Graphic Medicine: Can Comics Improve Our Health?
From Steven Garlock on March 23rd, 2020
Hi everyone. Welcome. I'm Rebecca Garden, a professor here at Upstate Medical University. Welcome to the second part of a series called Cripping Graphic Medicine. Can anyone not hear me? Okay. Good. I'm glad it's coming through. This series began last fall with a focus on comics and graphic narratives that deal with mental health and healthcare. Today we have a lecture and tomorrow morning a workshop with MK Czerwiec a nurse, educator, and comics creator who helped to create the field called Graphic Medicine. The details about the workshop tomorrow, if you can come, it's from 10:00 a.m. to 12 noon in 3509 Setnor Building and you can also see me after the presentation to get more information about that. This series has been supported by the Burton Blatt Institute and the Office of Interdisciplinary Programs at Syracuse University, and by the Consortium for Culture and Medicine. The key funder and catalyst for these events have been Syracuse University's Humanities Center. This series is part of their yearlong symposium on the theme of "Silence," which raises questions about the meaning and effects of silence, including questions of power and inclusion. So when we say that we're Cripping Graphic Medicine. We're using that term cripping to describe that way we are disrupting inequalities in power through strategies of inclusion. My colleague Diane Wiener, a professor of disability studies at the Burton Blatt Institute at Syracuse University, invited me to join her in proposing this program as a way to build inclusion, to cross all sorts of boundaries and barriers-starting with campuses and disciplines and professions. So you are all part of a budding movement of inclusion. How many of you are not from Upstate? Congratulations. You are part of a budding movement of cross fertilization. You are the pollinators. You've crossed the boundary to come to Upstate. Thank you for that. We make this event more inclusive and recognize those who have historically been silenced by acknowledging with respect the Onondaga Nation, firekeepers of the Haudenosaunee. SU and Upstate now stand on the ancestral lands of these indigenous people. We make this event more inclusive through the captioning, the real-time transcription of our discussion projected on the screen, and we also make they haven't inclusive through line sang winning interpreters and by video recording the lecture. So all of this enables us to reach and involve a much wider range of people. And we're able to do all this thanks to the audio-visual and set-up support from Upstate's Educational Communications and Environmental Services Professionals who have been fundamental in organizing the technical aspects today and environmental services. And also our caterer, Jennifer Jaffee who is working away for you to enjoy some delicious food at the end of the presentation. 2 And we are really grateful for the support and insight provided by Rachael Zubal-Ruggieri, who works with Diane at the Burton Blatt Institute. We are working to make experiences of healing, care, and healthcare more inclusive in this community by engaging with one of the founders of the movement called Graphic Medicine, MK Czerwiec. MK is a nurse, an educator, and the creator of the graphic memoir Taking Turns: Stories from HIV/AIDS Care Unit 371 and co-creator of the Graphic Medicine Manifesto. She co-manages the website, podcast, annual conferences, and online community of GraphicMedicine.org. MK teaches graphic medicine at Northwestern Medical School, the School of the Art Institute of Chicago, the University of Illinois Medical School, and the University of Chicago. She has served as the Artist in Residence at Northwestern Medical School, a Senior Fellow of the George Washington School of Nursing Center for Health Policy and Media Engagement and a Will Eisner Fellow in Applied Cartooning at the Center for Cartoon Studies in White River Junction, VT. Her next book, one that I'm eagerly awaiting, will be the edited anthology. 4 Menopause: A Comic Treatment. This should be coming out this spring. More of MK's work can be seen at www.comicnurse.com. As she wrote in the book Graphic Medicine Manifesto: "Graphic Medicine seeks to disrupt [the] power imbalance" (20). Let the disruption begin. Please join me in warmly welcoming MK Czerweic. [ Applause ] How about now? Yay. Thank you. This is so wonderful. It's wonderful to be here. Thank you for the invitation. Thank you for everyone who made this possible and thank you for all that I'm learning about accessibility. As I go through my presentation, it's my intention to describe the relevant images that correlate with what I'm trying to communicate. If I don't describing? 3 And it seems relevant, raise your hand and let me know because again, I'm learning. If I don't describe something and it doesn't seem relevant, that's okay. I have a lot of filler in terms of images because I like to be image strong since that's the work I do. So I also make comics under the name comic nurse. And I have an elevator speech for the work I do because I bring together such things that are not normally brought together and that's that I'm a nurse who uses comics to help me contemplate the complexities of illness and care giving. With the word uses, I mean to 5 refer to reading comics. What can I learn from comics about living with illness and care giving and disability. And by use, I mean actually making them, drawing. What do we learn from drawing different than writing text or stories or other ways of engaging with our stories around illness? That is what we will be unpacking a lot of here in this talk today. My goals in this, or in our time together, I want to define and describe what it is, graphic medicine. And then by answering sort of this question of why comics of all the things in the world, why would comics be brought into the healthcare encounter in the experience of illness and disability and care giving. Why comics? I'll show how reading comics can improve our health and drawing 4 comics about health, illness and disability can lead to a better understanding and increased sense of agency and perhaps improved health. My work is heavily informed by disability and disability studies. But I want to say that I'm not a disabilities studies scholar. I'm a fellow student. I'm learning and today I've already learned a tremendous amount. The images on the slide, on the one side there is a photograph of a wonderful colleague I've had the opportunity to be friends with and work with, reva a portrait artist. She is I think the