Medicine Goes Graphic

Amid all the work that Penn State researchers, staff, and students are doing to combat the coronavirus and deal with its impacts, one project might surprise a lot of people: The Penn State University Press is producing COVID Chronicles, a book of comics about the pandemic.

If your idea of "comics" is the Sunday funny papers, Archie & Jughead, and superheroes, get ready for a whole new experience.

"A cool thing about comics is that there's no topic that somebody, somewhere, is not addressing," says Michael Green, an internist and medical ethicist who teaches a course in comics at Penn State College of Medicine.

Since the publication in the early 1990s of Maus, Art Spiegelman's Pulitzer-Prize-winning graphic treatment of the Holocaust, comics have delved into the full range of human experience, with subjects ranging from the tsunami in Thailand to personal struggles with mental illness.

And over the past several years, through the scholarly and artistic efforts of University faculty and the PSU Press, Penn State has emerged as a world leader in the field of health-themed comics-what is now known as "graphic medicine."

Press success

Founded in 1956, the Press publishes mainly in the humanities and social sciences, with authors from all over the world. It currently publishes more than 100 new books and more than 70 academic journals each year, with particular strengths in art history, early American history, rhetoric, Medieval and early modern studies, and religious studies.

In other words, the Penn State University Press offers books of serious scholarship about serious subjects. Graphic narratives-comics-seemed like a radical departure in 2012, when Brill Professor of English Susan Squier urged editor-in-chief Kendra Boileau to publish graphic medicine books.

Squier, an eminent scholar of Virginia Woolf, got interested in comics in the 1990s, when she began exploring ethical issues of in vitro fertilization. "I was using cartoons to talk about debates about human embryo research and organ transplantation," she says. "I found that when I gave talks on my work, if I started with a cartoon, the audience would engage. A comic helped bring people out."

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Susan Squier, an eminent scholar of Virginia Woolf and discourse in bioethics, got interested in comics in the 1990s when she found that using cartoons helped engage audiences when she talked about ethical issues surrounding organ transplantation and embryo research. She and Penn State colleague Michael Green helped found the graphic medicine movement.

IMAGE: Patrick Mansell

But at the Press, it was a tough sell. Comics as a subject for serious scholarship didn't fit expectations. Graphic novels were also a stretch for Boileau personally. Unlike Squier, who had been studying and writing about graphic medicine for several years, Boileau was a novice in the field.

Once she committed, Boileau's first steps into graphic medicine were not timid. In 2015, the Press brought out two volumes. The Graphic Medicine Manifesto laid out the case for comics as a medium to explore issues of health and illness. Squier and Green each wrote a chapter, as did fellow Penn State faculty Kimberly Myers, professor of humanities and medicine in the College of Medicine, and Scott T. Smith, associate professor of English and comparative literature. The other book was My Degeneration: A Journey Through Parkinson's, a first-person account by newspaper cartoonist Peter Dunlap-Shohl.

Since then, the Press has published 18 graphic novels and anthologies and four scholarly books on graphic medicine. Boileau says she expected that most of the books in the graphic medicine series would be scholarship about graphic medicine, and that books of graphic medicine would be more like an occasional treat. As it turns out, it's the graphic narratives that have really taken off. Boileau says she gets more submissions and proposals for comics than she can keep up with-and those books have been selling very well.

They've been so successful that the Press had planned to launch a new imprint this fall. Graphic Mundi ("graphic worlds"), as they named it, would publish graphic medicine novels, broadly conceived. The initial lineup of six titles would include a memoir of growing up with a mother who is bipolar, a humorous look at the biology of sex in animals, and an account of environmental and social devastation in the Amazonian oil fields. Then came COVID-19.

The COVID Chronicles

When it became apparent how severely the pandemic would interrupt business-as-usual, the Press pushed the debut of Graphic Mundi to the spring of 2021. They also considered adding a book of short stories on COVID-19 to the initial group.

"I was actually resisting it, because it seemed opportunistic," says Boileau. After much discussion, she and her colleagues came up with a way to defuse that concern. They asked the artists to contribute their work for no fee, thereby reducing the cost of production, and will donate all profits from sale of the book to organizations that support small bookstores, bookstore employees, and comics artists, many of whom are suffering economic hardship during the pandemic.

In mid-April, the Press posted a call for short comics dealing with COVID-related stories ranging from personal tales of isolation, grief, or economic fallout of the pandemic, to the experience of having or treating the disease, to political aspects of how communities and nations are dealing with it. Within days, Boileau's inbox was flooded with proposals. COVID Chronicles was published on February 15, 2021.

