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Abstract
Among the growing number of works of graphic fiction, a number of titles dealing directly with the patient experience of illness or caring for others with an illness are to be found. Thanks in part to the Medical Humanities movement, many medical schools now encourage the reading of classic literature to gain insight into the human condition. Until recently, the medium of comics (the term is used in the plural to refer to both the physical objects and the attendant philosophy and practice surrounding them) has received little attention from healthcare scholars, even though some authors argue that graphic fiction is, in fact, a form of literature. This paper suggests that it is time that the medium was examined by healthcare professionals and studies some acclaimed comic works. Drawing on the principles of narrative medicine, this paper will ask whether comics and graphic novels could be used as a resource for health professionals, patients and carers.
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Introduction
What, asks Stephen Rachman,1 is the role of literature in medicine? What ends does it serve? To humanise professionals, or to study the narrative aspects of medicine? To look at the ways that storytelling might be therapeutic? To chasten medical hubris? The need to locate literature in medicine, he suggests, is generally seen as corrective to this century's overvaluing of medical science and technology. Narrative, Susan Poirier2 has proposed, is the ‘glue’ that holds literature and medicine together. According to Rachman,1 medical knowledge and practice has an inherently narrative structure and Rita Charon et al3 suggest that studying literature helps physicians grow in self understanding and that literary theory contributes to an ‘ethical, satisfying and effective practice of medicine’ and can lead to ‘a richer and more mutually fulfilling human encounter that better brings about healing’. For two decades, literature has been used within medicine as a reflective tool that attempts to bridge the gap between knowing about a disease and understanding the patient's experience of that disease.4 Alongside the study of classic works by authors of repute, one notices academic discussion of the more popularist, mass media arts such as film and television. Until recently, however, little attention seems to have been paid within anglophone medical discourse to what French critics call ‘the ninth art’: comics.
This underrated medium has recently begun to receive recognition and acclaim from literary critics, academics and broadsheet reviewers, with the graphic novel in particular becoming comics' ‘passport to recognition as a form of literature’.5 These hardcover collections of sophisticated stories are able to recruit readers from outside the usual comic demographic. Many titles are biographical or autobiographical in essence and this category has been christened autographics by Gillian Whitlock to ‘draw attention to the specific conjunctions of visual and verbal text in the genre of [comics] autobiography’.6 Among the growing number of autographic works, titles dealing directly with the patient experience of illness or caring for others with an illness are to be found. Green and Myers7 call these memoirs graphic pathographies and describe how they can be used in a ‘novel and creative way to learn and teach about illness’.
The focus of this paper is whether graphic fiction with (or indeed without) a medical theme could be a useful source of illness narrative on which clinicians, healthcare or social work professionals and scholars of narrative can draw. To that end I will argue that comics and graphic novels can effectively relate the patient experience and, indeed, the experience of the carer or healthcare provider, and that comics might have a particular role to play in the discussion of difficult, complex or ambiguous subject matter. For want of space, I shall not dwell on the visual aspects of comics here, although there is much that could be discussed with respect to the ways that comics could inform what Lupton8 terms the iconography of disease: the impact that portrayals of suffering in comics could have on the way that illness and disease are visualised.
Why comics?
Over the past two decades, comics and graphic novels have been studied by academics, and a growing canon of comics theory has evolved. In the English speaking countries this rather diverse field has tended to concentrate on historical, sociological, aesthetic and thematic aspects of the medium9 whereas Francophone scholars have examined the form of the subject from the viewpoint of semiotics. Versaci10 lauds comics as: “a unique and sophisticated representational medium that can express formal, thematic and political issues in ways directly attributable to either their poetics or their cultural positioning or some interesting combination of the two”.
The fascinating history of graphic fiction has been chronicled extensively by such authors as Weiner,11 Hatfield5 and Versaci10 who chart the journey of the comic strip from the promotional giveaway pamphlet via broadsheet staple, the arrival of the superhero, through the years of the comics code censorship to its modern day extended form: the graphic novel. Contemporary graphic memoirs trace their genealogy to the products of the counterculture of the 1960s and 1970s. While superheroes flourished, authors began experimenting with ‘alternative’ comics aimed at adult readers which, rechristened ‘comix’ or ‘commix’, delighted in graphic portrayals of sex, drug taking and violence.
