Comics as anti-racist education and advocacy

Academic medicine is increasingly recognising the importance of teaching about structural racism in medicine to help ameliorate racial health-care disparities. Yet such teaching can be challenging and, in some settings, considered controversial. Leveraging the power of narrative, comics can contribute to education about structural racism.

Structural racism involves the normalisation and proliferation of inequitable and interconnected societal systems, policies, institutions, ideologies, and practices that disadvantage, discriminate against, and reinforce inequities faced by racialised minorities. In the broader societal context of the USA, examples of structural racism include discriminatory lending practices that continue to bar Black, Indigenous, and people of colour from home ownership and access to quality education and initiatives that place the burden of harmful environmental exposures on minoritised neighbourhoods or limit access to public transportation, public spaces, voting rights, and healthy food options. In the history of medicine, structural racism is apparent in a legacy of experimentation on Black bodies, colonial and racialised medicine, “scientific” racism, and the segregation of hospitals. In contemporary health care, it includes the persistence of racialised medicine and science, unequal access to health care, clinical training programme ranking systems that disadvantage minority students, persistently disparate outcomes in Black maternal and infant mortality and any number of health and health-care disparities, and the continuing under-representation of communities of colour in academic medicine, health-care leadership, research, and on the boards of health-care organisations.

The stark racial disparities in COVID-19 cases, morbidity, mortality, and vaccination rates have amplified awareness and discussion of structural racism. Despite increased attention on the topic, the past year has been fraught with incidents that highlight how entrenched structural racism is in medicine and how challenging it can be to address. Despite much scholarly literature that espouses the importance of addressing structural racism to reduce health inequities, medical institutions often struggle to fit impactful teaching about it into curricula or even dismiss physician educators who teach about structural racism or advocate against biased policies. Such discomfort with engaging in discourse about structural racism makes teaching the topic all the more necessary.

In recent years, there have been calls to action for anti-racism courses in medical education to draw attention to and help dismantle these structures. This coursework should include a structural competency curriculum with in-depth study of structural determinants that impact the health and wellbeing of populations, an opportunity for transformational learning that provides for the growth of critical consciousness, and the role modelling of engagement in advocacy at every level from individual patient advocacy to system-level changes. Teaching about structural racism requires thoughtful, effective forms of communication. Peek and colleagues, for example, outline deliberate measures educators should take to create a psychologically safe space for conversations about racism, noting that it can help to “start with stories, not numbers”. This approach, which encourages learners to engage with empathy, can help diffuse tension and refocus them on a likely shared goal of improving outcomes for all. Approaches include using videos showcasing instances of interpersonal racism, curricula involving small group discussions that allow for intimate conversations about injustice, and lectures by academic experts in the subject, such as social scientists and medical historians. Unsurprisingly, some successful modes of education incorporate reading and creating narratives because they help to imbue lessons with humanity, making them relatable and more accessible.

As a readily recognisable form of narrative, comics are a powerful tool in anti-racist education and advocacy. Comics combine textual and visual elements to express ideas and create narratives. In our increasingly fast-paced world, comics can succinctly communicate information and evoke emotional responses, often by simultaneously depicting multiple narratives and balancing levity with seriousness. In this way, comics can draw attention to medical and societal inequities that might otherwise be normalised by displaying contrasting narratives in parallel panels (Figure 2, Figure 2 ). The directness with which comics engage a reader forces one to contend with the topics, the characters, and the story. However, given that the interpretation of the visuals in comics is left up to the viewer, they also create opportunities for personal interpretation and interpersonal discussions. These discussions remind readers of the existence of perspectives different from their own, and the fact that although readers can all see the same thing, they can interpret and experience it differently.

Figure 1.

Comparison between health-care providers' attitudes to patients with cystic fibrosis and sickle cell disease

CF and SCD are two autosomal recessive conditions with disease profiles notable for serious complications in childhood and early adulthood causing reduced life expectancies. CF is more common in populations with northern European ancestry and SCD is more common in populations with west African ancestry. Despite the disease similarities and the fact that SCD is about three times more prevalent in the USA, US National Institutes of Health funding for CF-based research is higher than that allocated to SCD-based research. Bias against patients with SCD seeking treatment with opioids has been well explored in the literature, and attitudes surrounding the treatment of this population by the health-care community can be affected by bias. This comic displays the parallel narratives of two similar diseases to expose the insidious but powerful impact of systemic racism in our approaches to patient care. CF=cystic fibrosis. SCD=sickle cell disease.

© 2021 Shirlene Obuobi

Figure 2.

Discussions about racial disparities dodge structural racism

This comic addresses the readiness with which medical education may circumvent conversations about the role of structural racism in health-care disparities. By not addressing structural racism as a root cause for these disparities, medical trainees may infer supposed biological differences. One study found that a considerable proportion of medical students surveyed in the USA believed that Black patients were less sensitive to pain or had thicker skin than White patients; these false beliefs may lead to biases when caring for Black patients, leading to racial disparities in patient care.

© 2021 Shirlene Obuobi

Many comic artists have already taken advantage of these qualities to address racism, including John Jennings, co-editor of The Blacker the Ink: Constructions of the Black Identity in Comics and Sequential Art, an award-winning collection of comics on Black identity and structural racism, and Whit Taylor, whose comics address such topics as increased mortality and morbidity faced by Black mothers (Black Mothers Face Far Worse Health Outcomes. How Do We Fix It?) and distrust in the medical system (African-Americans are More Likely to Distrust the Medical System. Blame the Tuskegee Experiment).

