Comics and the Pandemic

 

--PLEASE READ THE FOLLOWING NARRATIVES ON THIS PAGE 

--AND THIS PODCAST: HERE

ILLNESS NARRATIVES: in Healthcare

The first classification, Arthur Frank:  Professor Frank classifies stories into three common story types: restitution, chaos and quest. 

• Restitution narrative: this is the story most favored by physicians and other medical professionals and poses the emphasis on restoring health. These narratives often have three moments: 
• they start with physical misery and social default, 
• continue with the remedy (what needs to be undertaken) and 
• finish with the moment in which remedy is taken; 
• moreover, the narrator describes how physical comfort and social duties are restored. 
• These are often stories told about patients rather than by patients, also because they give little agency to the narrator: patients simply have to ‘take the medicine’ and get well. 
• Chaos narrative, which is really a nonstory: there is little narrative drive or sequence, just a list of negative things that will never improve and by which the narrator is almost overwhelmed. 
• The story signals a loss or lack of control, and medicine cannot do anything. 
• Quest narrative: this is the teller’s story, where the teller is in control of things. Narrators tell how they met the illness ‘head on’ and sought to use it, to gain something from the experience; 
• the story is a kind of journey, with a recognized departure, an initiation (the mental, physical and social suffering that people have experienced) and a return (the narrator is no longer ill but is still marked by the experience).

The second classification, Arthur Kleinmann: , The concept trilogy of ‘illness’, ‘disease’ and ‘sickness’ has been used to capture different aspects of ill health. 

• Disease is defined as a condition that is diagnosed by a physician or other medical expert, and it is considered as alterations or dysfunction in biological and/or psychological process, a deviation from the recognized ‘normal’ state, an isolated malfunction of a body part; 
• ideally, this would include a specific diagnosis according to standardized and systematic diagnostic codes. 
• This also means that the clinical specific condition has a known biomedical cause and often known treatments and cures. 
• On the other hand, illness is defined as the ill health the person identifies themselves with, often based on self-reported mental or physical symptoms. 
• It refers to the lived experience, to how the ill person and the members of the family or wider social network perceive, live with and respond to symptoms and disability;
• it is something being lived through the body and can have many types of meanings, in different contexts, to different people. 
• Lastly, Kleinman introduces a third term, sickness. Sickness describes a disorder in a generic sense as applied to a population or group. It is related to a different phenomenon, namely, the social role a person with illness or sickness takes or is given in society, in different arenas of life, often used to measure social consequences for the person of ill health.

The third classification, Mike Bury: This type of classification foresees that analysis must consider three types of narrative forms: contingent, moral and core narratives. 

• contingent narratives are concerned with those aspects of the patient’s story that deal with beliefs and knowledge about factors that influence the start of disorder. 
• If this kind of narratives describes events, their proximate causes and their unfolding effects in relation to the performative of everyday life, moral narratives provide accounts of changes between the person, the illness and social identity and help to (re)establish the moral status of the individual or help maintain social distance, introducing an evaluative dimension into the links between the personal and the social. 
• Core narratives reveal connections between the person’s experiences and deeper cultural levels of meaning linked to suffering and illness.

The fourth classification, John Launer: Stories can be divided into three types: progressive, regressive and stable one. 

• Progressive narratives move towards the personally valued goals; 
• regressive narratives move away from such valued goals; and 
• stable narratives sustain the same position in relation to the valued goals throughout the narrative sequence. 
• This last kind of narrative could be seen as less engaging than others, because it tends to relate a sequence of events without great drama—a form of storytelling that goes under the heading of the so-called contingent narratives. 
• The use of a progressive, regressive and stable framework allows an analysis that safeguards against over-interpreting the range reserved of meanings conveyed by patients’ accounts. 
• whatever narrative form may be identified in analysis, many accounts move from one to another, for example, from regressive to stable. 
• Consistency in narrative accounts may be achieved or sought by patients, but it may not: much depends on the context in which narratives are constructed and presented and on the intentional acts which they help constitute. 
• This classification is very useful to focus on the coping strategies acted by patients: if regressive or stable narrative may show no positive engagement and if narratives are progressive, this may represent an evolving positively situation.

