Department of Humanities
National Institute of Technology, Trichy-15
Email ID : raghavirags at gmail dot com
Received: 29-MAR-2015 Accepted: 14-MAY-2015 Published Online: 31-MAY-2015
How to cite this URL: Kasthuri RR, Venkatesan S. Picturing Illness: History, Poetics, and Graphic Medicine. RHiME [Internet]. 2015 May 31 [cited 2018 Feb 25];2:[about 6p.]. Available from: https://www.rhime.in/ojs/?p=1067
Comics have often been treated as a juvenile and sub-literary art form; however, taking cues from the new-found cultural acceptance of comics, particularly with the publication of Art Spiegelman’s Maus (1986), Chris Ware’s Jimmy Corrigan: The Smartest Kid on Earth (2000), and Alison Bechdel’s Fun Home: A Family Tragedy (2006), there have emerged, over the past decade, a new breed of comics dealing with the patient/caregivers’ experiences, perspectives and identities. Christened as graphic medicine, these illness narratives use comics as a medium to address wide ranging disease/illness related issues. The present review examines the following issues: What is graphic medicine? Is there a tangible relationship between underground comics and graphic medicine? If so, can we regard underground comics as historical precedent to graphic medicine? What are the uses of comics in medicine? Broadly put, drawing examples from various graphic medical narratives, the paper seeks to trace the history and poetics of graphic medicine.
Keywords: Graphic medicine; Graphic pathographies; Illness; Underground comics
“Comics have been the perfect medium for capturing discomfort that is very real but isn’t visible to others.”
“Comics are the right medium for the story I wanted to tell. They meld words and pictures to convey an idea with more economy and grace that either could.”
Origins of Graphic Medicine: Underground Comics?
The origins of graphic medicine can be traced to the 1960’s counterculture movement in comics popularly known as Underground Comics or comix. Originating in San Francisco and trumpeting “the idea of comics for adults”, underground comics departed from the prevalent popular superhero comics and dealt with controversial subjects like gender, race, sexuality and drug addiction among others. Mostly self-published and anti-establishment, these comics revolutionized the form and content of the medium by examining marginalized but socially relevant issues primarily through autobiographical mode.
Some of the prominent underground comic artists are Art Spiegelman, Robert Crumbs, Bill Griffith, Gilbert Shelton, Trina Robbins and Jay Lynch. Maus by Art Spiegelman which won the Pulitzer Prize in 1992 was initially serialized in RAW (1973), a popular counterculture magazine. Self-published and co-edited by Spiegelman along with his wife Francoise Mouly, Maus narrated the holocaust experience of Valdek Spiegelman (Spiegelman’s father) using the visual iconography of mouse and cats. In so doing, Maus was not only instrumental in raising the status of comics to an adult and literary art form but also is credited for inaugurating the present day “serious comics”. The publication of trifecta viz., Alan Moore and Dave Gibbon’s Watchmen; Fran Miller’s Batman: The Dark Knight Returns, and Art Spiegelman’s Maus: A Survivor’s Tale in 1986 also redefined the boundaries of comics once and forever.
These underground comics may be treated as forerunners of graphic medicine for the graphic medical narratives also deal with the complex and tabooed subjects in a creative way. The radical and transgressing spirit of underground comics is evident in the graphic medical discourse. For instance, graphic pathographies foreground liminal experience of the vulnerable body which is mostly un/misrepresented by mainstream narratives; and critique hegemonic medical knowledge and insensitive healthcare practices that traumatize patients and caregivers. Similar to the underground comics which prioritized the “poetic ethos of individual expression” and served as “a vehicle for the most personal and unguarded of revelations”, graphic medicine also provides a scope for radical and personal disclosures. Such narratives in addition to throwing light on the moral and ethical practices of the medical establishment also expand and deepen the boundaries of illness and healthcare discourse.
Akin to underground comics, graphic illness narratives experiment with diverse visual metaphors and styles to discuss complex issues like suffering, pain, and death. For instance, comic artist Allie Brash in her website hyperboleandhalf.com has re-signified simple homogenous images of the McGill pain chart to suit her subjective imagination. Furthermore, the underground comic is appreciated for its ability to “transform an object that was jejune and mechanical in origin into a radically new kind of objects”. Similar to this trait of comix, graphic pathographies creatively transform quotidian subject of illness and suffering into a literary artifact integrating visual imagery with written text. For instance, in Sarah Leavitt’s Tangles: A Story about Alzheimer’s, My Mother, and Me (2010) mundane objects like socks and a blanket are transformed into a symbolic reminder of her deceased mother, Midge. Additionally, graphic medicine resembles comix in its capacity to be remembered by “names and the reputation of the creators” rather than the title of their series. Thus, we believe that underground comics can be broadly considered as a historical precedent of graphic medicine.