Within medicine, comics have long been recognised for their ability to depict the illness experience, the trials and tribulations of medical education, and the challenges of health-care delivery. More recently, however, some medical establishments and health professionals have used comics to address racism and health disparities. In A Sense of Belonging, a comic published in The New England Journal of Medicine, physician Anita Blanchard discusses how racial disparities are driven by generational privilege, calling it the “oldest form of ‘affirmative action'” which “continues to challenge efforts to create a level playing field for physicians from minorities that are underrepresented in medicine”. This point is carried forward with the background of her own journey into medicine, entering medical school as a hopeful and eager student excited to care for her community, only to find that she was already behind her classmates. Although not a focus of their comics, physician artists such as James Fulmer and Michael Natter have used the medium to address topics such as inadequate interventions for racial disparities in health care and the importance of directly naming and addressing structural racism.

The social media platform of physician artist Shirlene Obuobi, who is a co-author of this piece, regularly explores topics related to structural racism in medicine. Under the moniker ShirlyWhirl, M.D. (@shirlywhirlmd), her comics reflect on her personal career path, following her through medical school and beyond. Initially, many of those reflections faced inward and portrayed such challenges as mastering difficult medical concepts, unfair evaluations, and attending physicians who did not remember her name. In residency, however, her comics have become more outward looking and explore such topics as physician workflow, the difficulties of providing equitable patient care under the USA's current health insurance model, sexual harassment, physician wellness, and structural racism. ShirlyWhirl, M.D's comic narratives serve as a way to bear witness to the system that provides patient care and to advocate and spread awareness of dysfunctional but normalised structures. Although these comics do not exhaustively delve into the scholarly literature on these topics, they offer a visual glimpse that seeks to inspire curiosity and engagement rather than reticence and avoidance.

Colour, style, and space are used in contrasting ways in these narratives to create mood. The general colour scheme of ShirlyWhirl, M.D. comics is bright and colourful. However, occasionally, the comics are longer, with the narrative stretched across multiple panels and presented in black and white (figure 3 ). Viewers implicitly understand this transition when approaching the comics. They may expect irreverence when reading the colourful, short comics, but stark emotion when reading the black-and-white narratives.

Figure 3.

Excerpt from Whistling, June, 2020

This comic, drawn shortly after George Floyd's murder in 2020, showcases an image of the artist holding her imagined future children, who are filled in greyscale, while the ghostly figures of Black children who have been killed by police in the USA look on. Panels like this one take advantage of temporal devices that can be used in comics; this panel simultaneously depicts the past, the present in the textual expression of ShirlyWhirl, M.D's fears, and the future. In addition, the figures are only viewed from behind, making the audience extrapolate on their expressions and add their own emotional contexts to the scene. Panels such as this one take advantage of perspective. Most people can empathise with fearing for one's children, and the demonstration that fear of police brutality, which is abetted and often left unpunished due to structural racism, is something the artist has considered when thinking of starting a family.

© 2021 Shirlene Obuobi

The main character of ShirlyWhirl, M.D. is an avatar of Shirlene, a young, Black female physician who frequently code switches between standard English and terms common in African American Vernacular English. This depiction contrasts with more traditional images of physicians, who are usually White, male, middle-aged, and wielding medical jargon like an intellectual baton. By repeatedly exposing readers to her portrayal of a physician, ShirlyWhirl, M.D.'s work expands perceptions of what a doctor should look and sound like. Another regular in ShirlyWhirl, M.D.'s comic series is a purple, featureless, humanoid figure who has come to represent health-care providers, administrations, and institutions (Figure 2, Figure 2). The identity of this figure is never clearly stated, allowing the viewer to extrapolate and project upon them an identity they may deem fits the role. By using this recurring figure, who is both alien and familiar, the comic draws focus to the system or practices being critiqued that are instrumental in perpetuating structural racism and systemic inequities.

ShirlyWhirl, M.D.'s comics are intentionally shared primarily through social media platforms that are accessible to people inside and outside of medicine, and thus the comics are read by health-care workers and laypersons alike. When asked about the role of comics in expanding their knowledge of and comfort with topics related to structural racism, readers of ShirlyWhirl, M.D.'s comics have said that they found comics easier to read and process than denser formats such as news articles or academic studies or publications. They thought comics were less “hostile” than other, potentially less accessible media, and some said that specific comics had allowed them to initiate conversations about racism with otherwise reticent loved ones. By making her comics readily available so that they can be discussed on an open forum, ShirlyWhirl, M.D. creates space that can feel safe for these conversations.

Taken together, comics that deal with racism in medicine and health care are a useful component of education about and advocacy against structural racism. These narratives are powerful expressions of the lived experience of the social and structural effects of racism and allow for more inclusive discussions to confront this reality and promote anti-racist actions. Leading with stories and incorporating narratives about racism, whether through comics or other narratives and expressive media, is an important pedagogical tool to engage learners and create a safe educational environment. However, these stories about racism have a broader relevance beyond the classroom. Collectively, they assert a social and cultural reality that demands more than acknowledgment and discussion; this is a collective experience that demands change to the structures and systems within medicine and society that perpetuate racism and racial health disparities. We hope that the stories now being told will be part of the meta-narrative that reflects an arc towards justice and equality within medicine and health care.