Review – Lissa: A story about medical promise, friendship, and revolution

For several years I taught course based largely on graphic novels at Stanford – twice in a medical anthropology graduate seminar and once for undergraduates at the Stanford school in Paris (we took a field-trip to the famous international festival for bande dessinee in Angouleme). As teaching devices, graphic novels provide an open-endedness and accessibility that is more difficult to find in ethnographic articles. The reliance of the storyline on character development, rather than an overall argument, requires an entirely different analytic style than the traditional article, and one with welcome challenges to ethnographic analysis and elucidation. As an aspect of the histories of graphic representation they draw on and develop, graphic novels also add opportunities for anthropologists to teach broadly on multi-valent story-telling histories, including political commentary and the rise of print media, as well as specific characters such as the Yellow Kid and Superwoman. Further, graphic novels provide models for students to try their own hand at new kinds of work.

Lissa presents ethnographers with a bold new direction well worth broad consideration. The parallel tales of the book’s subtitle – medical promise, friendship, and revolution – are told through two teenagers as they grow into adulthood. The text is urgently crisp. No dull filler conversations crowd the seamless integration and development of the themes of illness, struggle, and temporality, which gain force through their juxtaposition. This immensely satisfying read is ideally positioned to provoke some meaningful and deep discussion among undergraduates about issues that are hopefully beyond their direct ken.

Temporality, like mortality itself, emerges as the key touchstone of the book: stopping time, squeezing more time, accepting its passage, fighting for a better future. Characters, well-constructed as individuals in relation to their families and cultures, live their own struggles and engagement with distinct and competing visions of temporality. Lissa demonstrates this subtly and plausibly by interweaving the friendship of two very different women. The dialogue is sparse and clean, revealing utter difference in worldviews without preachiness, and the story comes to a straightforward, yet compelling, resolution.

Anna is the daughter of an expat American oil family living in Cairo, and Layla, her Egyptian friend, is the daughter of the apartment building’s bawab, or caretaker. The book opens with Anna’s mother, newly diagnosed with metastatic cancer, who dies a few pages in. Part II, “Five Years Later,” finds Layla in medical school, her brother back in Egypt after having been deported from Saudi Arabia because of a Hepatitis C diagnosis, and her father with a diagnosis of end-stage kidney disease. They are deep in the medical world of Cairo, a scenario that provides several insights.

For example, as a medical student doing rounds at the Cairo University Hospital, Layla witnesses an especially egregious case of advanced cancer. The doctor-professor complains, “These ignorant peasants always wait until the last minute to come and get treatment.” Layla boldly responds: “Most people don’t get good treatment even if they do come early! And why should people come see doctors who think they are ‘ignorant peasants’?!” (pp 94-95)

Meanwhile, back in the United States, by chance Anna attends a college lecture on genetics, learns that she may carry a gene, BRCA, that would put her at a higher risk of getting cancer. This leads her to consider her own testing options, and she finds that she will have to pay for the test out of pocket because of her relative youth. What follows is an extraordinary contrast between Layla’s father’s unwillingness to receive a kidney transplant either from a paid donor or from his offspring in Egypt and Anna’s continued research into prophylactic mastectomy in the U.S. The reader sees versions of greed as a social designation: the aforementioned doctor-professor’s comments on the greed of people who sell their kidneys for money is separated by a mere few pages from commentary on Myriad’s ownership of DNA through its genetic testing (this has since been struck down by the Supreme Court). Ultimately, Anna’s dad sends her $3500 for the test as Layla’s father dies for the lack of a kidney. Adding insult to injury, Layla is told off by the apartment building owner for not doing the sweeping, but the sting of this is in part balanced by the kindness of the pharmacist who gives them free medical supplies in exchange for previous familial assistance. Economic class and community are balanced in thought-provoking ways.

As Anna goes under anesthesia for her prophylactic mastectomy in the US, a revolution breaks out in Cairo. No spoilers here, but I urge you to pick up the book to see how it resolves.

The book includes some additional materials: an essay giving some directions for the first-time comics reader, a short piece on graphic novels as ethnography and vice versa, an interview with the authors, a teaching guide with questions, and further bibliographic resources. At first, I was skeptical about these additions: why not let the work stand on its own? But on reading them, I’ll admit that they would be extremely useful to integrate with discussion and assignments and do, in fact, make our jobs as teachers easier.

Lissa has relevance beyond the story it tells by demonstrating the value of expanded methods of gathering and defining ethnographic knowledge. Lissa’s reliance on character development rather than explicit analysis requires the author to tell by showing rather than explaining, thus giving the work an immediacy and vibrancy that is difficult (though obviously not impossible) to find in more traditional ethnography.  The novel’s pictorial dimension allows the authors to explore and illustrate elements of the story that are clumsier to describe in words, such as built environments and local material culture. Lissa does an especially nice job with the hospital scenes, Tahrir square, and in reproducing in cartoon form some of the magnificent murals that emerged from the struggle.

The graphic novel has potent ability to tell a rich, mulit-valent story when textual and visual narratives diverge, contradict, and converse – when they move beyond mutual illustration. To fully embrace the potential of the form in anthropology will take a clear commitment on multiple levels, including the development of collaborations with artists, funding for these multidimensional projects, training anthropologists in art and visuality, publication venues, and so on. But we have reached a critical mass and a recognition that anthropology has much to offer and gain through a more overt engagement with other formats and this infrastructure is slowly being built.

In this vein, Lissa gives us a fruitful direction for thinking through how anthropological knowledge might be made more relevant. For all of our defensive posturing on the value of anthropology, the cold fact is that ethnographic articles remain little-read outside – and I daresay even inside – the discipline, and even our most celebrated monographs rarely even make it into bookshops. While Lissa may be one of the first graphic novels written by professional anthropologists, Graphic Medicine, as a sub-category of graphic novels, is by now a well-developed area. Thus, there is a ready audience, and this novel’s contributions to that literature will deservedly have a broad reach.

With the University of Toronto’s imprimatur and its ethnoGRAPHIC series, surely there are no more excuses not to expand what counts as professional, promotion-worthy ethnography. And Lissa offers a fantastic model of how to proceed. Congratulations to its visionary authors and editors.

Lochlann Jain is a Professor of Anthropology at Stanford University and Visiting Chair of Global Health and Social Medicine at King’s College London

[Read the authors’ response here.]