The American cartoonist Justin Green is often credited with inventing a new genre when, in 1972, he became the first ‘neurotic visionary’ to ‘unburden his uncensored psychological troubles’ onto the pages of Binky Brown meets the Holy Virgin Mary, ‘an astonishing self-flagellation of catholic guilt and obsessive–compulsive disorder’ (figure 1).12 Brown (Green's alter ego) develops a compulsive neurosis as a child. Having been brought up in a strict Roman Catholic family, his obsessions soon take on a religious bent. Thoughts of causing harm to his family through non-compliance to compulsions turn to thoughts of inadvertently committing blasphemy against God. As he has just hit puberty, sexual obsessions get mixed in and he is plagued by intrusive carnal thoughts of the Holy Virgin. His world is soon weighed down by an ever expanding web of associations, obsessions and compulsive ritual. It is hellish for him, but the way that Green ironically portrays himself is as hilarious as it is grotesque.
Green J. Binky Brown meets the Holy Virgin Mary. San Francisco: Last Gasp, 1972, cover.
Green was only diagnosed with obsessive–compulsive disorder after his comic was published, at the time the condition was ill understood and there was no ready treatment; now in an age when the causes of obsessive–compulsive disorder are better understood, this comic book still works brilliantly as an example of what it is like to suffer the mental torments of the condition. This represents, then, a valuable document containing narrative untainted by memes or expectations of what it is to suffer this condition drawn from popular media or medical description. In laying out the narrative of his suffering, Green has become an example of what Arthur Frank13 calls ‘the wounded storyteller’: one who has lived through a profound experience and, by relating the story to others, has the ability to heal.
Autobiographical comics and graphic novels have since overturned the superhero of comics' past ‘in favour of the particularised and unglamorous common man or woman’.5 This movement has generally happened at the more radical end of comics publishing, stemming from the alternative commix scene, but gradually flourishing to include many types of portrayal of the self.
The human brain seems to work in such a way as to try to extract or impose narrative, even where none may exist. Comics use this innate propensity to their advantage. When one perceives two or more juxtaposed images, the brain assigns the sequence a narrative timeline. A comic strip is actually a sequence of static images, contained within panels, a ‘staccato rhythm of unconnected moments’,14 also known as a breakdown, with gaps in between. These gaps are known as gutters and it is here, in these narrow voids, that Scott McCloud proposes the ‘magic and mystery’ of comics takes place.14 It is, suggests McCloud, a medium of fragments which gives sense of a continuous reading experience so seamless it actually ‘feels like living’.15 The ‘rhythm of acquisition’16 in comics is governed by the reader, who might read slowly or fast, forwards, backwards or even skip to the end of the story to see what happens. This active engagement, the complicity between reader and author, may be one of the reasons the medium is so powerful. The interplay between the written and visual is subtle and complex; a comic does not ‘happen’ in the words, or in the pictures but somewhere in between.
The latter half of the 20th century has, suggests Will Eisner,16 ‘experienced an alteration in the definition of literacy’. The proliferation of the use of images as communication is being propelled by the growth of technology, resulting in text reading skills becoming less important. ‘Indeed, visual literacy has entered the panoply of skills required for communication. Comics are at the centre of this phenomenon’. Complex ideas can be quickly and easily digested as images or as a partnership of words and imagery. As literacy is being redefined, other definitions are also being challenged, with comic art being proposed as a form of writing.5 Chris Ware, a master of melancholic visual storytelling, calls it both ‘writing with pictures’ and ‘an emerging language’.17
Medicine in comics
Medical stories in comics are nothing new. Hansen18 has studied the portrayal of notable medical figures in the true adventure comics of the 1940s in which the quest for discoveries was portrayed as a form of heroism as valiant as that of the battlefield. What Justin Green started in 1972, however, has over the past decade become a recognisable genre within comics: the graphic memoir of illness or trauma. On my website (http://www.graphicmedicine.org/), I list over 60 graphic novels relevant to healthcare studies, with more being published each year. Many of these works are drawn and written by skilled comics artists who happen to have had a personal experience with illness or with caring for a relative with medical problems. These authors are able to cogently articulate their experiences in an immediately engaging way. Through words and image, the world of the patient undergoing investigation or treatment is laid out. Entering this world might help healthcare professionals to imagine themselves in the patient's place.
