In 2022, AcademyHealth and Health Affairs both launched 40-year anniversary celebrations. Coincidentally, I’m also celebrating a 40th-anniversary year. In 1982, as a reporter for the Chicago Tribune, I became one of the first general-interest journalists to cover the socio-economic aspects of health care. That long-ago beat eventually led to my embracing health care over journalism and a subsequent career as a health services researcher, author, policy wonk, consultant and activist.
But before I became a working reporter, my first venture into journalism was as a satire columnist for my high school and college newspapers. So ahead of AcademyHealth’s 2023 Annual Research Meeting, I decided to return to those roots and, as my contribution to these anniversary celebrations, examine what humor in comics and cartoons over the years can tell us about health policy.
Though foolishness is not a foolproof measure of public mood, it deserves to be taken seriously. Comedy, wrote the philosopher Henri Bergson, often serves as a societal corrective, rendering any violation of social norms “visible to all eyes by magnifying it” via caricature. Public policy is by definition a political endeavor, and politicians are acutely sensitive to the ramifications of “laughing with” versus “laughing at.”
The health policy humor examples that follow are intended to be illustrative, not comprehensive. In keeping with rigorous academic methodology I’ve divided them into three paradigmatic categories that, I admit, I made up: Timeless Themes, Timely Jabs and Ahead-of-Their-Time Punchlines.
Timeless Themes
More than a century ago, the humorist Mark Twain complained about doctors’ high prices, as well as a tendency to provide expensive treatments of dubious necessity or effectiveness. These are enduring themes, presented over the years with a varying intensity of satirical bite.
Meanwhile, profiteering by drug companies and penny-pinching by health insurers, which were not a worry in Mark Twain’s time, were the target of Joe Martin’s Mr. Boffo strip of December 2, 2015. Entitled, “Healthcare Plan with the Most Amount of Bugs to Work Out,” a white-coated doctor offers Mr. Boffo a vial of pills with a caveat: “Take two of these whenever you can afford it.”
Over time, a broad range of other issues have emerged to join these kinds of timeless targets.
Timely Jabs
While there are enduring comedic topics, humor is often harnessed to specific circumstances. For instance, one could see the ultimate failure of the Clinton administration’s mind-numbingly complex health care reform plan foretold by a July 13, 1994 Sylvia comic strip. It consists of just a single panel, with the titular character sitting near her cat and staring at a short questionnaire whose words fill most of the remaining space.
“Which claim would you be least likely to make in this lifetime?” it asks. “1. I believe I could teach a rhino to play ‘Norwegian Wood’ on the accordion. 2. Yes, I’m familiar with all the health care reform plans. I’d be glad to explain them and teach you a simple mnemonic device to keep them straight.”
Later in the 1990s, an avalanche of anti-HMO sentiment was triggered by news accounts that equated managed care with rationing (and eventually prompted a health insurer group to erase “managed care” from its vocabulary). The extent of public dissatisfaction was succinctly captured in a July 18, 1999 New Yorker cartoon by Nick Downes. It shows a group of girls sitting around a campfire, with the counselor saying, “Very scary, Jennifer – does anyone else have an H.M.O. horror story?”
Other types of health care system issues have also started drawing comedic attention in recent years. One example is a 2019 Brewster Rockit strip that caricatured a physician who refuses to accept the patient as partner – definitely a new type of topic. In the strip, a stubborn doctor steadfastly ignores a crucial diagnostic clue (the patient is invisible) even when the patient tries to remind him of it. “Oh, now all of a sudden you’re the doctor,” the physician snaps in response.
On the other hand, doctor’s concerns also start to generate public sympathy. Consider Robb Armstrong’s Nov. 5, 2010 JumpStart strip, portraying the life of a young African-American family. In a 2010 strip, a six-year old boy tells another that as class president he’s decided to “improve health care” by having kids call the other boy, “Provider” – even though the boy’s actual name is “Doctor”!
