Funny Thing about Pandemics: Queer Histories, Interventions and Communities in HIV, COVID-19, and Mpox

Andrew Spieldenner [AS]: Let's talk about pandemics. We've both worked in the HIV pandemic, which I guess is largest and longest standing pandemic of our lifetimes, at least until the emergence of COVID, which is ongoing still.Cindy Patton [CP]: You mean it's not over???AS: Funny thing about pandemics!CP: Yes. It's been interesting to watch the COVID pandemic policies in British Columbia—some of our public health leaders still do not really accept that airborne transmission has been the principal route of transmission for COVID. This is especially interesting because BC has also been a global leader in HIV clinical trials. The HIV scientists here would say that they are the ones who first to trial and then implemented “treatment as prevention”—initially conceptualized as getting the largest number of people with HIV on HAART as quickly as possible. Of course, when PreP first emerged, it was not considered “treatment as prevention” because the social marketing of PrEP was that it was more like a vaccine than a treatment. But eventually, BC's HIV service providers went all-in on the PrEP approach, so it was folded into the larger understanding of “treatment as prevention.” I suppose this emphasis on pharmaceuticals infiltrated the COVID policies. . . .Vancouver is a weird place, on one hand, progressive, but at the same time compliant. For example, Michael Brown's book on Vancouver during the early years of the AIDS pandemic suggests that the gay community here organized, but in a quieter way than say San Francisco or New York or even Toronto. Leftist politics got to a certain point, but no further. This underlying compliance has played out interestingly in COVID—at first, most people believed the government was doing the right thing. Social distancing is easy here because people are already a little stand-offish and we have lots of open spaces. But when it came to mask mandates, these were never implemented, not in schools, not on public transit. We were “encouraged” to wear masks, but there was also an invocation not to question people who were not wearing them because they might have some sort of disability.Because BC has invested heavily in biomedical research, there are competing research teams gathering data and developing models. Somewhere around the time that home tests became available, the government simply stopped collecting verified test data, and there was a tacit policy decision to let it rip. A lot of us feel like we're part of a little COVID experiment and our provincial health officials (not our Centers for Disease Control, who have been in tension with the provincial authorities)—that sounds paranoid, but actually the provincial health offices have published eight studies already, and these are now cited by policymaker in other places to say that masks are ineffective as a population wide tool. To be fair, some of the early policies were related to the fact that Canada got outmaneuvered in the vaccine market. We were very late to roll out vaccines, and so we were an obvious “natural experiment” for the idea of hybrid herd immunity that combines actual infections and vaccination.AS: I didn't know that. . . .CP: Canada was initially part of a partnership with the China government's military medicine branch called CanSino Biologics, to fast track a vaccine. In addition, Canada has a partnership with Moderna that involved early receipt of vaccine. The CanSino product didn't perform well, and Moderna had production problems. We had television news reports about the factory in some small town in Belgium that was supposed to be producing the vaccine doses that would come to Canada . . . it was all very sentimental. When that factory had production problems, the Canadian doses were cut so dramatically that it was like, never coming. So, Canada ended up with the small amount of Pfizer vaccine that was under contract, and then when the US dumped AstraZeneca, a lot came to Canada. But the government was nervous, so you were on a schedule to get Pfizer, but if you wanted to voluntarily take AstraZeneca, you were “invited” to go to your pharmacy.AS: Interesting, because when we look at these pandemics, they often reveal these circuits of power and how/where things get made. And people weren't realizing, what does that look like in global distribution and how might that impact the waves of disease and waves of outbreaks? There's a discussion of justice that we're very sensitive to in HIV that hasn't quite gotten to other kinds of global health.During the International AIDS conference over the summer, we were encouraging people to get vaccinated for mpox. When you walked into the Gay Village in Montreal, they asked you in French, have you had your monkey pox vaccine, it only takes twenty minutes for you to get it and then you're done. These people from all over the world were taking advantage of it, including a ton of Americans, because it just wasn't available in the US yet. Why are we able to access this vaccine on the streets in Montreal that we have no access to in the US or in other parts of the world? Those questions, I don't know why they're not part of public discourse more—why do these healthcare systems and these distribution systems break down, and other industries that pop up, like the COVID testing industry.CP: Vancouver was very quick to get mpox vaccination up and running. I suppose you had to be slightly hooked into the gay community or into MSM sex networks, but I remember walking down the street not long after the mpox vaccine became available. There were bus stops signs in the gayborhood—beautifully designed, ethnically diverse and culturally sensitive to gender variance—the very pinnacle of social marketing! I was hearing from people that you just had to walk in and poof! mpox vaccine. This was at the same point in time when it was really difficult to get a COVID vaccination—you had to register for an appointment. There was this very interesting asymmetry—the gay health bureaucracy had the ability to construct “gay and transgender men” as exceptional, as people who had very well defined needs. There was no comparable “COVID community”: at best there was prison advocacy or advocacy for poor people or advocacy for people who live on First Nations reserves, but these were based on conceptualizing “risk spaces,” which did not function in the same way as social marketing to encourage “people at risk.”AS: This gay health