One such author is Brian Fies who chronicled his family's struggle to come to terms with their mother's metastatic cancer in an anonymous, serialised web comic, Mom's cancer. He hoped that others similarly affected would find some comfort in knowing they were not alone. Mom's cancer19 is about the healthcare experience of an average middle class American family. Several themes emerge: Mom's feelings of bewilderment, fear and dislocation; her changing body image; the cost of treatment; and poor communication on the part of the healthcare professionals. There is an obvious lack of holism in her care: the different manifestations of her metastatic illness are treated by different specialists and Mom feels that different parts of her body belong to different people. Fies skilfully draws on his repertoire of comics devices, portraying ‘Mom’ as a version of the popular game ‘Operation’ to denote her body's perceived division between the various specialties supposedly caring for her (figure 2).
Fies B. Mom's cancer. New York: Image, 2006:12–13.
In another sequence illustrating the ‘balancing act’ of chemotherapy—harm versus benefit—Mom, hairless from her treatment, is shown walking a tightrope above a pool of crocodiles while various obstacles appear to throw her off balance (figure 3). Thus, as Fies explained recently during a comics workshop in Chicago (June 2011), a metaphor that might prove lame in textual form is rendered both illuminating and amusing in comic form. The subject of cancer is treated in a lighthearted, if somewhat wry, manner without making the story funny per se. Mom's confusion and suffering are sensitively documented and the book contains a fair amount of clinical information, maybe intended to help sufferers understand what they are experiencing.
Fies B. Mom's cancer. New York: Image, 2006.
Of course humour, often savage and self deriding, has been a trademark of alternative comics for decades. Humour in this context serves not to trivialise the subject but to engage the reader's attention in an area that might otherwise be avoided. Ken Dahl's Monsters,20 an award winning semi-autobiographical graphic novel about herpes, is at once outrageously funny, filthy and desperately empathetic. Dahl is superbly skilled in his articulation of anxiety, despair and social isolation while remaining clued into the absurdity and irony of social attitudes and behaviour. Ken has a cold sore. He is blissfully happy with his girlfriend Rory until he transfers his herpes simplex type 1 to her ‘nether regions’, at which point his love life and emotional well being begin to deteriorate. He manages to infect at least one other girl, who never forgives him, and is publicly humiliated by his friends who all know what he has done. As pain and guilt eat into his psyche, he starts to see himself as an oozing, virus ridden monster (figure 4). He seeks solace in abstinence, but finds the lack of human contact unbearable. He has no health insurance and cannot afford expensive antiviral drugs, so arms himself with an arsenal of dubious naturopathic remedies. Redemption is found, however, in self education and the love of a good woman, and the story has a hopeful ending.
Dahl K. Monsters. New York: Secret Acres, 2010.
Like Mom's cancer, the author has included much information within the graphic novel. It does an excellent job of informing the reader about living with herpes. This use of infographics is a common feature of comics and differentiates the medium somewhat from prose novels, blurring the boundaries of textbook, novel and autobiography. Monsters also says much about life in general, love, guilt and anxiety, bundled together in a first rate tragicomic graphic novel.
In contrast, David Small's Stitches falls firmly into the genre of tragedy, albeit with a hopeful ending. Beautifully drawn in washy monochrome inks, this is the story of an unhappy childhood, a dysfunctional family and an iatrogenic cancer, caused by the author's father! Small's parents, trapped in an unhappy marriage, are portrayed as cold and distant figures. His mother was a closet lesbian who admitted she didn't love her rather sickly young son. His father was a radiologist who was used to treating David's sinus problems with x-ray therapy, as was popular at the time. Unfortunately, this treatment caused a cancerous growth in his neck, although his parents ignored the growing lump for 3 years. When they are finally persuaded to take him to see a specialist, his mother berates him about how much the medical bills will cost (figure 5). The resulting operation leaves Small with a large disfiguring scar down his neck and voiceless, one of his vocal cords having been removed during the operation.