first on the... there is a resources list 6 that we handed out and that can be made available. The link to her website is one of the first things there. And I benefited a great deal from reva talking to me and about the work she does, formal portraiture with people with disabilities. It was something she didn't see. There she is lecturing at the New York Academy of Medicine. Another image on the screen is a panel from a comic that I made in which a doctor stands over my unconscious dad who is on a gurney and the doctor is speak to my mother and the doctor is saying your husband has had a massive stroke. You understand what that means. She said yes, that means I'm transferring him to another hospital. My mother was a nurse. I grew up with a dad who had had a stroke and was paralyzed on 5 one side and living in a family as our family dealt with that, I came to understand so when I learned about disability rights, a lot of things that I lived with and we experienced as a family became much clearer and I started to understand things. I was predisposed to understand how important this is and of course my work as a nurse during the aids crisis really reinforced all that. Those were my caveats. The other caveat is I know little to nothing about super heroes. Eye I've learned quite a bit. Everybody knows more about it than I do. This is a book that came out not long ago called "Uncanny bodies" by Scott Smith. 7 And I news confess thus far because I'm not well versed in the super hero story, the only chapter I've read is "A colleague and friend" living with cystic fibrosis which is towards the end and done in comic form. But I'm working on it. I'm a student. The term graphic medicine was coined by Ian Williams and it's meant to refer to the interface between the medium of comics and the did Is course of health, illness, disability and care giving. Kind of an intersection of these two things. When Ian first came up with the term graphic medicine, he is a physician who, at the time was living in south Wales and was a rural general practitioner. And what he meant was at the time a bit of a joke. 6 He meant the graphic, the comic itself could be the medicine that do somehow could a comic actually provide health, provide for a route to health? And in-- from our book, what we add to the definition is that so too graphic medicine resists the notion of universal patient and vividly represents multiple subjects with valid and, at times, conflicting points of view and experiences. So that it's very much of a thing that are seemingly in conflict that exist together yes and opposed to no but. And that's what we try to approach graphic medicine with. I would like to start with the comics origin story so I'll start with mine. I'm always asking that question, how did you get involved in 8 comics or where is your passion behind comics. I read the newspaper comics as a kid. I read peanuts as a kid but I did not have a strong rooting in the comics as a young person. Mine came more so in college and after. When I was working as a nurse on an aids unit. Brand new nurse out of nursing school and it was the early 90s, the height of death from aids happened about 1995 in this country. And so that was just before that I was working and so our patients, we would meet, fall in love with them and their families and they would become part of the family that was our dedicated care unit and we lost almost all of our patients. It was a very difficult thing to 7 come out to. One of the ways I cope with that and there is an image of a comic panel of me that I've drawn this from my book, I would go to a little cafe before work. I worked 3-11 evening shift and I would write stories in text. Would I write in a journal. It got to a point where that became much more of a burden and cumbersome and a little more difficult, actually to be reexperiencing things that I had just happen the night before. The reason I was doing that was to clear my head to go in fresh and care for myself. But that actually became more hurtful and harmful for so so I turned to images alone. I have on the screen an image from my group where I'm painting these pieces of wood and I would paint in memorial from patients 9 I had cared for and cared about a great deal. Then I got to the point where it felt like images alone were not capturing the whole story. The images were not enough story, the text was too much story. One day I was really struggling to find a way to take care of myself, to keep connected, but not suffer so much from being that connected with so much loss. And one day not knowing what else to do, I drew this picture of myself then I put words above it. This day of trying it is why I'm here 15 years later. Then I put a box around it. Then I made another box. What I didn't know at the time is the empty space between two 8 panels and a comic is called a gutter and the gutter asks you a question. It asks you a question like what's next? Take this static State of Being miserable and you have to turn it into something. You have to your Honor it into a story. It would ask the question of what next. So I went with it. I wrote that a favorite patient had died and then I drew and I kind of just continued doing this what I didn't realize at the time is that I was making my first comic. Rather than show you the comic this turned into. I want to show you what happened for me that day. There is a nine panel grid on the slide and top left corner I show you I was in a State of 10 Despair, confusion and feeling overwhelmed and as I progressed through each of the panel with a little bit of text and a little bit of image, by the time I came to the bottom right panel, much to my surprise I found myself in a place of hope and clarity. That act of doing that had a positive impact. I kept doing it making comics about the experiences I was having. Three examples of my very early comics. I don't expect anybody to be able to read them. It's very small but show what the these came to look like. Very naive drawing style. Colored on the computer, but the point was the doing of them. Not so much what I showed them 9 to anyone but the stories were I was trying to use this medium as a bridge between my life off the unit, and the life on the unit of my work that was quite traumatizing and the comics became a bridge that helped it work. I kept making comics. I wanted to make better comics. Could I have improved my drawing skills but I like naive drawing style. It's my jam. I decided I wanted to inform the comics with theory. I wanted to look at the theory why do stories help us heal? How does a story help us heal? What kind of narrative styles are there. What kind of work are the stories doing? Mostly that's what I went to study and I studied medical humanities at Northwestern and bioethics. 