active meth- ness, delirium, abnormal behavior, and even hallucinations ods of facing our fears, such as high-risk activities like sky (9,10). Zombies will also typically display a limited level diving or bungee jumping. According to psychologists, of cognitive function, with aggressive behaviors strength- watching 28 Days Later or navigating the characters of The ening as cognitive function declines (8). However, there Walking Dead through Telltale Games’ deadly streets can have been several exceptions. For example, in I Am Leg- be one way in which we, as psychologically bound humans, end, the monsters were able to emulate a hunting trap made confront our fears and attempt to prepare for the possibil- earlier by the protagonist. In the films 28 Days Later and ity of our fears becoming reality. Although we would not , the creatures had vastly amplified rage go so far as to suggest the beauty of our fears in the face and slightly mitigated planning and judgment, while still of hope, we should at least acknowledge the positive emo- mostly preserving other cognitive functions. tional effect that consideration of past success stories when The numerous parallels between zombies and rabies, handling rabies outbreaks, and infectious diseases in gen- as well as other infectious diseases that are a threat to pub- eral, could have on our society should a zombie apocalypse lic health, enable the use of a popular media creature to pro- occur. After all, a progressive society cannot be built upon mote the prevention and control of a public health problem. feelings of fear and anxiety; what better way to build feel- Pending specific training in public health or medicine, the ings of hope and community than drawing similarities be- layperson may gain substantial interest and understanding tween a seemingly unconquerable undead foe and a similar of rabies with our comparison and utility of zombies. In the counterpart in the history of public health that was success- media, protagonists always find a way to fight back against fully managed (to a certain extent)? the zombies and try to maintain their survival. The attack The need for psychological preparation driven by on infectious diseases is similar to this fight against a new fear can be a central motivation for community action,

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 5, May 2013 811 ANOTHER DIMENSION of which public health outreach can take advantage (11). versity’s Berman Institute of Bioethics (12). In the article, However, by using zombies in a slightly different man- O’Connor outlined several bioethical guidelines to consider ner, as an adaptable vehicle for instruction on prevention if one found oneself in a community that had a zombie infes- for rabies, and infectious diseases in general, we can in- tation. Some of the guidelines explain the threshold at which troduce much of the psychology behind zombies that a a person can no longer be considered a human (e.g., being blog post on preparedness cannot. Much of the bitten by a zombie) and when and how to kill a zombie in excitement and interest in our undead friends comes from a morally acceptable manner. Other guidelines underscored such evaluations of shared human psyche between reality the importance of minimizing the risk-benefit ratio for as and a fictional postapocalyptic world; these may include, many people as possible when devising antizombie strate- but are not limited to, slow degeneration of physical and gies, as well as the importance of community engagement. mental health, ethical dilemmas, and issues of morality. The most effective strategies incorporate the diverse voices For example, to generate empathy for patients having de- of the community rather than relying solely on the judgment generative diseases, like rabies, Alzheimer’s disease, or of the military, politicians, and health experts (13). Many even cancer, parallels can be drawn to the sad realistic of these bioethical guidelines come into play when promot- scenes of zombie films when the lone human (or zombie) ing public health intervention strategies for several other survivor hangs on to dear life (or death) and sanity in the diseases and health concerns, but O’Connor’s article also face of his encroaching demise. In addition, our former subtly underscores the frailty of such guidelines in the face example of officials beating to death 50,000 potentially of that threaten to destabilize health infrastructure. healthy dogs due to a rabies outbreak can be juxtaposed The article points toward a glaring need to ensure that the to the Kantian ethics behind killing potentially uninfected standards of public health are maintained even in the event humans (for safety reasons, of course), who have just been of an apocalyptic