The fifth classification, factual language and symbolic language

• Factual language: digits, facts, visits, number of healed people, contaminated people, of deaths. Mechanism of action by the COVID-19. Rules, countries, decisions made, who visited whom, who was the patient 0, people seen by patient 1, dates of the outbreak, age by mortality rate, gender by mortality rate, immune children, number of available beds by Region, days of isolations- 14 and/or longer, number of potential contaminated people by one asymptomatic carrier, number of masks available, number of ambulances in the streets, spread and fall of the stock market value, number of closed activities, number of online new services, number of days spent in home working, volumes of purrell sold, potential time to vaccines,  and so on….
• Metaphoric language: try just to see on the screen shot the numbers of healed and deaths and contaminated as they are in the Frankfurt, Paris, New York London stock-exchange market by analogy
• Sontag argues, obscures illness within dramatic narratives, meant to rouse and inspire…through vigilance and alarm. The problem with stories, of course, is that the action only unfolds through the choices and responses of characters – that is, us – which in turn evokes assumptions about moral values and responsibility…about blame.If the disease wins the battle – does that mean the physician didn’t fight hard enough? that the patient didn’t have enough will to victory? or that, perhaps, the patient might even have inadvertently sabotaged her own defences, through insufficient vigilance, or morally lax behavior? And if contagion spreads, infecting, corrupting…whose unclean habits are to blame? who is the source of the pollution? Sontag makes the connections: our metaphors of illness tell stories of passive weakness, of malicious vice, of threat and danger, which we then use against one another. Never mind this pathogen, that imbalance of brain chemistry, this insufficiency of antibodies, that excess of cellular activity: we have others to blame (and “they” are always “other), others who can be the target of our shame, helplessness, fear, hatred. It might be a natural, human, impulse to use stories to give shape and meaning to otherwise arbitrary, uncontrollable phenomena; the danger is that the metaphorical thinking that we use to build those stories for our individual comfort then takes on a life of its own. The metaphors are especially vulnerable to ideological use, not at the level of the individual body, but of the body politic – the metaphors of invasion, pollution, sickness are used to justify the marginalization and separation of whole populations: Jews in 1930s Germany; gay men in 1980s America; immigrants, refugees, “aliens” (and their children) who threaten us with the infection of difference
• In addition, -the plague and plague spreaders. The cancer metaphor of the society has quietly faded away: now the new words are “infodemia”, “the viral decisions of politicians”.

• Albert Camus the plague: 

  “Flagella, indeed, are a common thing, but flagella are hardly believed to be when they fall upon your head. In the world there have been, in equal numbers, plagues and wars; and yet plagues and wars catch men always unprepared. (…) Stupidity always insists, we would notice if we didn’t always think of ourselves. In this regard, our fellow citizens were like everyone else, they thought of themselves, the scourge is not commensurate with man, we are therefore told that the scourge is unreal, it is a bad dream that will pass.”

The sixth classification, Plutchik emotions: Plutchik proposed that eight ‘basic’ emotions are biologically primitive joy, fear, anger, disgust, sadness, (the same as Inside Out) plus trust, surprise and anticipation. 

• Plutchik argued for the primacy of these emotions by showing each to be the trigger of behavior with high survival value, such as the way fear inspires the fight-or-flight response.
• Plutchik’s psycho-evolutionary theory of basic emotions has these main postulates: 
• 1. The concept of emotion is applicable to all evolutionary levels and applies to all animals, including humans. 
• 2. Emotions have an evolutionary history and have evolved various forms of expression in different species. 
• 3. There are a small number of basic, primary or prototype emotions. 
• 4. All other emotions are mixed or derivative states; that is, they occur as combinations, mixtures or compounds of the primary emotions. 
• 5. Each emotion can exist in varying degrees of intensity or levels of arousal. 