11 What are the ethical imperatives when I as a caregiver go to tell a story about my care giving. What am I bound by ethically What are the best practices? How do I establish how to make comics ethically done and informed by all this theory. That's what I went to study. When I was there I kept it quiet I wanted to be taken seriously. But then I came across this book called mom's the cover of the book is a two panel image of a woman sitting up in bed with a bandage on her neck and I saw that across the room in this bookstore and I thought that's an image I'm familiar with professionally, not something I've ever seen on the cover of what looks like a comic. 10 And this book beautifully critiques the healthcare system in which he and his family found himself. The treatment, the process. It gave us a window into a world of experience that I knew as the family member of someone who had been sick but never seen shared in this way and I thought wow, people who are studying to become healthcare providers could read something like this, this is a new insight that we could really learn from. Brian said about creating this book, he said comics with the right medium, the story that I wanted to tell. Meld words and pictures to convey an idea with more economy and grace than I could alone. I instantly said this is amazing. Non-fiction by someone going through this. Are there more looks like this out there? 12 I wanted to show you inside the book. So he very powerfully describes this experience. I've got a three panel sequence where he uses the metaphor of a tight rope. He is specifically talking about when you have to give a patient and anticoagulant, when you have to stop the clotting of their blood. You are putting them on a tight rope because if they clot too much, they've got a problem with that. But if you declot them too much, then they've got a huge problem with bleeding. So it's a beautiful use of metaphor. 11 And I think, too, he was looking at the healthcare system at large of what we put our patients through and that's the kind of things he is showing us. There is an allocator in a pool below his mother on a tight rope and then a buzzard on the stick waiting to throw her off balance. It is a beautiful metaphor of what the healthcare system can put our patients through. Another image, he shows his siblings and himself becoming sort of super hero versions in the way in which they're trying to cope. He is a writer and researcher. He becomes a superhero who thinks he has all the knowledge. Sister is a nurse in the center and she is super nurse and wants to be in charge and the other sister feels invisible in this whole encounter. And he uses this as a way to use the kind of metaphor of super heroes and ultimately this is 13 the way in which the family experiences conflict among themselves. Again, the conflict among a family impacts the care of the lovered one but that's not something that we think about as providers. So I said, you know, are there more like this? And it turned out there were. And since then there have been an explosion of graphic memoirs, non-fiction by people living with illness, disability and doing care giving. And these are just a few examples on the screen. And some of these books cover things like Parkinson's disease, 12 mental health issues, cancer, eldercare, seizure disorders, Alzheimer's. Sexually transmitted diseases. So the range of diagnosis that these kinds of texts cover is really quite something, quite amazing. The important part about those books being non-fiction is that, and this is the sort of disruption piece, too, that I love about graphic medicine, is historically it has been doctors and medical illustrators who are paid by doctors and healthcare providers who represent what illness looks like. But through these graphic memoirs, it's the people who are experiencing it that get to show you what their pain looks like. They get to create, have some way of showing what their experience looks like and we can learn from that. I truly believe that those best positions to represent illness and caring care giving are those living with it. 14 And that's not in the clinical encounter who the authority is, but to my position, as a family member and a nurse, I believe that's hot authority in the situation should be. The patient and the family. And the image I'm showing is a person in a wheelchair holding up in Latin, the motto of the disability rights movement as I understand it, nothing about us without us. I Kecked with colleagues looking into the area, fast forwarding through the history of graphic medicine. This is a website graphicmedicine.org. 13 I co-run. It turns out this is something happening all over the world. You see the one box on the one side, that's a Spanish language version of our site and a whole community in Spanish language communities. Japanese language version of this site that will soon be linked. This is going on throughout the world. We have a podcast. An amazing explosion since the early days when I came across that book that people around the world, it turns out, had already been looking at the intersection of comics and medicine. You can search the site so if you have a particular clinical area, the comic about donating a kidney? Yes, there are. Hopefully you can find it through here or contact us through the site. Did I mention this is the home page of our medicina graphica page. 15 And what I'm showing is the home page of the site in basically-- this is a translation site into Japanese. This is a book series through Penn State University proposal press that took on the idea comics could be published through academic press and published the manifesto where we got together and said this could be a thing. We think this should be a thing. And they have published a large number of books and are continuing to publish a large number of books. Some of them are original comics 14 not just scholarship but like my degeneration is a comic by a man who lives in Alaska living with Parkinson's about living with Parkinson's. And and they publish my book "Taking turns" an original comic about my experience as a nurse. Kendra, who is the Editor-in-Chief of the press, said that when she first pitched-- when I pitched the first two books in the series a member of the faculty board, university presses have no business publishing comics. Now four years later, and 12 books later, I have a graphic novelist academic on the board and receive a lot of support for the series and I have to update the slide. It has been five years and there are 22 books in the series. This clearly is an area that's exploding. I'm running through a few things that blow my mind. The Annals of Internal Medicine, another resource available if you are interested. There were 81 comics. 