Techniques and Social Functions of the Graphic Documentary Style: How Japanese Manga Depicts Health-Related Social Issues 

Introduction

Graphic Medicine is a field that is developing, intersecting and converging multiple ideas fluidity in formats while drawing together different comic art forms to express ideas and experiences in related health and wellness environments.

This article reflects the presentation of ideas of fusion style melding fiction and reportage as developed by Midori Mizutani’s works on Young Carers. The paper explores the concept of Fusion Style which melds fiction and reportage. This involves the blending of the elements of fictional storytelling with factual reporting. The use of this style creates a narrative that is both engaging and informative, often making it difficult to distinguish between what is real and what is imagined. The popularity of this style in manga is due to its ability to provide deeper insights and emotional connections, making the stories more relatable and impactful for readers.

Fusion Style Melding Fiction and Reportage: Midori Mizutani’s Works on Young Carers

Representative of this fusion style melding fiction and reportage is Midori Mizutani’s work, which ranges from her graphic memoir about struggling with breast cancer, Early-Stage Breast Cancer at 32? I Refuse to Accept That! (2018) to her semi-documentary works from psychiatry or palliative care nurses’ perspectives, Why I Became Psychiatry Nurse (2017). Her career as a manga artist started with her autobiography based on her experiences of being a patient. Since releasing her first graphic memoir book, she has been searching for her unique style of fusing fiction and reportage. Her works feature medical professionals and patients, especially in the psychiatric ward setting, and can be classified into two categories. One tends to emphasize fiction, whereas the other emphasizes the documentary style. Her works tend towards fiction seem to be lyrical, whereas, on the other hand, her works seem to focus on social issues, as it is based on interviews conducted with support groups for young carers.

Mizutani’s latest work, As a Young Carer, “I Only Seem to Be Old”: A Diary to Regain Her Lost Feelings (2022) suggests that issues about young carers seem to be invisible and that young carers are inclined to be isolated. The work’s protagonist is an elementary school girl whose mother has been struggling with schizophrenia since the protagonist, Yui was two years old. During long years of child abandonment, Yui is expected to care for her mother and her young brother. Yui’s father cannot face the reality of their family problems and immerses himself in his work. Her grandparents and schoolteachers cannot be supportive of her. In a disturbing scene, Yui’s mother, driven by obsessive anxiety, threatens her daughter with a knife, fearing the daughter might secretly wish for her death (Figure 1). As a result, Yui emotionally shuts down, suppressing her feelings to the point of becoming almost robotic (Figure 2).

Figure 1

Figure 2

The protagonist’s turning point comes when she is a high school student. She is hospitalized in a psychiatric ward after being diagnosed with depression. However, she cannot rely on the medical professionals who work at the hospital to help her. She decides that her future career will be in nursing. This story covers the protagonist’s childhood days to her adulthood. She marries a nurse colleague and has her own daughter, but even while she is living a happy married life free from familial problems, the smell of her daughter’s diapers reminds her of her traumatic experiences of being neglected by her mother as a child. The protagonist hoped to have a “normal,” happy family life. While she struggles with raising her daughter, she relives buried emotions, such as anxiety, anger, and irritation. This process can be regarded as becoming younger rather than growing older. Gradually, Yui learns to accept her mother’s life of struggling with schizophrenia, and Yui’s memories of her mother–daughter relationships with her mother and her own daughter overlap. Hence, Mizutani’s As a Young Carer (2022) should be regarded as a coming-of-age story.

In this work, Mizutani (2022) aims to share actual situations involving young carers. Recently, in Japan, social issues pertaining to young carers have been drawing attention, but intervening in the related familial issues tends to be difficult. The story reflects this when a school nurse notices the protagonist’s problem, but the school administration decides not to intervene in a family matter. Consequently, the protagonist remains isolated. Additionally, a literary column suggests practical tips for supporting young carers in one’s neighborhood and provides information about support centers that can help.

As a Young Carer (Mizutani, 2022) is based on in-depth interviews with several people with experience of dealing with young carers. The story’s detailed episodes are the result of combining multiple anecdotes with fictional characters. In the author’s afterword, she mentions children’s tendency to have too much pride. Indeed, the story’s protagonist suppresses her emotions and tries to manage everything instead of asking for help. The protagonist’s mental landscapes are finely depicted through manga. Children tend to find articulating their mixture of confusion, resignation, and loneliness using difficult words. By using manga instead, serious social issues about young carers can reach numerous readers. The story reflects this when the protagonist urges her father to read manga depicting the same mental health symptoms her mother is displaying. After reading those manga, the protagonist’s father can tolerate and manage his wife much more smoothly. Indeed, this work is expected to provide support for people who are struggling with the young carer issue. Doing so is an important social function of medical manga.