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Initially reluctant to venture into graphic medicine, editor in chief Kendra Boileau has overseen the publication of 18 graphic novels and anthologies and four scholarly books on graphic medicine since 2015. She is preparing to launch Graphic Mundi ("graphic worlds"), a new imprint in the field, in early 2021. The tagline of the imprint will be "Drawing our worlds together."

IMAGE: Patrick Mansell

Reaching readers

The list of topics in COVID Chronicles confirms that "graphic medicine" often encompasses more than straightforward accounts of disease.

"Narrowly defined, it has to deal with an illness and has to be explicitly about a patient," says Green. "But many of us are thinking much more broadly than that."

Squier agrees. "Sure, it's what's in the hospital, in the clinic, but it's also health care, it's public health, it's big issues like the impacts of war, the health impacts of climate change, environmental pollution, social disparities, class, race."

Green believes "graphic novels," as both fiction and nonfiction books of comics are commonly called, are excellent vehicles for subjects many of us might find difficult to approach in more traditional ways. They are usually quick to read, yet they are emotionally powerful and able to evoke empathy for people and situations the reader might never have encountered before. "Something about the combination of words and images delivers more information than you would get from just the sum of its parts," he says. "When you put them together, there's an almost magical third thing that happens."

Squier thinks the "third thing" is a visceral response to the pictures. "The image draws you in," she says. "It makes you pause and connect to it with your emotions, with your body." The images can be looked at again and again, as the reader identifies with each one and tries to understand it. Boileau thumbs through Vanni, a tale of a family's struggles during the Sri Lankan conflict that the Press published in 2019, and finds a wordless panel that shows a man in a small fishing boat at night. The scene is peaceful, yet the man is despondent, almost in shock. "Just the expression on his face…" she says. The image can be taken in quickly, but it invites a closer look, a deeper read. Reading a graphic narrative "is more a digging down than following a thread across," she says.

Boileau has found that comics reach a wide variety of audiences, from those who can't or won't read long text pieces to highly-educated professionals, and are especially helpful in getting information to people who might have trouble reading it in text form.

Comics are even being used in legal documents. A hospital in Berlin, Germany, developed a graphic version of its informed-consent form for cardiac stent surgery and assessed how effective the 10-page comic was compared to its standard 40-page text version. "The comic version did better at reducing pre-op anxiety, it had better post-op outcomes, it was better right across the board," says Squier. "People who got the long form would say, 'You gave me all that, I was just too anxious to read it.' "

Whose story counts?

Despite the success of ambitious, medical-themed comics, until recently, graphic novels were viewed by many as being something of a joke, especially when they dealt with serious subjects. "One touchstone moment for me was meeting [a prominent physician/scientist] and saying 'I'm working on comics in medicine' and having him go, 'I fail to see what's so funny about medicine,' " says Squier. "He assumes that comics are funny and trivial."

She traces much of the stigma against comics in the U.S. to "disguised class resentment" against the poor and less well-educated immigrants who were the audience for many early comics in the U.S. "There's the sort of 'high culture' view that if it's accessible, it must be stupid," she says.

That view highlights what she and her comics colleagues think is a major strength of graphic novels: They speak for those whose voice is often disregarded in society.

"A lot of us who work in health care try to think about, whose story counts?" says Green. "Illness is typically presented from the doctor's point of view, and the patient's voice gets drowned out. Many of the comics that have been written around medical topics prioritize the voice of the patient in a way that's really important for doctors to understand. It's not just what's happening pathologically when somebody gets ill, but what their experience is like. How do they feel when they have this diagnosis, and how does it affect different aspects of their life?

"Seeing that story unfold from a variety of different points of view can be really illuminating. Using comics is quite helpful for doctors to really see and understand more fully what illness is like."

Humanizing medicine

Green sees his work with comics as following in the strong tradition of humanities at Penn State College of Medicine, the first medical school in the nation with a department of medical humanities. He credits current department chair Bernice Hausman and the college's leadership with being open to courses use a variety of ways to explore what it means to be a doctor.

His own interest in comics and drawing goes way back; at a recent high-school reunion, Green's classmates still recalled him as the class artist. But he didn't realize the power of comics to deal with serious subjects until the early '90s, when he read the groundbreaking Maus.

"It just blew me away," he recalls. "I had read a lot of Holocaust literature. This was as good as or better than anything I'd read, in terms of the impact. So I said, I wonder if there are similar examples that have to do with health and illness. I started looking, and that's what got me down this road."