16 I think that's more toward 90 now again this is a disruption. Average person doesn't normally have the ability to have their work published in a medical journal. Some of these comics are not by providers but by people living care giving. A center comic called dear Dr. One, a comic and dear Dr. 2 above it by a trans man who talks about the experience of trying to receive healthcare as a trans person and actually they're just like, these are things that went well and kind 15 of trying to model that positive behavior. So this is an incredible, again, disruption. I love that term. National library of medicine collects graphic medicine and has a traveling exhibit. Patricia Brennan said without graphic medicine we were incomplete. It addresses an unaddressed dimension of health and provided us a way to archive the experiences, the expressions of that dimension of health. They don't actually collect text memoirs of illness but felt this was something else and this is the traveling exhibit. On the slide is an image of the traveling exhibit of graphic medicine curated by Eleanor who did an amazing graphic memoir called marbles. Michaelangelo and me. And follow-up book called rock steady about maintaining mental health that is a benefit to anyone as far as I'm concerned. Last I'm talking about the community. There was a first graphic 17 medicine conference in London in 2010, second in Chicago and then as I mentioned since then, people have come together and talked about this every year. But what is interesting is that so many aspects of our work we try to be interdisciplinary and this slide is, unfortunately, one of the slides you are never supposed to use which has 50 million words on it but basically it talks about the kind of positioning from which people come to this community resonance in theater studies, 16 bioethics, chaplaincy, art therapy, hard sciences, historians, creative writers, mental health professionals. It seems that because this thing of comics is something so many people find resonance with, people are finding ways it is incredibly relevant to so many different kinds of works. Librarians, pharmacists, physician, all have areas of utilizing graphic medicine that can be found out in the world. So this is a little late to do this. I'm going to define a few terms. Particularly the term comic. What I mean when I use the word comic because boundaries and borders become important and there are people who argue something isn't a comic, whatever. I use the term comic to refer to sequential art that conveys a narrative and often incorporates text. Things about comics and comic studies once you put out a definition you've excluded something. My definition excludes single panel comics. 18 Image and another image and another image and another image and again as I mentioned, the gutter space between these panels in this image implies time. And our brains will actually instinctively link sequential images to create a story. Our brains just do that. We put things together and we try to create a story. And there are all kinds of interesting research around that and I'm not going to go into 17 that now. Comics plural is a medium, right? Expressive medium that contains many general are within it, right? So to think of comics as only super heroes would be like thinking of movies as only cartoons. I have silly titles as if all movies were cartoons, right? Just kind of make the point that it's a vast world one of the things I love about comics, there are so many access points. So many people came up reading superhero comics. That's an access. Mine was the newspaper comics. That's a path. There are the underground alternative comics. Mad magazine and the underground. There are a lot of access points to comic, which I love graphic novels, this is art Speigleman who created the graphic novel "Mouse." He says that graphic novels are long comic books with a spine that want to be reread. They're all comic, right? They don't need to come up with 19 a fancy term like graphic narratives. They're comic. There is a stigma people think they're not real or serious or scholarship because they're comics but in the end they're comics. Why comics? One of the great uses of comics in healthcare, that's why I'm moving into what comics are doing in healthcare. They're incredible educational 18 tools. A great way to teach. I have an example on the screen Iggy and the inhalers. A pediatric allergist and immunologist created because he was a little kid with asthma and he couldn't figure out which inhaler was for emergencies and which one was for every day and there is no uniform packaging so he created these characters as a little boy and he grows up and he is a doctor that turned this into an official learning mechanism. Create stickers and basically used the power of the stories of the comics and the characters so there is bronco, the bronco dilator, opens things up with his lasso. The emergency. And Coltron, the controller who is this shooting thing is the long acting one. They act it out and researched it at asthma camp in Wisconsin, they came up with a pretty good understanding based on the comic. That's one example. There are hundreds and hundreds of examples. There is a long relationship between comics and public health 20 messaging for adults. A lot of the earliest history goes back to war and using comics in war with soldiers, particularly around sexually transmitted diseases. But of course it's also been used in public health crisis like flu, kind of emerging public health crises, particularly common during the aids epidemic to use comics as a way to teach. 