From epidemic outbreaks to pandemics, global risks for human health have nowadays moved from fiction to reality, eliciting major questions from the scientific community and decision makers alike.1 From a public health management point of view, the main issues in dealing with large-scale existential risks can be summarized as follow: How to avoid the crisis, and, if the event cannot be avoided, how to minimize losses of human lives? However, a major unknown steps in the way: the human factor. In terms of public health management, 2 types of actions can be taken to gain a measure of control over this complex variable: first, to educate the population on how to properly deal with a crisis situation, and, second, to develop models to predict mass behavior in emergency crises.2

Unfortunately, both of these aspects face major practical issues. Anyone who has ever tried to teach epidemiology knows that getting students to be interested in such a topic can be extremely challenging despite the major importance of this discipline for public health policies, management, and practices. And, while the spread of an epidemic can be modeled with reasonable levels of accuracy, predicting the behavior of individuals and populations when confronted to such large-scale events is far from being an easy task.

A few universities seem to have found in zombies a way to address the first of these 2 concerns.3-5 Taking advantage of the popular enthusiasm for zombie movies, more and more institutions are offering courses on zombies and ways to survive a zombie apocalypse, as possible models for broaching questions related to catastrophic crises-culminating this fall with the first zombies-based MOOC (Massive Open Online Course) offered by the University of California, Irvine, through the Instructure MOOC portal.4

When drawing examples from popular culture for teaching purposes, the question is to know how adequate the subject matter at hand may actually be for the class. In the present case, can zombie apocalypses really teach us anything useful? While using zombies as a pedagogical tool can be interesting, the practical value of the acquired knowledge may still be limited. This effect would be even more striking in parts of a course related to "zombie biology" or "zombie behavior," which would not only be likely to be simply irrelevant in a science curriculum but could also bear the risk of confusing the students on what is prospective and preventive science and what is fictional pseudoscience.6

On the contrary, such kinds of science fiction settings-which may, in fact, describe events less dramatic than those featured in zombie outbreaks or other postapocalyptic narratives, but still having a strong survivalist component-could be used to elicit different points of view supporting multidisciplinary content for a course. For instance, zombies could represent an ideal medium for accessing themes such as global public health policies, crisis management, or even nutrition. In fact, both by its structure and by the teachers involved, the University of California, Irvine, MOOC is a massively interdisciplinary course, with professors coming from backgrounds as diverse as social sciences, physics, public health, and mathematics. While such topics may at first sound difficult to reconcile or unite, they all shed light on important facets of public health management under extreme conditions, such as those likely to occur during a major crisis. The advantages of such an approach for students is obvious, since it allows them to form a more complete picture of what crisis management entails-not only health-related issues but also the many issues associated with dealing with human beings, individually and in large groups, as well as with unstable and harmful surroundings.

However, each coin has 2 sides: one risk would be to have a model of content-driven rather than of goal-oriented teaching. This multidisciplinary aspect can be a weakness as easily as it can be a strength. When teaching disconnected topics that are only linked by their relevance to a popular culture phenomenon, one runs the risk of permanently staying on the surface of things, without giving students the tools to understand the more advanced facets of each subject. Another related risk would be the lack of internal coherence between the different disciplinary components of such a popular culture-based integrative course. Nonetheless, such a strategy could also break the boundaries between subjects, showing connections between them and encouraging students to tackle various problems in original ways.

Educating individuals using conventional or technology-supported university courses is a first step. However, to prove itself really useful in terms of impact on public health management, this strategy should also be extended toward the "education of the system." If mathematics is, for instance, essential to create precise models of population dynamics and social sciences can highlight how human beings are likely to react, individually or as a group, all that knowledge is operatively useless in the context of an actual crisis if it cannot be translated into public health practices. In fact, zombie scenarios have already been used for practical workshops on crisis management. For instance, the Center for Interdisciplinary Clinical Simulation and Practice of Drexel University experimented with a zombie outbreak simulation.5 Students attending the simulation were not told that they would have to deal with mock zombies; instead, they had to deal with the "outbreak" without any preparation whatsoever. Once again, the value of preparing groups of professionals for such an unlikely event may not be a priori self-evident. Still, the element of surprise is present in many disasters and being able to react to even the most unexpected event could be a valuable skill for many public health practitioners and decision makers, especially since such situations would be likely to cause widespread distress in the public. In addition, fake zombie outbreaks are relatively easy to stage, making them potentially convenient to use for training groups of professionals who might have to take collective charge of people in the event of a catastrophe: political leaders, health care professionals, teachers, police officers, just to name a few.

