Isabel Mudford (@isabel_mudford), policy adviser and PhD Scholar at ANU, examines the overlaps of the COVID-19 and HIV pandemics in highlighting health inequities. She asks critical questions about who is given care, by whom and how, and the role of marginalised communities in advocating for the attention and concern of public health regimes.

For almost two years, the relationship between public health and social and economic disadvantage has been laid bare. Even in some of the richest cities with robust public health systems, COVID has disproportionately impacted the poor, and other disadvantaged people.

How and who we decide to care for is political. These decisions stem not only from access to capital or infrastructure, but from long histories of discrimination and colonialism, including within healthcare settings. While these histories are oppressive they also include experiences of community organising and the formation of organisations that advocate for increased attention to the health needs of these groups. How people and minorities come to be accepted as worthy of care by public health regimes are ripe for critical analysis, particularly at a time like this.

When COVID first emerged, LGBTIQ+ Health organisations around the country commented on how this experience reminded them of the first few months of the AIDS epidemic. As we began to grapple with how to minimise transmission of COVID-19 through harm reduction and communicate complex social, medical and political ideas to diverse communities, former AIDS activists and advocates shared their experiences of advocacy and policy making for minorities within the regimes of public health emergency.

Australia’s response to HIV/AIDS was considered as one of the most effective in terms of disease transmission. Key to this success was the embedding of affected communities including gay and bisexual men into the policy and political machinations of the country. AIDS Councils emerged in every capital city and began to agitate for attention to HIV and targeted, compassionate public health responses to these groups. These organisations remain active in the HIV prevention, awareness and peer support space and most have more recently expanded their mandates to include advocacy and primary health service provision for non-HIV related health issues.

My doctoral research examines the emergence of the category of LGBTIQ+ Health in Australia and how this category influences our understanding of what it means to be an queer person. This research sits within the field of critical public health, a theoretical area that is attuned to power and governance within public health regimes. Critical public health is interested in the relationship between labour, capital and the production of healthy bodies. I am looking at how the health of LGBTIQ+ people has come to be of care and concern despite histories of being neglected by public health institutions.

My interest in this category has come about through my involvement in helping to produce it. Over the last decade, I have worked in a variety of ‘LGBTIQ+ Health’ roles including as a peer support worker, a policy advisor, a Health Promotion Officer, a ‘LGBTIQ Special Projects’ coordinator, Chair of the ACT Ministerial Advisory Council, and most recently a political and policy advisor specialising in health and LGBTIQ+ communities. This work has been done inside and outside of LGBTIQ+ Health Organisations and in collaboration with community organisations, public servants, governments, organisational directors, doctors and other clinicians, and of course other LGBTIQ+ people.

Interestingly, the positions I have held have almost always been funded as either suicide prevention, or as HIV prevention but my practice has never directly been about either of these issues. Instead, my work has been focused on the correlation between being queer and experiences of health issues as disparate as cancer, drug and alcohol use, anxiety, aging, sexually transmitted infections and domestic violence. While I don’t dispute the evidence base that indicates poorer access to health services for LGBTIQ+ people, I am interested in how access to healthcare has come to be seen as the primary concern of LGBTIQ+ activism, advocacy and care and the relationship between this and our increasing access to citizenship.

Within a few weeks of the first diagnosis of COVID in Australia, Australian LGBTIQ Health organisations, almost all former AIDS advocacy organisations, produced websites, information sheets, social media posts, and other documents outlining the potentially devastating impact that COVID-19 could have on people within LGBTIQ+ communities.

The cover of Equality Australia’s report

JOY FM, an LGBTIQ+ community radio station based in Melbourne began making daily podcasts on the impact of COVID on Australia’s LGBTIQ communities including episodes on the impact of COVID on casual sex, trans and gender diverse people, and people living with HIV. Equality Australia, a national LGBTIQ+ legal advocacy organisation swiftly produced a report on the impact of COVID on LGBTIQ+ people and communities, covering issues such as equity in hospital admission, access to health services, discrimination in healthcare, experiences of domestic and family violence while in lockdown, use of drugs and alcohol while in lockdown, social isolation, and mental health.

For LGBTIQ+ Health organisations and the members of the communities they worked with to produce documents, forums and other sources of information, COVID was understood to be an LGBTIQ+ Health issue. LGBTIQ+ people are constituted throughout this LGBTIQ+-COVID ephemera not just as members of the public but as particularly vulnerable to the social and viral impacts of COVID-19.

Early on, this information produced LGBTIQ+ people and communities as a particular category of concern within the broader context of the pandemic. There is an implicit understanding that this vulnerability requires interventions from both LGBTIQ individuals+ and public health institutions.

While COVID-19 is not epidemiologically associated with LGBTIQ communities, these campaigns constitute LGBTIQ people as ‘at-risk’. To borrow Catherine Walby’s articulation that ‘declarations of epidemics are declarations of war’, it is important for us to question how and by whom LGBTIQ people have been brought so clearly into the COVID battleground.

Understanding COVID as a queer health issue is an example of the way in which LGBTIQ+ Health as category is constituting queer people as vulnerable, and at ‘at-risk’ to an increasingly broader range of health issues other than HIV/AIDS. My work examines how LGBTIQ+ people are being produced as a population ‘at-risk’ of ill-health at large, and how the practices, policies and programs that form the category of ‘LGBTIQ+ Health’ have become the central interest of contemporary LGBTIQ+ activism, advocacy and care in Australia.

This category is being formed and reiterated at a time when LGBTIQ+ people have just obtained a new style of citizenship enabling us to get married, raise children, be protected from discrimination at work, and when accessing services. The relationship between the attainment of citizenship and the attainment of public health attention creates questions about the unspoken compromises that our communities make when accepting mainstream care structures. How LGBTIQ+ Health has come into being, how it functions as a category, and how it provides care to LGBTIQ+ people is an insight into contemporary queer citizenship, both as a form of governance and as the exercising of sexual and gender practices, identities, and experiences.

COVID-19 and HIV share the status of being two of the most significant global health events of the last fifty years. The response to both of these viruses has evidenced the health impacts of social marginalisation and disadvantage. The politics of care - who is cared for, by whom, and how that care is administered - is an important topic of critique and investigation as we continue to respond to COVID and as we build the category of LGBTIQ+ Health. As public health practitioners and policy makers, especially those of us working with diverse communities, we should remain attuned to the inequalities of care, mindful that vulnerability discourses risk masking the structures and politics of who and how we care.

The histories and politics of care: LGBTIQ+ communities, pandemics and health in Australia