event. bitten but still retain all of their cognitive functions. Even There has been speculation on whether a virus akin the morality of quarantining hundreds of thousands of hu- to rabies could become a threat similar to that of zombi- mans citywide, sometimes even along racial and ethnic fication. Authors of a National Geographic article titled boundaries, can be more engaging when discussed within “Zombie Virus” Possible via Rabies-Flu Hybrid? shed both contexts of rabies and that of zombies. some light on what they believe to be an irrational fear of such a predicament (14). First, there is a mechanistic bar- Discussion rier to creating the perfect zombie virus from the rabies Within the past couple of years, we have seen zom- virus. Contrary to the immediate onset of zombification, bies gain traction not just in media, but also in the field of the onset of rabies within the body is about 10 days to 1 public health. Zombies entered the health circuit in mid- year for incubation. In addition, there is a genetic bar- 2011 when, after the Tohoku Earthquake in Japan in early rier to induce the symptoms exhibited in zombification March of that year, the Centers for Disease Control and within the genetic code of other viruses; it is scientifically Prevention (CDC) opened up a disaster forum on the mi- unheard of for 2 viruses to borrow traits or fuse (14). De- croblogging site Twitter. In it, the CDC asked members spite the availability of cutting-edge of the general public what sorts of emergencies they were that could combine the airborne potential from influenza, prepared for and what tactics they were using to ensure personality changes from measles, fever and delirium disaster preparedness. Several persons showed interest in from encephalitis, and internal bleeding/necrosis from the preparing for a catastrophic zombie attack. These respons- Ebola virus with that of the rabies virus, little certainty es were most likely meant to be facetious, but they demon- exists that such a virus could be viable in vivo and still strated the prominence of zombies in popular culture and leave its host alive. their utility for drawing attention to health issues. As a re- If a cocktail of deadly virus could not even mimic sult, Dr Ali S. Khan and his colleagues wrote a column on the traits of a zombie, is there any other microorganism the Public Health Matters blog of the CDC Web site (11). out there that could? In fact, this answer is closer than They used zombies as the hook to draw readers into an one would expect. Simple misfolding of proteins in the article detailing how best to prepare for a zombie apoca- brain can lead to the creation of a whole family of these lypse and, by extension, any kind of disaster, be it natural anomalies, called prions. Prions can ultimately lead to or manmade. brain disease, encephalopathy, which may result in per- The popularity of the CDC’s tongue-in-cheek zombie sonality changes, loss of cognitive function, and muscle apocalypse article prompted other organizations to create twitching, all highly characteristic of a potential zombie. their own, shedding light not only on disaster preparedness Fortunately, current scientific evidence reveals prions as but also the ethics of zombie killing. Among them is an op- incapable of causing widespread epidemics, and with an ed piece written by Daniel O’Connor of Johns Hopkins Uni- incubation period of 12–18 months before death, prions

812 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 5, May 2013 Zombies—A Resource for Public Health Awareness do not seem much of a threat to be compared with a zom- increase interest in and awareness of notable public health bie apocalypse. issues affecting the world. The government might also be a barrier to a zombie out- break, by isolating and controlling the source of such infec- Acknowledgements tions from circulating worldwide. Still, some may argue that We thank Sandra Perez for editorial assistance and the governmental response to a zombie apocalypse could lead to Centers for Disease Control and Prevention for its work using discrimination against zombies as a minority population. We zombies as a tool to increase awareness of disaster preparedness, assume that much of postapocalyptic society relies on the which prompted this work. often untrue depiction, and in some cases even satire, of non- functioning or ill-functioning government for entertainment Ms Nasiruddin is a master’s degree candidate in the Program value. Still, when we are dealing with disease outbreaks in Public Health at the University of California, Irvine. Her inter- beyond our understanding, we must first develop a capable ests are neurological and psychiatric disorders and the integration society that can effectively deal with outbreak control and of the arts and humanities in medicine. civic problems before mentioning any possibility of a cure. For now, we can at least rest in peace without worrying that References a zombie epidemic is just around the corner. 