Small D. Stitches, 2009:122.
There is relatively little text in this book, with long periods of ‘silent’ graphic narrative, the mood, sombre and dysphoric, being effectively conveyed by the artwork. These non-narrated sequences might convey what Frank13 would call the author's ‘chaos narrative’: the ‘story that no-one wants to hear’ articulated visually for want of a voice. There is more ‘showing’ than ‘telling’ and this is how comics should be; the reader is left to construct the narrative from the pictorial sequence and, as a resultant, the story comes to life in one's head. One feels the discomfort as the voiceless adolescent David is ignored at parties, rendered invisible by his lack of voice. It is through art he is redeemed, however, as his talents attract the attention of his peers and, more importantly, potential lovers. He recovered his voice too, over a period of about 10 years, so the story could, according to Frank's typologies,13 be said to turn from chaos to a ‘restitution narrative’, but his period of enforced muteness has clearly marked him to this day.
Cartoonists who have experienced illness are telling their story, as Frank13 puts it, not just about a wounded body but through a wounded body. In Small's case, the wounds, now turned by time into scars, are both physical and emotional.
Miriam Engelberg, a computer programmer working in the non-profit sector, documented her diagnosis and treatment of metastatic breast cancer in Cancer made me a shallower person.21 She was not a trained cartoonist, but her untutored, charmingly naive style lends an air of veracity to the work. It is a collection of gag strips, dark, well observed and funny, rather than one continuous narrative, but it spans the time from initial diagnosis to palliative care for brain metastases. Each strip tends to deal with one particular aspect of having cancer, from the awkwardness of her friend's greetings after her initial diagnosis (‘social niceties are never quite the same after you've had cancer’), through the ‘why me?’ self searching, nausea, wig buying, daytime TV and tele-marketers to depression and despair. There are some choice moments, one episode features an overly cheerful radiotherapy tech, Dina, a Christian who plays the patient evangelical songs during radiotherapy. She preaches at her patients and wears a glove puppet called ‘cheer up kitty’ to try to get them to smile as they are having their treatment (figure 6). Engelberg was a self taught cartoonist and her graphic diary is the result of someone who decided that lack of training in the graphic arts should not be a barrier to self expression. Such stories might prove enlightening to healthcare professionals, as well as carers, friends and relatives.
Engelberg M. Cancer made me a shallower person—a memoir in comics. New York: Harper, 2006.
Engelberg rails against the way that her life is reduced to a Kubler-Ross ‘stage’, attached to her diagnosis (‘FUCK Kubler-Ross’) and has much to say about the way that a cancer diagnosis stigmatises and isolates the individual. Despite the slight air of wackiness, she is obviously a ruminator, a deep thinker, who has found the best way to express her thoughts is through her scribbly drawings and handwritten balloons.
It seems plausible that graphic novels about specific illnesses might be consumed by readers with some sort of vested interest. Comics offer a window into the subjective realities of other sufferers and provide companionship through shared experience in a more immediate manner than might be gained from joining a self help group or reading patient information leaflets. Illness narrative confirms directly that others have been through a similar catastrophe and, hopefully, lived to write about it. Comics offer an engaging, powerful and accessible method of delivery and consummation of these narratives.
There is something about the juxtaposition of drawings and handwritten text in comics that subverts the normal rules about what can be depicted, how it can be described, what one should think of that description and the subtle meanings and counter meanings that can be read into it. Laying out a proposition in text tends to require precise language if one is not to be accused of obfuscation. Comics, like poetry, seem to allow more leeway in terms of meaning and, like film, offer the possibility of words juxtaposed with a contradictory image. In prose, writers certainly have a range of rhetorical devices available but the number of possible strategies in comics is multiplied. Ambiguity and metaphor can be layered, bestowing properties that seem to lend comics to the portrayal of complex or taboo narrative. Where language is lacking to describe bodily sensations or complex emotional states, metaphor can play a vital role in communication. Comics' language is always characterised by a plurality of messages;5 difficult, ambivalent, chaotic or incomprehensible impressions, narratives or visions can be articulated.