Graphic Medicine: Terms and Themes
Graphic Medicine is an interdisciplinary field which explores “the interaction between the medium of comics and the discourse of healthcare”. In integrating visual imagery and written text, these graphic pathographies or illness narratives in comics form, in recent times, have emerged as a “definitive sub-genre of life writing”. Particularly with the launch of a website titled graphicmedicine.org in 2007 by the British General Practitioner and comic artist Ian Williams, graphic medicine gained immense popularity. Later in 2010, Williams along with MK Czerwiec, popularly known as Comic Nurse, restructured the website to facilitate the growing admirers of this field. At present, the website provides information about diverse comic formats ranging from manga to web comics pertaining to healthcare. In addition, the website also publishes book reviews and lectures appertaining to graphic medicine and, in the process, functions as a repository of graphic medicine scholarship.
Considering the popularity of graphic medicine in recent times, annual conferences are organized to explore various aspects of health care such as medical negligence; the vexed doctor-patient relationship; patient identity; role of insurance providers; and challenges of caretaking, among others. The first annual graphic medicine conference, titled Comics and Medicine, was held in London in 2010, and every year thereafter as shown in the Table.
Table: Theme and location of the annual graphic medicine conference since the first one in 2010
|Year of Conference||Theme||Location|
|2010||Comics and Medicine||London|
|2011||Comics and Medicine: The Sequential Art of Illness||Chicago|
|2012||Comics and Medicine: Navigating the Margins||Toronto|
|2013||Ethics Under Cover: Comics, Medicine, and Society||Brighton|
|2014||Comics and Medicine: From Private to Public Health||Baltimore|
|2015||Comics and Medicine: Spaces of Care||Riverside|
Recently, a special issue on Graphic Medicine was published by Configuration, a journal published by the Pennsylvania State University. As guest editors, Susan Squier and J. Ryan Marks attest to the scope of the “vibrant new field” and state thus: “graphic medicine challenges our very notions of what art, medicine, literature, and scholarship should look like…for graphic medicine is, above all else, a visual medium”. By regularly organizing such annual conferences, Ian Williams and his colleagues not only interpret the potential of graphic pathographies – which address various issues related to health and medical care – but also legitimize and canonize the scholarship on graphic medicine. As an epoch marker in the history of graphic medicine, Ian Williams with his collaborators have published the first definitive book on graphic medicine titled Graphic Medicine Manifesto (2015; Pennsylvania State University Press).
Justin Green’s Binky Brown Meets the Holy Virgin Mary (Fig. 1) perhaps is the first graphic medical narrative. In his introduction, “Art Spiegelman credits Justin Green [for] inventing the genre of autobiographical comix and states explicitly that without Binky Brown there would have been no Maus”. Published in 1972, Binky Brown Meets the Holy Virgin Mary pictorially un-closets Green’s Obsessive Compulsive Disorder (OCD) against an orthodox Roman Catholic family background. Torn between grief, self-reproach and passion, the graphic memoir explores Green’s experience of his illness as he develops a sexual obsession with Virgin Mary. Justin Green’s Binky Brown, according to Ian Williams, “inspired subsequent generations of artists to articulate their corporeal experiences in words and pictures”. Written ahead of its time, Binky Brown was left unrecognized until the post-millennial era which began celebrating the comics medium. However, it is Harvey Pekar and Joyce Brabner’s Our Cancer Year (1994) which launched graphic medicine definitively. Thereafter numerous graphic narratives such as Brian Fies’s Mom’s Cancer (2006) which narrates the lung cancer experience of his mother Barbara; and Alison Bechdel’s Fun Home: A Family Tragedy (2006) which discloses the closeted gay identity of her father, popularized the medium and reinforced the potential of this form.
Narrated by doctors, (professional) caregivers or patients, these graphic medical narratives through challenging the monopoly of medical knowledge constitute a new form of knowledge which is predicated on subjective realization of illness. For instance, autographies like Miriam Engelberg’s Cancer Made Me a Shallower Person: A memoir in comics (2006) and Tucky Fussel’s Mammoir: A Pictorial Odyssey and Adventures of a Fourth Grade Teacher with Breast Cancer (2005) provide a patient’s perspective of illness. Both these artists apart from pictorially narrating their breast cancer experience critique the “epistemological authority of the medical profession”. Likewise, Ian William’s Bad Doctor (2014), Darryl Cunningham’s Psychiatric Tales (2011), and MK Czerwiec’s Comic Nurse (2006), narrated from healthcare providers’ perspective, sheds light on the vulnerabilities and the fraught physical and emotional struggles of healthcare practitioners. Similarly, caregiver narratives such as Stan Mack’s Janet and Me: An Illustrated Story of Love and Loss (2004) and Sarah Leavitt’s Tangles: A Story About Alzheimer’s, My Mother, and Me (2010), narrate the challenging roles of caregivers especially in cases of terminal illness and also examine the moral and ethical responsibilities of caregivers toward the diseased (Fig. 2).