bureaucracy that was built up during HIV, it's interesting how the government relied on and expected the gay health bureaucracy to take over the health department's role during mpox and, without any funding, do the community education, do the vaccine distribution, do the advocacy work that needed to happen. There still isn't government funding bolstering those efforts in the US. The reliance on the gay health bureaucracy—at the same time that it exists, it's also under threat, as funding changes and shifts. There's little investment by the government into these community-based responses in public health efforts. And community-based responses are what actually gets us across the line and gets more access.You brought up sex networks—I walked into one of the strip bars in Montreal. And the dancers were asking me if I got the mpox vaccine. There's nothing more motivating than a stripper asking you to go get the vaccine.CP: You mentioned the gay health bureaucracy—I'd like to go back to the 1970s for a minute and to think about the forms of gay health activism before HIV. As you know, there were a series of gay health summits beginning in the 1970s. New York was a key city for gay liberation, as were Los Angeles and San Francisco, but there were other important places like Denver and Portland, Oregon. Activist Walter Lear, who was a generation older than the gay lib folks, was already well-positioned in the public health system. His personal archives are held by the University of Pennsylvania, and I had an opportunity to go through them. In addition to his work on reproductive rights and universal health care, Dr. Lear was involved in Philadelphia, and later national, gay and lesbian health initiatives. During the Carter administration, there were a number of people who were invited to work within various departments on queer issues. For example, late Eric Rofes was doing work on education, and group of gay psychologists, doctors, nurses, and social workers were involved in an initiative at the CDC.Walter Lear and others created an explicit gay health agenda that was actively negotiated within the Carter administration. There were several parts of the plan, including a proposal by some of the lesbian physicians, psychologists and social workers, to include the diagnosis of “homophobia” within the DSM. In retrospect, there are all kinds of problems with this, however, at the time, it was a way of saying “it's the people who hold these beliefs who are pathological, and not the thing they fear.” Along with the diagnosis would come federally mandated antihomophobia training, or really “treatment” since homophobia would be a clinical syndrome. It was very funny to read it, but this idea reflected the strong analysis within the emerging health gay bureaucracy that there was something fundamentally, socially and psychologically wrong with many people in America.The other parts of the gay health proposal program were public health training, some internships that would bring gay doctors to Bethesda to NIH. The thing that struck me pouring through these papers was that the lesbian/gay health movement at that point was actively debating what changes would be necessary to change the hostile conditions that gay Americans were facing. Of course, the government ultimately refused to do any of these things, but the meetings and collaborations created a lot of connections between the clinicians and the public health people. This was critical a couple of years later when the first cases of AIDS appeared.There was recognition at that time that “venereal disease” rates, were higher among homosexually active men, and the people who had organized the initial health summits, including gay physicians, physician assistants, as well as some activist nonphysicians, applied for and received federal money to do a study on access to treatment. Their goal was to show that if local mobile clinics (essentially, “buses to the bushes”) were operated by gay men, then more gay men would attend VD clinics for testing and treatment. It's a great research question, and remarkable in some ways that the government funded it, but from a social science research point of view, it was poorly designed. However, the study did show that gay men were more inclined to seek help from a gay-managed services, and this study became the evidence that people within the public health world and gay world pointed to. We take the idea that subgroups prefer services delivered by people like them as a kind of commonplace. But I think we have to put some limits on this kind of thinking once the services become bureaucratized. Who are the clinics then responsible to?Fast forward to mpox in Vancouver . . . we are a city where gay health services are extremely bureaucratized. In the 1990s, there were waves of radical gay male organizing but once groups began to rely on government funding (because of the scope and complexity of HIV), they transformed into something unrecognizable to my generation. For example, the precursor to HIM—Health Initiative for Men—was a group called Gayway, a place to form “positive” gay men's community. If a guy wanted to offer knitting lessons, Gayway would post it, and people would go and have knitting lessons. But the organization changed to become more like a social service agency, albeit run by gay men. When the funding for PrEP came along, they jumped on it. Some of the “older generation” of activists questioned whether this is what a community group should be doing, but taking money to do this biomedical intervention was seen as a way to engage in other kinds of services. That never really happens. The group is now visible to the government as a place to do more medical interventions, so groups like HIM were perfectly positioned to run the mpox program, having promoted PrEP like a vitamin for sex, promoting the mpox vaccine was totally logical.AS: It's interesting how those units of community or these categories of community don't get changed in public health bureaucracy, even though the actual living conditions have changed dramatically for many, many of these categories.I love homophobia as a clinical problem. One of the real magic moments of the last few years was the movement for Black lives. The fact that they put racism on the public health agenda so clearly and white supremacy as a problem that has dire effects on public health is brilliant. More and more I think that maybe we need to contextualize homophobia and transphobia in similar ways. Not the same way, but in