Nonetheless, the main interest of zombie outbreaks for pandemic studies may not lie in their putative use as a pedagogical device but in their major, yet untapped potential for research. Just as teachers from varied backgrounds can work together on a course, researchers from equally diverse fields might come together in a laboratory. Crisis management and decision making involve complex phenomena, which might be tackled more efficiently by a diverse team of researchers, each bringing his or her own perspective to the issue. In that view, the study of popular culture descriptions of fictional catastrophes could represent an extremely useful tool for the exploration of existential risks, as science fiction provides a lot of settings in which some aspects of large crises are developed, allowing to safely test various scenarios. In the present case, would it be possible to predict human behaviors-both the most likely to occur and the most appropriate-from a zombie apocalypse narrative?

Popular fiction may not predict the future, but the fact that some popular works resonate strongly with the public indicates that they might have a certain insight into human psychology. Obviously, fiction and reality differ in more than one way, and there is indeed some distance between a zombie apocalypse and a real-life epidemic outbreak. When people suffer from a strongly-possibly lethally-infectious disease (eg, an extremely virulent avian flu or a pandemic version of the severe acute respiratory syndrome), it is unlikely that they would be running around trying to contaminate all the healthy humans they encounter. The very definition of a disease is that sufferers are significantly weakened, or even killed-and the definition of death in a world exempt of zombies is that the dead do not run in herds to feed upon the living.

Nonetheless, zombie outbreaks display many components of what real-life catastrophic pandemics could be like. The apparent randomness of the event, unprepared population, destruction of social structures, mass mortality, and the extreme degradation of environmental conditions are some of the main features of zombie narratives, as is the necessity for survivors to protect themselves from altered, hostile surroundings. Consequently, such popular culture-based settings could provide unique opportunities to focus not merely on the diseases themselves but also on the resulting social dynamics among survivors and on behavioral issues in general, emphasizing the practical and ethical question of survival in a world where existing structures have been wiped out by an epidemic. Such a multifaceted approach would require the intervention of specialists from very different fields, and zombie scenarios could be used as preliminary guidelines to provide an insight into what sorts of collaborations could be more fruitful. This could prove a definite asset in a context where some researchers may have little experience of working with different fields and could have initial difficulties in planning interdisciplinary partnerships. The importance of an interdisciplinary methodology may thus be yet another valuable lesson zombies could help drive home.

Still, an important question remains. Zombie apocalypse fictions are, first and foremost, entertainment. In other words, they are constructed around the many unspoken rules of the genre. As a result, if one seeks to deduce behavioral models from zombie movies, one should first disentangle what could be real human behavior in a situation of existential risk crisis and what is merely a cinematographic plot device-an operation that might prove tricky. For instance, protagonists of zombie apocalypse scenarios often react to the outbreak in a way more similar to medieval people facing plague or leprosy than to contemporary practices. Survivors tend to flee and barricade themselves from the threat, instead of trying to rationally analyze what is causing the disease and find a cure for it, as contemporary scientists would hopefully do. However, this particular plot device also exemplifies the fact that a large part of irrationality still subsists in popular perceptions of epidemics. One might indeed argue that awareness of irrationality and popular representations, and their potential impact, might be paramount when trying to figure out behavioral models of survival in worst-case scenarios. Rather than exactly representing an epidemic, zombie outbreaks appear to represent what we could call the ultimate catastrophe in our culture, sharing traits with pandemics, natural disasters, and even armed conflicts. While this makes attempts to use them as a behavioral model risky, zombie outbreaks could also reveal deep collective fears and beliefs about natural catastrophes, an insight that would prove useful in dealing with populations affected by disaster.

As out of place as zombies may seem in a laboratory, studying them could have fascinating outcomes in public health research for the management of emerging crises.

Zombie outbreak simulation: A simulation using zombie-based scenarios devised to teach emergency or crisis preparedness; it can be either virtual (as a theoretical construct or in a virtual environment) or physical (see below).

Staged zombie outbreak: A zombie outbreak simulation that uses either actors or the participants themselves to embody the progress of a zombie-like contamination; this type of simulation can be used as a practical exercise in emergency or crisis management for groups of people.

Example of a zombie outbreak exercise

Staged zombie outbreaks are easy-to-develop practical exercises for crisis preparedness. The following example takes place in a health system context:

Setting:

* Staff and patients should be told beforehand about an upcoming practical crisis management exercise, without knowing its exact nature.

* A few actors (external or internal) represent the origin of the outbreak.

* Any person in direct contact with them would become "infected" and spread the epidemics.

* In order not to disturb the normal functioning of the center, the exercise would last 1 day maximum.

Evaluation:

* Initial communication: How long did it take to inform members of the center of the emergency?

* Efficiency of the reaction: Did all services cooperate optimally? Did some panic reactions occur?

* Containment: Did the teams succeed in containing the epidemics? Was the contaminated area reasonably small?

* Protection of the population: Was the evacuation of nonrequired people optimal? Were the patients adequately protected or transferred to noncontaminated areas?

* Casualties: How many human casualties ("contaminations") occurred before the epidemics was contained?

* Communication: During the crisis, were the communications between team members and managers and between the center and the outside world adequate?

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