Graphic pathographies, apart from dealing with physical and mental illness, also shed light on injury and disability experience. Some of the popular graphic disability narratives are Al Davison’s The Spiral Cage (1990) which records the artist’s experience with spina bifida; Chris Ware’s Acme Novelty Library 18 (2007) which narrates the life of a young girl after her below-knee amputation; and Kaisa Leka’s I am Not These Feet (2009) which recounts her trauma after amputation of her feet. Dave Lupton, popularly known as Crippen—the disabled cartoonist, is renowned for championing the disability art movement. Through his humorous single panel colored cartoons, Crippen strives to vocalize the experience of the disabled. Interestingly, he provides descriptions for his gag cartoons which aid readers with visual disability to access his cartoons (Fig. 3).
Cartoon Description that accompanies figure 3: There are three people wearing white coats standing around a small podium on which is a young man seated in a self-propelled wheelchair. On the wall alongside of them is a notice board, upon which are the words ‘The Disabled and how to recognise them. By A.N. Expert’. One of the ‘experts’ is looking at the Disabled man through a magnifying glass whilst the other is saying: “And you’ll notice that their eyes are set very close together!”
Graphic Medicine and Material Culture
Having traced the emergence of graphic medicine to underground comics it would be instructive to know the material conditions that facilitated the rise of a new genre called graphic pathography. The nascence of graphic medicine can be linked to the emergence of illness narrative itself. Anne Jurecic in Illness as Narratives catalogues the major socio-economic shifts and material determinants for the proliferation of illness narratives in the twentieth century. Jurecic considers the rise of health activism in the 1960s, and specifically the AIDS activism of the 1980s, as altering the public perception towards “personal disclosures” of illness. Correspondingly, the concept of risk society which emerged in the 1980s with the publication of Ulrich Becks’s Risk Society: Towards a New Modernity has also contributed to the rise of illness narratives. As Jurecic explains, “the knowledge of health statistics” has indirectly triggered personal health disclosures.
Parallel to these developments, the pictorial turn in literature and the increasing visual and optical culture thanks to television and internet further paved way to the growth of comics. In fact, in 1988 National Endowment for the Humanities (NEH) report titled ‘Humanities in America’ pointed to an increasing affinity towards images. Additionally, as WTJ Mitchell succinctly puts it: “we live in a culture dominated by pictures, visuals, stimulations, stereotypes, illusions, copies, reproductions, imitations, and fantasies”. In this context, the emergence and popularity of comics, which combine both image and text, was inevitable.
Uses of Comics in Medicine
Comics were primarily used as a pedagogic tool in the healthcare system, especially to facilitate those with poor cognitive skills. For instance, graphic narratives like Kirsti Evans and John Swogger’s Something Different About Dad: How to Live with Your Asperger’s Parent (2010) educates children between 7-15 years about adapting to the idiosyncrasies of an Asperger person. No different is Ed Hillyer’s Love S.T.I.ngs (2009) that aims to create sexual health awareness and safe sex practices among teenagers. However, in recent times, not only has the target demographics of comics changed radically but also they are no longer treated as mere pedagogical tool. In his lecture delivered at the Mayo clinic, Dr. Michael J. Green has expressed that reading graphic medical narratives have helped the healthcare professionals to reflect and comprehend the issues that might not have been previously considered by them. Reading and interpreting graphic medicine, he further argues, have not only enabled medical students to be empathetic listeners but also has enhanced the diagnostic reasoning of students. Further, he also states that “the medium of comics provides students the freedom to reflect honestly (and safely) about the forces that shape their emerging professional identities.”