From the medical manga perspective, this work addresses what we call “the second patient.” This means that somebody is required to care for patients in the family. That carer might experience a tremendous amount of psychological and physical stress, but they tend not to be cared for themselves. This phenomenon has gained recognition as a social issue, especially for young carers. In the realm of family issues, even social workers and social welfare have difficulty intervening. In this story, when the protagonist is a high school student, she is hospitalized in a psychiatry ward due to her depression, where her world widens as she chooses her future career. In the psychiatry ward, the protagonist has peace of mind and gets a precious opportunity to talk about her predicament with medical professionals and patients in the ward.

This story aims to raise a large number of readers’ awareness of the social issue of young carers. It is a typical coming-of-age story in which the protagonist overcomes her experience of childhood neglect and understands her mother’s life of struggling with schizophrenia. Young carers’ hopes are entrusted in this work.

Urban Legend Manga: Stories About the Toxic Mother Issue

On the other hand, Shugo Shiroyagi creates his graphic stories using anonymous anecdotes via social media. Many of his works are in the four-frame cartoon style. Several of these works are not classified as part of the medical genre but rather as urban legend comic stories. Shiroyagi‘s I Thought Everything Was for the Children (2023) depicts the family issue of a toxic mother and her relationship with her child. This work is presented not as a four-frame cartoon but instead as a serious manga story using the semi-documentary technique.

This might resonate with “Graphic Mundi” in the global context, which focuses on health and human rights themes.¹ The label “Our lives do not go well,” which applies to this work, deals with depicting feelings about the difficulty of people’s lives. Works with such a label cannot be classified as medical manga. We will focus on some resonances with Graphic Mundi concepts and analyze social media-based semi-documentary techniques.

Shugo Shiroyagi collects anecdotes via social media and publishes his works basically as four-cell cartoons. Over ten works labeled “Our lives do not go well” have already been released since 2023. This label urges authors to take on the challenge of adopting new styles. Shiroyagi’s works are essentially a collection of four-cell manga. I Thought Everything Was for the Children (2023) was published in book form. Given that his style comprises four-cell manga, a serial book-length story would be challenging. This story depicts a typical family with a father, a mother, an elementary school-age son, and a preschool-age daughter. The perspective focuses primarily on the mother, but later in the story, the perspective changes to that of the sister, who has grown into an elementary schooler.

The mother is always concerned about her son because he has been physically weak since his premature birth (Figure 3). The son has a gentle, kind personality. The mother tries to motivate him to excel on his entrance exam even though he is reluctant to do that (Figure 4). He fails the exam and points a knife at his mother. Eventually, he becomes a shut-in. The mother is indeed affectionate with her beloved son. Nevertheless, the son is spoiled. On the other hand, her daughter tends to be left alone even after she reaches school age. At home, the girl always feels tense because her mother is strict about instructing her brother to study. The daughter feels unnecessary in her family. Contrastingly, she tends to be comfortable at school. In the epilogue, which is from the young girl’s perspective, the daughter decides to leave her family in the near future to live as an adult. This cynical ending addresses current social issues about toxic mothers and social withdrawal in the age of the declining birth rate in Japan. This story is not directly connected to the medical realm, but it depicts the mental landscapes that lead to depression using the manga style. The mother, son, and daughter become depressed when their lives do not go well. The mother in particular affectionately dedicates herself to her son and is unaware of becoming a toxic mother. As the mother descends into madness, her depiction shifts to chaotic brushstrokes.

Figure 3

Figure 4

The fictional story this work tells is based on anecdotes collected via social media. The label “Our lives do not go well” emphasizes the semi-documentary style as a fusion of fiction and reportage. The social themes of toxic mothering and social withdrawal are often discussed. However, this story depicts the case of an ordinally family, not a special one. Using the manga style can bring these social issues close to us. Similar to the plight of young carers, intervening in the toxic mother problem is also difficult. Anyone might be liable to become a toxic mother or a bystander father. In the age of social media, “the grass is much greener on the other side.” This should be noted as a kind of modern disease.

