Medicine is getting serious about comics

Dana Walrath discovered graphic narratives while her mother, then in the middle stages of Alzheimer's disease, was living with her.

Her mother's ability to use and understand language was failing, but she devoured such sophisticated illustrated books as Maus and Persepolis that took on, respectively, the Holocaust and growing up in Iran.

"She was able to bring the story in through a visual channel," said Walrath, a medical anthropologist at the University of Vermont who earned her doctorate at the University of Pennsylvania.

When Walrath set out to write about her mother, Alice, an imaginative Armenian immigrant who often forgot that the kind woman named Dana was her daughter, it seemed natural to pair words and pictures.

The result is Aliceheimer's, Alzheimer's Through the Looking Glass, a slim book of wise, accepting essays and gently trippy drawings of her mother wearing dresses literally cut from pages of Alice's Adventures in Wonderland.

It was Walrath's entre into a small but growing publishing genre - graphic medicine - with strong roots in Pennsylvania. The book is part of Pennsylvania State University Press's year-old Graphic Medicine series, which also features a scholarly book on graphic medicine, Graphic Medicine Manifesto, as well as The Bad Doctor, about being a doctor, and books on having Parkinson's disease and being a young caregiver.

One of the Manifesto authors is Michael Green, a Penn State physician who teaches a course on graphic medicine for fourth-year medical students. It yielded a journal article about the disturbing prevalence of horror themes in comics about the medical-school experience.

The Annals of Internal Medicine, a serious medical journal based in Philadelphia, also started publishing a graphic medicine series about a year ago. Green contributed two of the comics. Another came from William Doan, a Penn State theater professor and playwright.

The Annals project grew from its popular On Being a Doctor essays, which allow doctors to explore the experience of medicine. The comics have tackled complex, emotionally charged topics from another vantage point, said Darren Taichman, a University of Pennsylvania pulmonologist and Annals editor.

Feedback has been "overwhelmingly positive," he said. "People [say] that it has touched them. It's made them think. It's resonated with their own experience."

Green, a bioethicist at the Penn State College of Medicine in Hershey, said there is some overlap with the growing use of "narrative medicine" in medical schools. It teaches students to tell prose stories, but tends to focus more narrowly on helping them become better listeners. Graphic medicine is open to doctors, patients and caregivers.

Walrath sees graphic medicine as an outsider medium, better equipped than words alone to bring perspective to a tragic, incurable disease.

"Dana, why are you good to me?" her mother asks in one of her essays.

A picture of a little woman nearly swallowed by her word-covered dress graces the opposite page. The woman's face is old, but her eyes are big, childlike and lost.

"Because you're my mother," Walrath answers.

There's a long pause. "I'm your mother?"

There's another pause. "Who's your daddy?"

Walrath fills in her mother's history.

Her mother thinks again. "I wasn't very good to you," she says. "I'm sorry."

The daughter forgives. They are finishing their unfinished business, a theme of the book.

One of the striking features of Walrath's book is her easy acceptance of her mother's faltering sense of reality. If her mother thinks it's 1944, so be it.

Walrath's anthropological appreciation for different perspectives is well-suited to the graphic medium. "Anthropologists know there are multiple realities," she said.

Like Walrath, Green is a fan of Art Spiegelman's Maus, published in book form in 1986. The Holocaust survival tale is a landmark work that moved graphic narratives well beyond the comic book form.

"Holy cow," he thought when he read it. "I had no idea you can tell such a serious, important, adult story using comics."

Curious, he searched for examples of graphic medical stories. He found a few. One thing led to another and he started the first medical school class on graphic medicine seven years ago. He also helped organize an annual international graphic medicine conference that has grown from 75 participants to the 150 expected this summer in Scotland.

His analysis of student drawings made it into the Journal of the American Medical Association last December. Forty-seven percent contained horror imagery. The students drew their workplaces as "dank dungeons" and portrayed supervising physicians as "fiendish, foul-mouthed monsters."

This was food for thought for Green and his colleagues. Poster-size renditions of the students' work decorate a hall not far from the admissions office. Green says he has been told the comics are a recruiting tool.

He says the course gives medical students valuable time to reflect. He says a "doctor who is more self-aware . . . is a better listener and more empathetic with people."

His own work for Annals dealt with troubling events during his training. One involved an end-of-life case - he was ordered to perform CPR against his better judgment - that led to his interest in bioethics. The other involved a mistake that has haunted him for 30 years.

He had already written a short story and a poem, about his failure to recognize the significance of a heart murmur in a patient who later died, when he tried the graphic form with the help of a hired illustrator. "The comic really seems to capture it best because it was so visual," he said.

William Doan wrote a play - Drifting - about his younger sister's death in December 2014, two years after a car crash severely injured her brain.

He and Green, who saw the play, talked about an end-of-life project. Then Green mentioned his interest in graphic medicine. "I didn't know there was a graphic medicine movement before that," Doan said.

He began working on a book-length graphic version of his sister's story for Penn State Press. Annals published his shorter comic, "She Never Woke Up," in January. It is a spare, moving exploration of his grief and unanswered questions done in ink washes and watercolor.

"What we didn't know is what really happened," Doan wrote. "And more importantly, we had no idea that not knowing what happened would make no difference at all. What happened was not the answer we needed."

Doan, 57, says the graphic book will explore more of the ethical issues involved in his sister's lengthy vegetative state. Now on sabbatical to ready the play for rehearsal and finish the book, he says he is finding the graphic work healing. As painful as it is to remember his sister's suffering, the drawings have become a way for him to inhabit her story. He says he sees a new kind of beauty in the wounded face he draws, a dawning acceptance of the ending none of us can control.

Like theater, he said, the visual quality of graphic narratives seems to heighten an emotional experience he could not convey in prose. The quiet, slow pace of the work, coupled with the physical engagement of the drawing, has "almost become a form of meditation," he said.

He'll be talking about it all at the graphic medicine conference. "Suddenly," he said, "graphic medicine is my world."

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