Complex emotions are skilfully portrayed in David B's Epileptic which uses a dark, expressionist style to convey the turmoil in the life of his family caused by the illness of his brother. It is a very influential piece of work in which the margins of reality, dreams and imagination are blurred. David grew up with an elder brother who suffered from severe epilepsy. Jean Christophe is a bright imaginative child with a talent for drawing that the two brothers share. Focalised through the author as adult, the book explores how Jean Christophe, who is cared for jointly by the family, becomes a ‘case’ to be studied and experimented on by a variety of moralising and self serving practitioners, both orthodox and alternative. David, anxious that he too will develop the disease that ‘stalks’ him, feels trapped as a guardian of, and in some way defined by, his sick brother. The complex emotions that surround his brother's illness and manipulative behaviour are discussed honestly. David is torn between wanting to protect and resenting his brother, fraternal love turning to hatred at times. In one episode, David hopes that his brother will kill himself inadvertently while adding petrol to a bonfire. He half heartedly runs to tell his father, thinking that by the time he gets back Jean Christophe will be dead. Fortunately, he isn't. When JC has a fit, David slaps and kicks him, under the pretence of trying to wake him up and later in the book he fantasises about stabbing him to death (figure 7).
David B. Epileptic. London: Jonathan Cape, 2006:266.
B draws Polynesian or Celtic looking monsters and ghosts as visual metaphors for his brother's illness and his own tortured psyche. The artwork is so stunning that Chute22 suggests the visual abstraction is sometimes too much and suggests Epileptic is ‘ultimately about art, representation and creative energy as much as about epilepsy’. Epilepsy itself is depicted as a serpentine dragon that writhes through the scenes and through the characters' bodies: possibly another illustration of Frank's13 ‘chaos narrative’. The imagined spirits of dead relatives and solicitous ghosts are portrayed as strange animals, carefully woven into the magic realist narrative. Epileptic shows that the graphic form can articulate chaotic events and thinking that would be difficult to convey in conventional prose: events that are, literally, difficult to put into words can be rendered visually for quiet consideration by an engaged reader. Contemplating sequential art might be different, too, from other forms of visual consumption, such as watching a video of someone having an epileptic fit. Shoshana Felman23 found that when her students viewed Holocaust testimonials on videotape, they afterwards displayed signs of shock and trauma. In a healthcare environment videos are sometimes shown in a tutorial setting where one has no control over how one views the material and where ones feelings and thoughts might be contaminated by the reactions of one's fellow viewers. This might constitute a distressing event which might in itself colour the professional's attitude in some way. The reading of comics is generally a solitary activity (although subsequent discussion might make an entertaining group event) in which the reader controls the pace of the narrative.16 While reading about (or thinking about) distressing events can also be traumatic (as might watching a video alone), the method of reading a graphic novel could allow gradual exposure to and emersion in the events which might provide a neutral environment in which processing of the narrative understanding proceeds without the interference of group responses or self consciousness. Video, which we are conditioned to consider a veracious medium, also tends to feature real people which can evoke a strong empathic concern for the subject. Comics, conversely, display drawings: iconographic representations of characters who, while still evoking an empathic response, are not freighted with the immediate resonance of a video documentary of human trauma. We still feel and understand the character's suffering, but at something of a distance, and without the conditioned responses of lens based media.
Truth and fiction
Graphic fiction raises some ‘knotty questions about truth and fictiveness’.5 In creating a representation of themselves, autobiographers are constructing an avatar that is bound to differ from the person their peers perceive. Narrative, fashioned from the author's memory, constructed so as to make sense of events or portray a worldview, is bound to differ from the series of events that others remember. One should perhaps forgive a little artistic license:“despite the implied claim to truth that anchors the genre, the autobiographer's craft necessarily includes exaggeration, distortion, and omission.”5
Comics can highlight questions of authenticity in a number of ways. Self reflexivity is often used: the portrayal of the comic's making within the narrative. The artist is seen drawing the pages we now read, or talking about the process of making the comic. These metafictional devices emphasise the falseness of the story and allow something like the truth to be conveyed, fictive yet truthful because it implies its own making. Hatfield5 calls this kind of authentication through artifice ‘ironic authentication’. It seems that caution should be applied however: a constant self undermining through irony could lead to the work, or the medium itself, being rejected as having a lack of depth or rigour.