19 And even for chronic illnesses like diabetes and health prevention like vaccines. There is a lot in public health with comics. So I think comics are an incredibly powerful learning tool. If you have a high density of information. There is a lot to learn. It's really important that the learner learn and 3: The learner is in a high stress situation. So that explains why you can imagine go into your doctor, you are really nervous about what your diagnosis is and all of a sudden you are given a diagnosis that requires you to learn a lot, like diabetes, a cancer diagnosis, a diagnosis where not only do you have to accept that, deal with the emotions of dealing with that and the stress of dealing with that but you are asked questions about what treatment modality you want to take, how did this happen, all this stuff comes at you at once. Comics are really good in situations like that and one of the ways we know is because this is what you get on an airplane, right? You go it this thing in comic 21 form that tells you, you are in a stressful situation. You need to know what to do and learn this information. It's a very efficient medium. The image I have on the screen is from the back of the seat in front of you on a plane that gives visual instructions. It can potentially transcend literacy challenges and can add this visual attraction and 20 appeal to images they are often low cost and low bar of entry. Pretty straightforward to make a comic. Perhaps not as detailed as an example but a basic comic is pretty easy to make. That's my theory on why I think comics are used. The other thing that comics bring is story, narrative. We experience a world through stories, righted? And the example I always use and the image on the screen is of a mom, two moms are dropping their kids off at daycare. A comic I drew for this to illustrate the point. One of the moms has her arm in a cast and yesterday mom didn't have an arm in the cast. The other mom says well, gosh, Pary, what happened? Right? What does she need? She needs a story that links yesterday when there was no cast and today where there is a cast. The only thing that makes that make sense is the story of what happened in between, right? And so as people who are with people and want to understand what is happening in health, weigh need stories. But also the people who are experiencing a change in their 22 health condition, we have a need to tell a story, right? So she starts telling the story, well, I picked up Susie after school, went to the store. I fell. So in telling the story, we are doing some really important work. And there are people who have written theory about the stories 21 we tell about our illness and our bodies, how the kinds of stories are whether they're helpful or not helpful and the act of telling them and retelling them is helping us in different ways. And so there is a lot interesting theory but comics built in calm with stories of illness, right? Another amazing thing about comics and what they're capable of is the use of metaphor, visual metaphor, taking the way we talk about our bodies that we can't see or aspects of our lives that we can't see. They give us metaphor and we can regard them, right? So Peter Dunlop in his book "Mighty generation" living with Parkinson's, a piano crashes down between him and his doctor and this discord and musical notes flying in all different directions, to make you see what that felt like for him. So to make visual, to externalize that for what it was like for Peter. The mediumh, the medium of comics comes with powerful conventions and I'm using an example from a book called "Signature Wound: Rocking TBI or Traumatic Brain Injury" by Gary Trudeau. To tell the story of the speech 23 bubble and thought bubble. First panel is a soldier in bed in I.C.U. and we can see a thought bubble and he is identifying the other person in the frame is his lieutenant, lieutenant B.D. And lieutenant B.D. in a speech bubble says how's it going, soldier? 22 And the next panel we see the soldier in the bed tries to speak. And he can't quite get the word out. He tries to show... and the next panel he tries again or the next panel he tries again and the speech bubble, and in the final panel of the comic we see his speech bubble trying to say a word and his thought bubble with complete ability to express his thought. That's all I've got. He is experiencing aphasia. Cognitively in tact but can't speak. So that makes it explicit. We have the ability to examine the interior thoughts of the characters in the frames what are you thinking in a clinical encounter that you are not saying? What are the doctors thinking in a clinical encounter they're not saying? Is there a discordance between those two things? Those are rich learning experiences and great comics to make. Another comic that shows the power of the medium itself, a wonderful example is C.C. Bell's el Deafo and there is a page from the book on the screen where we can see that the characters are all speaking. 24 There are empty word bubbles and we see a thought bubble of C.C. that says "I can't hear." Clearly words have been said but they're not received because the word bubbles are empty. On another page, interesting she uses the medium very creatively where there are, again, an 23 interaction with her mom and her doctor and her doctor is putting on an adaptive device and as the adaptive device comes into being on in the final panel, we can see sort of coming in to being heard because they're in the doctor's speech bubble but we see that they don't quite make sense yet and as the book progresses on the next page, the words start coming together and we can understand them. What she is showing us is that she was hearing gibberish. And then living without a voice. We see in the panels that Georgia uses the color red to indicate sort of her, you know, this sort of boldness of her experience, her lack of a voice. She uses it to represent sound and hearing and sort of the sensory experience. I'm sure there are people in the room who have written about this book in a far more sophisticated book than I'm conveying it but it's a really powerful use of the medium, to sort of do this important work. Another reason for comics in healthcare is comics are a powerful tool for advocacy in improving health outcomes. I want to share a few examples. Terrific online comics on a web satisfied called the nib, they have now a great archive built up but there are comics there that talk about bioethical 25 issues like the experiment. Cartoonist Whitt Taylor who does work for them who has a master's in public health and she brings that the to her cartooning, looking at race and how it impacts health and health outcomes. 24 Another cartoonist in there did a wonderful comic called medicines woman problem looking at gender bias in medicine and kind of one of the things I love about this comic is it's very data informed about how it takes an average of five years and five doctors for autoimmune patients, 75% of whom are women, to get proper diagnosis. She uses her own personal experience and the power of story and then brings in data to kind of really look at the larger problem. So that's really a wonderful resource to have online. Then another great project I want to tell you about. This is a Seattle King County dental clinic and medical clinic. It's a free clinic that the county does. And during the debates around the Affordable Care Act, a group of cartoonists from the Seattle community came to this clinic and sat down with people and asked them why are you here seeking care and turned some of the stories ethically attending to all the important issues of story telling and sharing and turned those stories to why people need health insurance into comics that could quickly be disseminated on social media and help with the debate. That's on the resource sheet. Comics for health coverage. 