The moment that I was informed that we had become a COVID-19 department, I was devastated. This coronavirus is so frightening, and I knew that I could die from it. I am a person who needs to be in control, and I had lost control, I was so frightened. This entire new situation was scary—a situation of life or death. Moreover, I was in it. At the level of the team, we did not know what to expect, personally and collectively, as a department. I did not know what was expected from me as a social worker and what were the guidelines; everything was new. We created everything from the beginning, and I was scared.

Emma, a social worker in the hospital’s Corona Department

 “In our country, we know what a war is, and in the healthcare system we know how to function in the hospital during times of war, but still, this is a new war, a war that we have never handled, an invisible enemy, and it is frightening all of us.” In similar vein, Doron said: “to be significant, to be at the front is important. Before it was the army that was at the front, now it is the turn of the healthcare system to be at the front.” Sara, nurse

“In the Internal Medicine Department, I have been working for the past 18 years with my team, physicians, nurses, secretary—we have a common language. I felt especially secure in those days. How I will be able to use, in an efficient way, a new situation and new staff? This is ridiculous.” Dikla a nurse

“This will increase the feeling of insecurity…think that the entire situation is new and scary; so, what will I do without my friends who I have been working with for years?” In particular, the need to be protected during shifts was pronounced. As Sara told us: “In order to continue to come here, I need to feel that someone is taking care of me. I do not care who in charge of that in the hospital, but I need to feel safe; it is essential for me.” Tania, a social worker

“I cannot believe it… because of the workload… it is only because of the workload… I have to tell you that I haven’t eaten for whole days…I grab something. It is not that there isn’t any food, but we don’t have the time and the needs of the staff draw you and you can’t ignore them; you need to respond to each one. At other times its different, of course. Here you can’t say anything to them. It’s the mask; it creates wounds on their noses, so I brought them cream. This kind of mask or any other; so, I saw masks in the grocery store and I bought them pink surgical masks so they would feel joy. Every day I am bringing something to make them happy. All the time. Yes, the protective equipment is a problematic issue by itself… I understand since I am involved in that; it depends on the equipment that comes to Israel, but it is not always suitable… this equipment is insane.” -Julie, a nurse in the ICU

Julie’s “I Poem” I cannot believe I have to tell I haven’t eaten I grab something [to eat] I brought them cream I saw face masks I bought them masks I am taking out [something to make them happy] I understand I am involved

“I love my job, and I love the feeling of contributing. People around me, outside the hospital, talk about us [the HCWs]. I am in the frontline. It is pleasant and heartwarming.” -Michal, a nurse

Michal’s “I Poem”
I love [my job]
I love [the feeling of contributing]
I am [in the frontline]

“I believe this will continue …. I discovered the richness of family and personal life, which reinforced things that I knew about myself and my [hospital] family—we are sturdy and dedicated and we cope well. I am filled with appreciation for the Infection Management Department that created a safe environment.” --Dina, nurse

Dina’s “I Poem” I believe I discovered I knew [about myself] I am filled [with appreciation]

Themes: Trauma and Stress

A deceased is a deceased but the separation from the family is extremely difficult, the wrapping process is a different from what you normally do in the internal ward. In addition to the regular wrap we put them in a nylon wrap and that is horrifying. A really unpleasant sight. It is like you put your patients in a plastic bag and you close it with a zipper. And then you cover with another bag but from the opposite side. An unpleasant wrapping of a patient since it is supposed to be isolated.--Golda, nurse

Look, the coronavirus is something completely new. A whole new disease that we do not have a clue how to treat, how to behave with it … and the craziest thing [is] that no-one in the world has the knowledge how to treat this disease, no knowledge-based expertise, no medical literature. So, you are constantly calling your colleagues in the country and around the world. Then, you are planning how you will cope with your first coronavirus patient. And then you are planning your second patient and the third. The decisions [as the head of the ICU] are just on your shoulders. They said to me: you are crazy … you are crazy; what are you doing? But I had to listen to myself, my instincts, and I said I have to go with my feelings and intuition. The decision is all yours. And what is most crazy is that you do not know what will happen next. Now it [the patient’s condition] is fine and five minutes later the patient can die and there is no-one to consult with because no-one knows [anything] about COVID-19.--ICU Physician Marina