Or consider a 2009 Peter C. Vey New Yorker cartoon that underscores patients’ responsibility for their own health. A tombstone epitaph declares that the deceased “forgot to ask his doctor everything he wanted to ask him.”
Speaking of tombstones, the 1999 Institute of Medicine report To Err is Human, with its estimate that up to 98,000 Americans were killed each year in hospitals by preventable medical error, generated an outburst of public and political attention. That prominence made patient safety fair game for cutting comedic criticism.
The Mary Frances character in an August 30, 2006 Sylvia strip refers to a report that “1.5 million Americans a year are harmed by medication mistakes” and laments, “There is little incentive for hospitals to invest in technology that could prevent errors right now.” Mary Frances eventually settles for helping a friend “by making a list of your medications and comparing them to those you’re taking.”
That savvy comic-strip counsel likely touched more members of the public directly than the Joint Commission adding medication reconciliation as a national safety goal just one year previously.
The return of health care reform prompted a flurry of pro-and-con comedic commentary. An example of the latter can be seen in a 2007 Prickly City strip by conservative cartoonist Scott Stantis. It shows four doctors lounging aimlessly (smoking a cigarette, reading, blowing a gum bubble and holding up a “Slow” sign) while the patient lies neglected in a nearby bed. Just a “sneak peak (sic)” at “national health care,” the caption advises.
But perhaps the greatest tribute to the power of comics to help shape public opinion was economist Jonathan Gruber boiling down the 1,900 page Patient Protection and Affordable Care Act (a/k/a Obamacare) into a graphic novel. “A comic is a great way to reach people,” enthused Gruber about Health Care Reform: What It Is, Why It’s Necessary, How It Works.
Ahead-of-Their-Time Punchlines
Insightful humor can highlight serious issues years long before they rise to policy prominence. So, for instance, in 2000 the Institute of Medicine reviewed the relationship between surgical volume and outcomes. But five years before that, a Doonesbury strip pithily summarized the problem. Military veteran B.D. is told by a VA doctor that some surgeons haven’t operated in six months. “How do they maintain proficiency?” an astonished B.D. asks. “[Operating on] melons,” the doctor replies.
In 2022, bipartisan legislation was introduced in both the House and Senate to protect medical devices from cyber-attacks. That possibility first gained widespread attention after a 2012 episode of the TV show Homeland portrayed a fictional U.S. vice president being assassinated after terrorists gained control of his pacemaker.
But way back in 2001, Doonesbury character Zipper Harris had the idea to download and license the real-time wireless output from Vice President Dick Cheney's defibrillator. In the wake of the Homeland episode, Cheney revealed his defibrillator had actually been modified to prevent hacking.
Other notable comedic early warning signals include a searing indictment of the yawning mortality gap between Black and white babies in a 1999 Real Life Adventures strip by Gary Wise and Lance Aldrich, long before health equity attained national prominence, and Kaamran Hafeez’s 2015 New Yorker cartoon that became an instant classic (“You can’t list your iPhone as your primary-care physician”).
What Humor Teaches Us
It’s no surprise that the high cost of medical care, prescription drugs and health insurance consistently attract comedic barbs. What’s more surprising is that topics such as patient safety, computerization of medical records, surgical outcomes and shared decision-making now show up in comics and cartoons (not to mention late-night TV, Internet memes and other comedic venues). That new visibility vividly demonstrates the way in which researchers, journalists, policymakers and others continue to propel a broader and deeper level of health care concerns into mainstream public discourse.
“It is rigidity,” wrote Bergson, “that society eyes with suspicion.” That philosophic assessment more than 100 years ago still describes the source of the humor today, as when a six-year-old bureaucrat proclaims that even a child named “Doctor” must be called “Provider,” or when an arrogant physician refuses to listen to an invisible patient pointing out his invisibility, because only doctors can make a diagnosis.
In our increasingly partisan nation, everyone seeking ways to make health care safer, better and more affordable would do well to keep in mind both the dangers of rigidity and one proven strategy to combat it. A touch of insightful humor can often open eyes and, with a little luck, hearts.