For the past 11 years, he's taught a month-long elective course in which 4^th-year students read medical-themed comics and produce their own graphic story about an experience from their time in medical school. Few of them have expertise in drawing, but through conversations with professional artists and workshopping their drafts with classmates, they create vivid graphic stories about events like connecting with a difficult patient, making a mistake, or being chewed out by a supervisor.

"I wasn't surprised that they were having some dark experiences," says Green. "I was surprised, pleasantly surprised, with their willingness to be open about the negative things that they were experiencing and how powerful their stories are."

So far, Green has gotten overwhelmingly positive responses to the course from Penn State colleagues and college administrators, but he is sometimes asked why such a course should be taught in a medical school. Beyond the value of giving students a platform to describe aspects of their schooling that are important to them, he says, the course achieves what might be called stealth goals.

"I think there are skills involved in making a comic that are transferrable to the skills of being an effective physician," he says. "Being able to communicate non-verbally and to understand other people's non-verbal communication. Being willing to deal with the discomfort of not being good at something and not knowing how to do it. Being able to ask somebody else for help.

"It's hard to teach these skills, and who says the only way to do it is by explicitly medical means? Sometimes you can achieve these other kinds of goals by doing something that's entirely different."

As it turns out, he says, "These are all things that people get better at by reading and drawing comics. To me, that's the ultimate reason why we should teach graphic medicine in medical school.

"What I want is for the students to become better doctors."

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Michael Green with a poster of a student's comic about an experience she had as a medical student. The popularity and effectiveness of Green's elective course in comics for students at Penn State College of Medicine are influencing medical educators across the country.

IMAGE: Penn State Health

What's next?

With faculty at three campuses active in producing, studying, or teaching about graphic medicine, Penn State scholars have been instrumental in the field's growth and in pursuing research on the impact and uses of comics in health care.

Squier and Green helped found the graphic medicine movement and are still major contributors to the field. Squier, now retired from Penn State, continues to explore the linguistic and artistic value of comics and is active in Pathographics, a Berlin-based group that focuses on stories of specific medical conditions and how they affect individuals and communities. She is president and Green is vice president of the Graphic Medicine International Collective, a nonprofit organization devoted to expanding the use of graphic narratives to tell stories related to human health.

Green and College of Medicine colleague Kimberly Myers are doing research to find out whether medical comics can caregivers, patients, and patients' loved ones cope with a serious health threat. In a recent study, they surveyed clinicians at a movement disorder clinic before and after reading My Degeneration. The staff already knew a lot about Parkinson's, so their knowledge of the disease didn't go up, says Green, "but their empathy for patients and their understanding of what patients worry about improved greatly." He and Myers are now doing a follow-up study of how reading the book affects patients.

Green himself wrote a short comic about a mistake he made as a young resident. It was published in the Annals of Internal Medicine, the preeminent journal in the field, whose editorial board liked it so much it decided to develop a graphic medicine section, with Green as its editor.

Emily Steinberg, lecturer in fine art at Penn State Abington, is a graphic novelist whose 2019 story about her experience with hip replacement surgery was published in the Press' book Menopause: A Comic Treatment.

At the Penn State University Press, the new Graphic Mundi imprint is on track to debut early next year with COVID Chronicles and the six other titles originally planned. The Press is also tapping into the robust comics scene in other countries, acquiring North American and translation rights to graphic novels from Europe, Asia, and elsewhere.

"Penn State, and the Penn State University Press, Kendra in particular, have really been worldwide leaders in this area," says Green. "We're getting to be known as the place to go to for these graphic medicine comics."

Reflecting on the appeal of graphic medicine and the unexpected power of comics to make readers see things in a new way, Squier says, "It requires a kind of open-mindedness to be willing to sit with something that at first may read as trivial. It really pushes us outside of our comfort zone and makes us have to learn how to do something new. That's just the best. That's how you keep yourself alive."

Kendra Boileau is assistant director and editor-in-chief of the Penn State University Press. Michael Green is professor in the departments of humanities and internal medicine and director of the program in bioethics at Penn State College of Medicine. Susan Merrill Squier is Brill Professor Emeritus of English and Women's, Gender, and Sexuality Studies at Penn State and Einstein Visiting Fellow at the Freie Universität, Berlin. Kimberly Myers is professor of humanities and medicine and Distinguished Educator in the College of Medicine.

This story appears in the Spring issue of Research/Penn State magazine.