26 The other thing I think that is really great about comics, bearing witness to stigmatized realities, right? Things we don't want to talk about. Comics are often fine engaging 25 that because part of the underground cultural history. Things like care giving. We don't talk about the day to day realities of that. In this comic, "Special exits" included in the frame of the comic, bed side commode. An incredible tool, righted, incredibly important thing. As a nurse I was excited to see this. She shows us what it itself like to wash her own mom's hair or giving a bath for the first time. It's stigmatized and hidden away except for some some of these wonderful books. Issues around mental health. Stigmatized very common in comics. There are two areas that initially we found that comics focusing around mental health and cancer and so there is a lot of great examples of mental health comics is in the high efficiency of the medium she is showing us the state between mania and depression. The horse on the carousel as being up and down and rapid cycling in the center and as I try to describe it, I'm using far less efficient words she used in her image. All the phases of her manic depression are and then again another brilliant metaphor of when she feels like she is experiencing a manic phase, the metaphor of a boat being dragged 27 out to the chaos and the mania and trying to reach for the shore and knowing that she can't. She shows us what that feels like when she is about to enter 26 a manic episode. Women's health issues. A shameless plug for a book I just finished editing. Flipping the script. This is Rachel House, a cartoonist from the U.K., two words you never want to hear from your doctor, vaginal atrophy. And then she flips the script and creates a trophy for her vagina. Wonderful visual imagery of disruption. Dying stigmatized. Death is less, death itself natural dying, violent dying is fine to show in cultural forms and pop culture but natural death if it is portrayed, not accurately portrayed but that's not true in comics. Here is an example of Roz Chast did a comic called "Can't We Talk About Something More Pleasant" and uses the humor common in her work in the New Yorker and she engages directly with her mother's dying and her father's death and actually, believe it or not, natural death, this is a focal area of a lot of my research and my work, comes up with really wonderful ways and quite a few graphic memoirs, my own included. So, yeah, it's really exciting to see that that is out there and that's part of this movement. One of the last things we don't talk about is caregiver 28 suffering. The fact that we as caregivers and those of us who provide social services and those of us in the community doing work in 27 difficult situations, we are also troubled and traumatized by those we care for and a colleague of mine Ian Williams to coined the phrase graphic medicine, he coined, he talked about his struggle with bearing witness to this small town and kind of knowing troubles and how it weighs on him and how doctors are impacted by the struggles of the patient. Is in an image from dean, and the images of a full body image of her mom, Alice, wearing a robe that is made up of cut-up pages of Alice in wonderland and she radiates lines with iconic images of her Armenian youth. Her facial expressions are fabulous and what her mother's struggles. She was trying to help us think about Alzheimer's in a different way, about being present to the place where the person with Alzheimer's is rather than where we want them to be. And she said in the introduction to this book, around the world comic artists, caretakers, parents and assorted onlookers are taking up their drawing tools, pens, papers, scissors and computers to depict illness in ways of being human that had been stigmatized and this is what the essence of graphic medicine is, that disruption piece. So again revisiting the question of why comics, right? One other thing that comics are great for is a medium of research, right? 29 So I've a comic on a slide by a colleague of mine named Muna Al-Jawad. She has two frames. 28 One is of a doctor. This is my practice. I work here on the wards. And this is my theory. I write and read from my computer away from the ward but because they're necessarily based in my experiences, comics link what happens on the ward, my practice, with what happens in my head, my theory. And it's a similar process to analyzing qualitative data. So research methodology, and the next example I'm showing from her work she shows the word itself and then layers archeological layers underneath the word and kind of like, as she says, trying to get at what is going on underneath the clinical especially counter and what happens in it in the encounter and traveling through that like an archeologist with a flashlight and she comes upon the word bubbles. Basically has a citation to the literature she is referring to. A way that comics can be used in scholarship, the wonderful example and another example is a comic I'm showing nine panel comic that basically is a research study about what are randomized control trials. The example this cartoonist is using is the practice that nurses will routinely change an I.V. site every three days. What is the research about that. Should that be the case? Let's look at it and learn about randomized control trials are. This is very true to the research study. 