Fittingly, since 2009, The Penn State Hershey Medical School under the supervision of Dr. Michael Green offers an elective course on ‘Graphic Storytelling and Medical Narratives’. The three major objectives of this course as Dr. Green writes are : “1)[to] expose students to a set of medically relevant graphic narratives that provoke critical reflection about the experience of illness and the ways patients and their families interface with the medical system; 2) equip students with critical thinking skills for reading and understanding comics that are relevant to medical practice; and 3) nurture students’ creativity by helping them develop their own stories into original graphic narratives”. The fourth year medical students in the course are familiarized with patient narratives like David Small’s Stitches: A Memoir (2009), and Ken Dahl’s Monsters (2009), and at the end of the course they are also encouraged to create comics. Ashley Pistorio’s Vita Perseverat or Life goes on (2010) published in student British Medical Journal, is perhaps the first graphic narrative of a medical student recording her intern experiences. This exercise, according to Dr. Green, apart from increasing the empathetic bond between the doctor and the patient also helps the medical students to surmount what MK Czerwiec calls ‘narrative constipation’ which is the “stuffing down” of emotionally fraught stories within a healthcare provider.
In comics, artists, through integrating subjective perception of illness with objective medical truths, create their own iconography of illness. In so doing, they not only constitute a new form of knowledge but also offer a personalized iconography of illness. For instance, Brain Fies in Mom’s Cancer represents the metastasis of his mother’s cancer by visually transforming his mother into a maple tree with taps that ooze cancer instead of maple syrup. Similarly, Marisa Acocella Marchetto in her Cancer Vixen: A True Story imagines the cancer cells under the microscope as evil green-faced smiley faces who mock at her with tongues out, and by showing the middle finger. Marchetto also imagines herself as a cancer kicking super-woman with female accoutrements like lipstick and five inch heels. This ability to creatively reconstruct an illness experience through personalized iconography or, to use Elisabeth El Refaie’s phrase “pictorial embodiment” enables the sick person/caregiver to confront illness experience effectively. Yet another feature of comics is the economy of expression which enables readers to comprehend the intricacies of illness more readily that a written text. For instance, Tucky Fussel in Mammoir represents the dread of her breast cancer diagnosis in a single frame by portraying herself as an isolated diminutive figure facing a high tide which might drown her forever. This panel which spreads across the entire page vividly captures the fear, trauma and paranoia of a cancer diagnosis. In short, as Susan Squier observes, being a “hybrid genre”, comics have “the capacity to articulate aspects of social experience that escape both the normal realms of medicine and the comforts of canonical literature”.
Graphic Medicine in India
Graphic medicine in India is still in its nascent stage. University College of Medical Sciences, Delhi is “the first medical institution in India to start a Medical Humanities Group in 2009. The group has a kaleidoscopic approach to Medical humanities and familiarizes the students with “lecture series (Confluence), street theater group, film screenings, exploration of Indian culture (Society for the Promotion of Indian Classical Music and Culture Amongst Youth [SPIC MACAY]), Augusto Boal’s Theatre of the Oppressed workshops, disability studies (Infinite Ability)” among others. Recently, the group has launched an online graphic medicine club called “Comicos” under the aegis of Dr. Satendra Singh (doctor/artist) with an aim “to explore the impact of graphic fiction on the lives of medical professionals and patients alike”. Comicos, apart from providing an update about national and international events in the field of graphic medicine, also contains gag cartoons related to disability. Interestingly, yet another medical doctor turned comic illustrator is Dr.Dhodapkar from Bhopal. Although the majority of his comics focus on political issues he has published a play titled Doctor Jawani Ki Prem Kahani (2005).
Apart from the online graphic medicine club, organizations like World Comics India and Comic Con India conduct annual workshops in cities like Delhi, Bangalore, Mumbai and Hyderabad and promote comics in both rural and urban areas. Similarly, Grassroot Comics, a social initiative of World Comics pioneered by Sharad Sharma in the mid-nineties strives to promote the power of comics as a medium of “self-expression”. Grassroot Comics are mostly created by the public “in various regional languages [and] cover several social issues such as the unrest in northeast, rights of girl child, use of corporal punishments and child sexual abuse.”
To conclude, beyond the pedagogical role of comics within healthcare, graphic medicine illuminates subjective realities of illness as experienced by patients. The underground comics or comix of the 1960s can be considered as the historical precedent of graphic medicine for the graphic medical narratives share the characteristic autobiographical and radical spirit of the comix. Graphic pathographies apart from visually foregrounding the illness experiences of a sick person also effectuate an empathetic listener in the readers. Far from being a mere pedagogical instrument that creates awareness about specific disease, graphic pathographies offer visual metaphors to the sick person to reconstruct his lived illness experience, and in doing so they not only constitute new mode of knowledge but also empower the patients through graphically organizing their traumatic lives. Furthermore, the levity and the economy – decisive features of comics – also facilitate the ability to narrate illness experience in a creative and poignant way. This being the case, as Squier predicts, “the future tense” of “literature and medicine” lies in graphic narratives.
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