The Normal Heart Illustrates Normal Principles of Epidemic Management

I just watched HBO's The Normal Heart, a star-studded movie based on Larry Kramer's play of the same name. (Incidentally, in 2001 the HIV and Hepatitis B-positive Kramer received a liver transplant at my institution, UPMC, which had been pioneeringly transplanting HIV-positive patients since 1997.) The setting of the movie is the early days of the HIV epidemic and its plot revolves around the actions taken to increase awareness of this nascent epidemic. 

For those in infectious diseases, the story of how HIV and AIDS rose in the public consciousness is not new. In my own case, I remember learning about this disease in the early 1980s from my mother, a pulmonary medicine physician in a small town outside of Pittsburgh. She recounted to me a chilling story of having no nurse to help her perform a bronchoscopy on a dying AIDS patient with Pneumocystis pneumonia. She used a paramedic.

Watching this movie now, given the context of my own interest in emerging infectious disease, a few aspects really struck me. 

Social Network Analysis is Crucial

In any outbreak of a novel infectious disease--from HIV to MERS--it is vitally important to understand how people are getting infected. Old-fashioned detective work is usually how this is done. In the modern age, electronic social networking tools like Facebook and Twitter might make the activity more technology-driven but the principle remains the same. In the movie, the polio-afflicted character portrayed by Julia Roberts realizes that many of her patients are all sexual partners of each other and anticipates that they will all infect each other. Understanding the epidemiology and dynamics of infection through social network analysis often provides brilliant insight into the factors driving an epidemic.

Public Health Communications

During outbreaks there is an almost an unquenchable need for those at risk of infection to know how to protect themselves. During the early stages of an outbreak, misinformation may provoke anxiety, false security, or lead to incorrect actions to be taken. The Normal Heart effectively dramatizes the fact that when HIV was thought to be sexually transmitted, that and other information had to be disseminated. The Gay Men's Health Crisis served in that role.

Sentinel Populations Provide Early Warning

Outbreaks affect populations disproportionately. Not all elements of a population may be at risk. For example, veterinarians are at higher risk for rabies than the general population. Similarly, with HIV, men who have sex with men, injection drug users, and hemophiliacs were groups that were at higher risk because of the higher rates they were exposed to blood and body fluids. Currently, sentinel populations of interest include bushmeat hunters (novel viruses) and poultry farmers (avian influenza) and situational awareness of the illnesses these groups are afflicted with can potentially provide an early warning that a novel virus is spilling into the human population. 

The Normal Heart is primarily a movie about the social politics of the early AIDS epidemic and the intransigence of those trying to draw attention to what has risen to become the current #1 infectious disease killer. However, for those interested in more the movie provides some insight into how a disease emerges and the reactions of those caught in the midst of the ongoing war between man and microbe.