30 It just uses the images and the sequential methodology of the comics to translate that 29 research. And you know, as a practitioner, I would sure like to do my continuing education in comic form than be given a handful of scholarly articles. I mention initially that one of my goals is to help you see that reading comics in the clinical encounter in the healthcare environment and in disability and around kind of access to health, all of that, is incredibly useful but I also mentioned that I wanted to convince you that making comics can improve our health as well so I'm going to move into that section. Comics provide us a space, opportunity and format for processing complex healthcare experiences and our reactions to them. Comics are an excellent way to access our stories. They build one bit at a time and help to us organize thoughts and feelings. They have a structure built in. I'm very easily overwhelmed by a big problem that I go to write a paper about or to think about or struggle with, but if I just have one single panel that I'm dealing with, I can think about that bit of the problem and I trust the process that like the next panel I'll deal with the next bit and as you write and draw also, aspects of the story come to the consciousness that you may not realize were part of the story. Soming about the time it takes to sit there and do it and process things in different ways 31 and using image and text in conjunction and we know 30 different things are happening when we use word and when we use text, when we read text and when we read images. Different parts of our brain are in use. Again there is really interesting research around that. The other thing is that comics can be fun and you use fun loosely. It can be an enjoyable experience because often and even when it's a very difficult topic that's being discussed and being done in comic form, it can still be less difficult to engage with. I have a cover of a book called "The fire story" follow-up book to mom's Cancer because his entire home was burned in the pubs fire in 2017 and he responded by going to, after they lost everything they owned to going to COSTCO and bought a pad and markers and drew what they were experiencing and it turned into this book. He said something, again, as I mention, he is the guy who created mom's cancer, he said something essential. A comic takes reality and pares elsewhere everything that is unnecessary until you get to the heart of the experience and I think that's the process that happens as you start to draw about experiences in health and illness and disability and care giving. You need a piece of paper, a pen or pencil. If you have crayons, that's great too. It's an accessible medium. 32 You maying sitting there saying, 31 I can't draw, right? Well neither can I. You've seen my drawing style before, right? The truth is I started looking. Why don't we all draw as a way to reflect on our thoughts and feelings? We did it as children, but why did it get left behind? If you walk into a first grade classroom and you say to the class, who here is an artist, you get this. Everybody raises their hand and the teacher is smiling and they're like, yes, we're artists. If you down the hallway to fifth or sixth grade classroom and you say who here is an artist? Unfortunately not too many people raise their hands. Somebody in the back will say I'm an artist and maybe somebody next to them will say no, you're no. You can't draw. And then there is something wishing I wish I could draw but I don't have that. And then the teacher will say that's Billy. He's the one who can draw. The rest of us can't. That's absurd. We could all draw. What happens around that age is that the two things: 1 is that there is a part of our brain that goes online that is responsible for judging ourselves and others, right so we stop spontaneously singing. We stop spontaneously dancing or drawing. The other thing compounding and unfortunately goes against most of us drawing is that we then in 33 32 our education, we have access to words. We can write and we can read for most part and so this words become the thing we use and we leave images behind, which, I think a travesty, because we can all draw. We all have a visual skill. There is a biological reason and we judge ourselves and the cultural thing that we are supposed to use words. But at that point in our education we weren't all Shakespeare. We weren't all like these master writers but we all just had to learn how to use words better, right? But for some reason that didn't apply to images. We were all expected at that point to be able to be photo realistic in our drawing. Photo realistic drawing only one portion of drawing. There is a great power in the act of drawing and we leave it behind and I think that's terrible. A huge influence in my career is Lynda Barry, a genius. She said if a four-year-old won't draw, we worry but if a 40-year-old won't draw, we think that's normal. Why? So what I'm saying is and hopefully you can come to my workshop tomorrow and we can test this theory but I believe we can all draw to some degree. We just stopped practicing. Imagine what wore handwriting would look like if you stopped drawing in the fourth grade? Sarah Leavitt said that when people say they can't draw, what they usually mean is they can't 33 34 reproduce something realistically but a good drawing conveys what you are trying to communicate and people who look the eight can understand it. You can get that done with stick figures. I think that is a treasure chest but on top of it is the I can't draw gorilla and if we stop using that as a reason to not draw and get past that, that is great. I know I'm running close to time. I work with my students and ask them to draw a clinical encounter. Whether my students are in an art school and draw an encounter where they were the patient or someone else was a patient or medical students and they draw an encounter where they learn to be a provider. These are rich and powerful drawings that the conversations we have about these drawings are incredibly a revolution as either patients or providers and you don't look at either of them and say I wish they were more photo realistic. You can get out the pressures and situation that people are trying to represent. One of my favorite drawings was by a medical student, very Picassoesque drawing of him sitting there in the chair. He was the first year medical student and shows himself in a chair next to a patient crying and giant arm extended over her and what he said about creating the drawing I want to remember this is why I became doctor, so I would be like this and it was a visual reminder while his head 34 was stuffed with all the things 35 that doctors heads get stuffed with. This is a very basic drawing and you don't look at this; I don't think and say I wish it were better. That's a powerful image I get grown-ups to draw all the time. These are people drawing what they believe a good death would look like. I try to like use this to do important, the work would be to get them to talk about what they want their advanced directives to be, what they want their wishes be to if they can't speak for themselves and we are doing it with crayons. I think drawing with do important work in healthcare. These are a couple of drawings from seminars. First