1. Littlewood R, Douyon C. Clinical findings in three cases of zombifi- cation. Lancet. 1997;350:1094–6. http://dx.doi.org/10.1016/S0140- Conclusions 6736(97)04449-8 Zombies can be used as a powerful tool for increas- 2. Ackermann HW, Gauthier J. The ways and nature of the zombi. ing awareness of issues of public health significance. The J Am Folkl. 1991;104:466–94. http://dx.doi.org/10.2307/541551 3. McAlister E. A sorcerer’s bottle: the visual art of magic in Haiti. popularity of the CDC piece on preparing for a zombie In: Cosentino DJ, ed. Sacred arts of . Los Angeles: apocalypse has been instrumental in teaching how to pre- UCLA Fowler Museum of Cultural History; 1995. p. 304–21. pare for disasters like the Tohoku Earthquake in Japan. 4. Davis EW. The ethnobiology of the Haitian zombie. J Ethno- We propose continuing these efforts, building on the pharmacol. 1983;9:85–104. http://dx.doi.org/10.1016/0378-8741 (83)90029-6 popularity of zombies to increase public health aware- 5. Shaw P. A history of zombies in video games. PC World. 2010 [cited ness in the general public, and explore additional issues 2012 May 28]. http://www.pcworld.com/article/206769/history_ that may have not been considered in the past, such as zombies_video_games.html infection control, mental health issues, ethics of disease, 6. Rabies. PubMed Health A.D.A.M. Medical Encyclopedia. 2012 [cited 2012 May 28]. http://www.ncbi.nlm.nih.gov/pubmedhealth/ and potential. These issues can be explored PMH0002310/ by taking advantage of various forms of media, including 7. Chinese county clubs to death 50,000 dogs: Campaign against rabies 1) distributing informational pamphlets, books, and other prompts mass slaughter in southwestern China. Associated Press. printed media explaining the similarities between zombie 2012 [cited 2012 Dec 19]. http://www.nbcnews.com/id/14139027/ ns/health-pet_health/t/chinese-county-clubs-%20death-dogs/#. infestations and lesser–known outbreaks and how to pro- URibxVqjdms tect oneself and others; 2) creating satirical or dramatic 8. Centers for Disease Control and Prevention. Rabies. 2012 [cited public service announcements to promote defensive com- 2012 May 3]. http://www.cdc.gov/rabies/ munity strategies against infectious disease outbreaks by 9. Wilson T. How zombies work: zombies in popular culture. How Stuff Works. 2005 [cited 2012 May 28]. http://science. using zombiism as an analogy; 3) using interactive games, howstuffworks.com/science-vs-myth/strange-creatures/zombie3.htm computer programs, and applications to en- 10. Resident Evil: T-virus. Resident Evil Wiki. 2012 [cited 2012 May able the public to safely experience the natural progres- 18]. http://residentevil.wikia.com/Tyrant_virus sion of real epidemics on different levels of aggregation 11. Khan AS. Preparedness 101: zombie apocalypse. Public Health Matters. Centers for Disease Control and Prevention. 2011 [cited (e.g., individuals, communities, policymakers, medical 2012 May 18]. http://blogs.cdc.gov/publichealthmatters/2011/05/ and public health officials, both infected and uninfected), preparedness-101-zombie-apocalypse/ with and without intervention strategies such as vaccina- 12. O’Connor D. Bioethically bracing for zombies. Johns Hopkins tion, quarantine, or extermination; and 4) and facilitating Berman Institute for Bioethics Bulletin. 2011 [cited 2012 Jun 10]. http://bioethicsbulletin.org/archive/zombie-attack/ the creation of clubs, societies, blogs, and even magazine 13. Cattorini P. Shall I become a zombie? Stories of illness, ethical articles across age ranges, academic institutions, and in- dilemmas and visions of society. Med Secoli. 2009;21:1017–35. ternet interest groups to share the excitement of apply- 14. Than K. “Zombie virus” possible via rabies-flu hybrid? National ing what we can learn about zombies to more applicable Geographic News. 2010 [cited 2012 Jun 15]. http://news.national- geographic.com/news/2010/10/1001027-rabies-influenza-zombie- avenues of life, such as public health and epidemiology. virus-science/ We must also consider the possibility–no matter how re- mote–that zombies could very well be replaced by oth- Address for correspondence: Brandon Brown, Program in Public Health,, er popular culture icons in the future. To that end, we University of California, Irvine, 653 E Peltason Dr, AIRB Ste #2020, Rm must continue to adapt and use these pop culture tools to 2024, Irvine, CA 92697-3957, USA; email: [email protected]

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