Metafictional devices allow, as Gardner24 puts it, ‘the autographer to be both victim of the trauma and detached observer’. This split is evident in Green's work and is a commonly seen phenomenon: the narrative voice is that of the ‘present day’ author looking back on their younger selves, commenting perhaps on the foolish things they got up to. There is usually a ‘sense of distance between the ‘naive’ self depicted in the autobiography and the older, more sophisticated self responsible for the depiction.5
How is this debate about the veracity of autobiography relevant to healthcare studies? A good deal of a healthcare professional's work is eliciting and recording a version of the patient's autobiography. Students are trained to pick up and note signs of an ‘unreliable’ history such as an inconsistent account of events or a contradictory description of symptoms. Such disparities risk a patient being labelled a ‘poor historian’, a phrase used widely to this day, resulting in their self story being discounted as unreliable and any subsequent discourse treated as suspect. Considering the problems of published autobiographies may help healthcare workers understand the nature of personal narrative and hence may lead to a more considerate and enlightened attitude when dealing with the patient's history, releasing the professional from the obligation of teasing out the objective ‘truth’ while permitting insights from the subjective story to aid in both diagnosis, proposed treatment and, most of all, understanding of the patient's illness narrative.
Making comics can be an illuminating activity for healthcare professionals too: in a recent international conference, Michael Green25 presented a soon to be published paper which gave evidence that creating a graphic story improved confidence in core skills such as empathy, communication, clinical reasoning and diagnosis in his students. I have a parallel career as a comics artist (under the nom de plume Thom Ferrier, http://www.thomferrier.com/) and have found that the construction of autobiographical stories is a deeply reflective process, forcing me to confront previously unacknowledged motivations and needs as a professional and to question the systems within which we work.
Conclusion
The sheer volume of published works containing subject matter relevant to medicine seems to invite some sort of critical examination from a healthcare studies viewpoint. All graphic fiction is not equal however, and while proposing the inclusion of some graphic works within the canon of illness literature, it must be remembered that the rise in public and academic estimation of the medium risks a widespread rush to laud its properties without due critical consideration. Leaving authorial achievement aside, there is also the problem of how different types of work should be assessed beside each other. Some purport to be the result of genuine experience, some are plainly fiction, drawn from supposition, and some are a mixture. How should one equate these in value? Should a distinction be made at all? The nature of autobiographical writing is changing and the process itself has lately been viewed from new angles.
Much more work could be done in this area, and no doubt will be: the academic appraisal of graphic fiction is in its infancy, and its examination by academics involved in healthcare related studies is very sparse to date. Many more threads could be teased out: comparing graphic narrative to film, poetry, literature, medical textbooks or medical photography.
It must be noted that the vast majority of work relates to the American healthcare system, and this may provide an interesting window into American healthcare for readers from other parts of the world. The overrepresentation in this discussion of the American system may reflect stateside domination of the comics medium, a paucity of published material relating to other anglophone countries, or this author's inability to read the colloquial modern French in which many bandes dessinées are written.
It seems that the comics medium, due to its unique and specific properties, is ideally suited to portraying the subjective experiences of the author with regard to illness and suffering and is furthermore ideally suited to the education of both the public and professionals and that published graphic memoirs of suffering may be of help to the similarly afflicted, or carers and family of the ill. These works, at their best, are powerful and rich texts, well worth investigation by scholars interested in medical narrative. The graphic novel is a relatively new and accessible medium in which few people can claim ‘expertise’; shared discussion of such works could open up a way of exploring attitudes to healthcare and issues surrounding medical treatment, the body and society in a calm and neutral environment.
Footnotes
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.