image is a stick figure who is supine, surrounded by people who are meant to be his family in a bed. He is the person in the bed has a tear but also a smile. The surrounding people have frowns. A tiny person, baby or child is in bed with the person. This is what this individual's conception of a good death is. And then the other one was by one of my medical students an astronaut hovers over earth in some ways and the oxygen tank shows it is low and she is smiling. She felt that was a good death. And then I know I need... I'm going to skip this because I want to mindful of time but can I talk about that if anybody is interested. A project where people were 35 working with combat veterans and making comics with them and 36 that's a whole other area where comics are being used. In summary, how are comics being used to improve our health or how can they improve our health? First as a powerful educational tool, a powerful reflective tool, third as a method of research and to create communities. People come together around comics to make them and to read them and talk about them. To amplify the issues that face patients and cares caregivers and to put those front and center and tool for communication across boundaries and to help advocate for change and so those are the ways I believe comics can improve our health. So thank you all so much for coming. If anyone has any questions, I think we have some time to talk about questions and things like that. And on the resource sheet, comicnurse.com, you can email me there and@comicnurse at most other social media if you want to be in touch or questions or areas of interest if you want to know if there is anything out there. Our goal is to serve as a resource to provide that. [ Applause ] >> Thank you. So I have the references here, the resources. You can pick up a copy. There is also a sign-in sheet. It's just really helpful for us to have a record of who came so that we know how, what the scope was of the impact of this lecture. We have some time for questions 37 or comments so feel free and I can just run this over because we are recording this and in order for the captioner to hear what is being said, we need to use the mic. So just raise your hand if you have a question or a comment. Does anyone already make comics? Hopefully that will change tomorrow. >> We have a whole range of people in the audience, including someone who I'm just going to quickly introduce, Giordana who makes comics with youth and refugees so working in the area that you were 36 just starting to talk about, do you have a comment or question? Do you want to just say hello? >> Hi everybody. As mentioned already, comics are very great tools to take away some of the stigma and trauma away from the population that you are working with and also engage in cross cultural exchange. So in the medical field with the encounters that you have that might also come in handy. Also working in very high stress environments, it's something that allows me to relax and process as well. I'm happy that you talked about the fact that, you know, not all of us have time to really reflect by writing. And that can actually go over some of the traumatic experiences that you might experience, that might be adding oil to the fire but if you draw an image or something else that is representative of what you went through, you are not only processing it yourself but you might give someone else an 38 opportunity to do that as well. Thank you so much for being here with us. >> Thank you for saying that. One of the reasons I think it is so important for M.K. to be here at Upstate because we like you have students who are under a lot of stress. And this comes out in multiple ways. So this is a way of healing. So I don't know if you want to speak to that and maybe it's a good cue to talk a little bit about the work you are doing with veterans. >> Was there a question? >> That's what I was going to ask. >> Please do talk about that. >> The specific project I was referring to there was one at the center for cartoon studies in Vermont and they have a group of students who need to do the assignments to make comics and they wanted them to be engaged in the world. And they're into fly cartooning. So they worked with veterans at the V. V.A. hospital in the area and the veterans would tell stories about what they had been through, kind of are going through, trying to figure out how to deal with the P.T.S.D. and so they would kind of put the person telling the story together and giving the person telling the story, all of the decisions as far as how are you represented? What do we show? What do we not show. What order do we show it in. So that they have control over the story that's being told. >> And what the cartoonist is doing is just sort of knowing how comics are made drawing that experience under the guidance of the person telling the story. It's a really powerful way to bear witness to the trauma and to help to hopefully help them express it in a way that they have agency over when perhaps they didn't have agency over the trauma that happened to them. That's one example was the book I was showing you called "When I returned" an anthology of those stories and then there's one of people experiencing sexual trauma, to make the decisions how it gets represented, what is in the frame, what is out of it. A way to gain agency over something that happened that had 37 you no agency over so there is a lot of really interesting work happening. I don't know if that answers the question. >> I would just add having learned about that, I find it so relevant to the work that Diane Weiner and Rachel and I are to do, making comics more inclusive, where you could have people paired up. So there might be someone who is not going to be as adept at using the crayons and paper to draw something or even adaptive devices like I. PAs and styluses so you could have somebody taking over control of the drawing and someone else saying this is what I would like the comic to be. So I find that hugely helpful. >> The other thing I was going to say is that so the workshop, as I organized it and I may kind of change it based on the needs of whoever is there, is an attempt to kind of put some of this into practice so we can look at how to use your visual language and use it to the service of helping cope with difficult situations and cope with just life as it is difficult. >> Any other questions? All right. Well, we have a beautiful reception, so please stay and enjoy and also have informal discussion and thank you all and thank you join me in thanking M.K. again. [ Applause ] >> Thank you to you as well.