similar ways. Because globally we see countries that turn their backs on us just because they proclaim that culturally we don't exist here.CP: What did you think about the mpox reporting? I noticed on my New York Times feed that their graphical representation of the geography of testing positive for mpox is almost identical to the graphics they use to represent COVID. It's as if some God creates a giant disease incidence graph On High, like pink is COVID and blue is mpox.AS: Those visualizations, they're meant to be and with for a lot of my work is in and the countries even It this of don't need the vaccine because we have no But no of the why the of mpox as a public health of became important because then mandated to do least activists that you have a that there was in fact a of a kind of gay activism in the of more so than in COVID. went and in to personal about how their was with mpox. had been they were for they were in their they had been through the mpox And then after of this, a them for mpox and I guess you did have it. Because you weren't that And I a of that kind of activism for an for vaccine One thing about is that there are . . . people who are to become active in the Their the larger because you have people are into a what they in is not understanding the not understanding where to go if they have kinds of health related to this that they To use into a ways of doing sex and in a that they are about but not quite at noticed about how to be our first were saying things like gay out was by so was really a up for people who went on the without really the things that a to know if to of my were like, don't why it's on and I was like, “it's the I was of the early . . . the forms of that are within gay male became visible through the of HIV and now mpox. HIV, we see now that the movement of the out into poor or poorly creates local like what we with gay have the and medical to at least the that is even though the is now in places where the distribution is more and the more There were these in the in the US. The health would the a certain number of to to people or up a place for These of white gay men of a certain social It would be to people of in places like there was the same kind of for a long And it some of the community groups that are more not service but they're more like, have or talk about getting you a Those had to really to get other gay men to kind of I do this, this is to and it's I also interesting in the kind of first or is this about whether it's a And I like we're like right back to the where the idea you're a and your is a sex the is And this sort of to think like what are the things that are here that a little to go from point A to point it it not there be into a small or There was a on the part of the to a of some If it's just then it be gay because is not and it's not sex and sex has to have got to be how it with people. activists were quick to public health of queer men not to have I don't to this to but the generation of into have been to that is by And they're on the until we this There was a kind of don't me what I and do for But the they were is not one as the critical producing In the well have been gay but not in in our discussion we about and It just the might be the problem with how we're with the community is mpox a gay disease because it's not gay And if it's then it's got to be because of And that discussion around . . . so about gay sex like that that it's about Because we don't have in the health bureaucracy, no way for them to queer sex in a way that the sex and the sex to one or have been about the and impact on the but what about the These to be a lot of how many and was I was on last as all of this was because the was a and now back to and a very people into any because they don't feel or because positive for I really with my of justice around these things as well as kind of an and an that this is asked of me and not the It's the of the to this community with the to out a best think I have about years before And then out of the US and into The last years has it's totally to this is not my I think at some point our is to hold for other people to like and be able to their of who was part of was doing an with a doing of people of and so at the it never to you to do about the in the And I did We had all of this organizing and it never to you do I think that an interesting question One is what are the any of us at any point in But also do we help people the in the And not saying there wasn't because I think many people who came into the AIDS movement came out of like the which was a of activism at that in I remember in about the of rights or what we called and which we called These were critical parts of the within gay in early There were all of and efforts that were out of a of we were to many of our first were around some of created That is a very that would be by a You a community around a because not what they're there But you're there is a when we don't those we forward we see with and what to be HIV organizing with people living with HIV and especially certain queer people of to and responses and to whether it's around or and Those things don't get in the they get in did not well in the COVID A number of years a of us did a on the and had a group of men doing in which they of where We had a very of the that people through the how they organized their time, how they with and When I walk in the some of the have been down and are I know there is still a of but it is to get around the it quite We once the to hold a community but people who a and when those people no in the . . There's and the the that open up or when people do knitting those are And I think people to hold them and to hold them as kind of necessary for how we I about queer . . . I see things that are supposed to to me that there are gay or queer people at that but do they what I years as an living through I having a little of but I think to just a I see a lot of people in my who are queer so I know how queer as an and even as a that a or a but does it a larger of I guess I that a of across would be but now I feel I from a generation before that built up a gay community and a gay that meant at the able to point to a place where I go to when I was to a because it was was important to I don't know where it's now and how this generation or If it on like social to do it, then that has already That that kind of I to gay . . You gay It is a and so globally . . But why health be that

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