This work represents a turning point for Shiroyagi. Before he created it, his works were a collection of four-cell urban legend manga about social media.² Compared with his previous works, with the label “Our lives do not go well,” he took on the challenge of depicting a book-length serial story. As an extension of his interests in urban legend, he shows that members of an ordinary family are liable to lose their way given the current trend in urban life. Presently, people tend to be conscious of how other people perceive them. Consequently, some people push themselves too hard. Furthermore, Shiroyagi publishes his works, including some individual episodes, via social media. This means that general readers can read his works without purchasing his books. His social media account has more than 600,000 followers. He posts new work in the form of four-cell cartoon manga almost daily, and he makes profits from social media. He always calls upon his readers to share anecdotes via social media. This is a new business and a creative model for manga artists.

Graphic Documentary/Reportage: Multiple Types of Perspectives

You Are Not the Only One Who Feels Lonely (Yoshioka, 2016–2017) is a graphic documentary manga based on interviews and the challenges of hearing impairment. Hearing impairment symptoms and conditions vary widely depending on whether deafness, tinnitus, or other auditory disorders are involved. The manga medium can depict sounds using onomatopoeias. One episode suggests that people with deafness experience daily life as if they are “covered in a glaze;” that is, we can see them, but they cannot hear what we are saying. The narrator conveys the worries, difficulties, and even the joys of the auditorily challenged. In particular, by providing medically explicit explanations, manga works shed light on these individuals’ daily lives.

This work originally aimed to foment a scandal involving a deaf music composer whom another composer accused of using a ghost writer.³ The deaf composer’s music had been regarded as miraculous; however, his claim to it turned out to be insincere. Even the man’s deafness was doubted. Before meeting with the deaf composer, the author researched hearing impairments and interviewed multiple deaf people and relevant specialists such as medical authorities and sign language translators. In the graphic documentary, the author, Koji Yoshimoto, represents every man’s viewpoint and tries to stand by the targets. Unlike in most documentary films, the comic artist himself is depicted as an interviewer.

Although the deaf composer was certified as having a hearing disability, he was suspected of only pretending to be deaf, and the graphic documentary attempted to investigate his condition. The truth remains a mystery. Through this research, the author and his readers learned that the Japanese medical field of otolaryngology, that is, the study of the ear, nose, and throat (ENT), is lagging. It attracts little money, and there exists significant difficulty identifying the mechanisms underlying hearing impairment and tinnitus. Based on various interviews with doctors and patients, this graphic documentary attempts to explain the current situation of medical studies in this field and presents images from each patient’s soundless world (Figures 5-6).

Figure 5

Figure 6

In manga methods, onomatopoeias are effectively used, and non-linguistic sounds can be visually expressed. Not only do deaf people enjoy reading manga and imaging sounds, but everyone recognizes that our world is filled with numerous types of sounds, noises, and voices. Among this project’s major achievements is depicting deaf people’s world using visual expressions.

Regarding Japanese deaf manga, Yoshiko Okuyama work, Reframing Disability in Manga (2020), which covers deafness, blindness, autism, and gender identity disorder. This book is an excellent guidebook on Japanese disability manga in English. By referring to the chronological transition the depiction of deafness has undergone, we can help to address the challenges facing efforts to improve social environments regarding disabilities.

Another of Okuyama’s scholarly books, Tōjisha Manga: Japan’s Graphic Memoirs of Brain and Mental Health (2022), discusses a graphic documentary manga work about mental depression. The titular word tōjisha means a “party or insider involved in litigation,” and in this context, tōjisha manga works centralize mental health patients’ voices through medical education and public education resources. Among works related to Okuyama’s, Keiichi Tanaka’s Utsunuke: An Ode to Depression (2017) is a graphic documentary from the tōjisha perspective. Tanaka is a long-careered gag manga artist who is recovering from depression. Based on his experiences of struggling with depression, he created an episodic memoir in which he personifies depression as a mascot character (Figures 7-8). He also interviewed celebrities such as musicians, novelists, and other manga artists and depicted their experiences through graphic reportage. Tanaka appears in the stories he authored as an interviewer, and the celebrities tell their stories using Tanaka’s manga style. Okuyama introduced this attempt in English.

Figures 7-8

Conclusion: Graphic Medicine for Enhancing Social Inclusion

This conference paper has overviewed the current Japanese trend of using graphic documentary techniques to interweave fiction and actual experiences gathered via in-depth interviews with medical professionals or patients. Using the manga style is a means to widely disseminate content about serious issues to numerous readers in the form of detailed episodes. Furthermore, combining fiction and reportage, especially to depict mental landscapes, gives readers strong impressions in the realms of social issues such as young carers and toxic mothers. In the global context of graphic medicine, visual manga techniques engender health-related social issues among wide general readerships towards enhancing social inclusion.

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