Themes: Security and Knowledge

At the beginning of the corona outbreak, there was a lack of food, protective gear, and clothes and shielding eyeglasses to protect ourselves. We had to shower between the shifts, and there was a shortage of showers in the hospital, and we had to fight for the basic needs to be protected, especially during the weekends. It was horrible. Everyone was terrified. There was a lack of food in the Corona Department. At the beginning, I did not have what to eat during the day. I felt broken and choked …. There were shifts that I did not eat for almost 12 h.--Orr, nurse

I did not have a life except the work at the hospital these past few weeks. I did not have a private life at all. I did not meet my family. I am tired all the time, I just want to sleep like a human being, to eat, to be away from the hospital and from the Corona that is all over; these 12-h shifts killed me. I am a single mother and I have a daughter. My daughter was all by herself at our house. It is unbearable; she was all by herself for all those days of the corona, and I was here taking care of other people.--Sara, nurse

There was constant anxiety and fear that we would infect others; we [at the Corona Department] felt like lepers … and then the isolation from my family since I was so afraid that I would infect them. I was isolated like a leper. My children could not go out to play with other children because I was terrified that I would infect my children and that they would infect their friends with coronavirus. At the beginning of the coronavirus, my daughter was so stressed out from this crazy situation.--Dorit, nurse

“The Head of the Department is constantly updating us … I do not feel detached … I feel secure, knowing where I stand.” --Dan

“ … a lack of communication and information about what is happening at the hospital at the general level and not at the sector level bothers me. I am worried.” Avi, administrator

“Uncertainty concerns me—assessments of the situation and updates by my immediate supervisor would help me.”  “I feel like I’m in the dark and don’t know what’s going on.”--Ruth

Theme: Need for Belonging

We were all a big family helping each other. I felt so close to all my peers; working together in such a tough time was different from what I had known in the last 26 years that I have been working in the hospital. As a team, we have become closer to each other, and I have discovered additional angels in my team …. In our department there is a sense of “togetherness” and comradery. Professionally, there will be changes; there are thoughts about modifying procedures in light of the current pandemic …. Relating to each other, currently feeling that we are a united and cohesive group.---Vicki, administrator

This period is a mixture of emotions. The reality is that everything is so new and unfamiliar. Nevertheless, the staff are so devoted to each other and struggling to do their best to help each other and changing shifts due to the lack of nurses. Sometimes they asked about treatment and I did not have an adequate answer. How I will say it? This is the period that we are re-inventing the protocols and rules of treatment. I am telling them that I am so sorry but there are no guidelines yet.--Pam, ICU nurse

“A good word, a compliment, and a positive attitude made me feel valued and…reassured.” “A kind word makes my day …. It is essential for me to get feedback on my work and to know that I am doing my job well.”--Lori, nurse

“The presence of management in all departments and during all shifts made the staff aware that there was someone with them.” She added: “Personal appreciation by the management increases motivation and reduces concern….I would like to see more direct communication with management… in my team, I feel appreciated. I don’t feel I’m getting feedback from management.” --Alma

Management worked well during the crisis; I want to thank the management for the adaptions that were made by mobilization of staff and change of policies and for taking the time to listen; and in my opinion, the hospital and management are doing well.--Dan, assistant nurse

Theme: Meaningfulness

“Patients with coronavirus helped me to feel valued and meaningful, [especially] the conversations with the patients and the phone conversations with their families out there in their homes, so worried about their loved ones. I was there for the patients and their families, and it allowed me to feel meaningful and to want to continue treating patients.”--Carol, nurse

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