**1. Introduction**

During the COVID-19 pandemic medical communication has been put to the test. The death toll continues to climb around the globe amidst mixed messaging and hopes for a return to *normal life*. First discovered in the Chinese city of Wuhan in 2019, COVID-19 is a disease that is a result of the SARS-CoV-2 virus. Due to mortality and infection rates, the World Health Organization designated it a global pandemic early on in its spread.

In a global health crisis, the healthcare industry and state health ministers rely on the effectual transmission of health communication. This communication must be of high quality and easily understandable. According to health crisis communication guidelines set by the WHO, communication during a pandemic is crucial. Communication must take place early on in the crisis and information must be constantly updated. The WHO also suggests that public health information disseminated during global health crises needs to be made available to those across various socioeconomic strata— that is, critical information must reach lower income populations and populations with lower literacy rates.

WHO guidelines recommend that this information be communicated jargonfree, in language that is easy to understand, and in various modalities, including the use of narrative and visuals. This research was developed to add to the body of literature that the World Health Organization calls for through its identified research gaps and recommendations for crisis communication (**Table 1**). This research presents comics as a viable option for effective and ethical communication during pandemics.

Confusion and the spread of misinformation during public health crises necessitates the exploration of new modalities of health communication. This study assesses the communicative value comics may have in clinical settings— the use of simple visuals and language is a method of health communication that may be highly effective. Information that is made personal and presented in a non-complex format may also be easier to remember.


#### **Table 1.**

*Summary of World Health Organization Findings, Recommendations, and Research Gaps for Communicating Risk in Public Health Emergencies [1].*

#### *Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

Comics could also be an important way to teach patients important skills such as asking for clarification. When presented with short and easy language accompanied by simple visuals, patients may more readily understand information [2]. In the instance of a complex virus, such as SARS-CoV-2, a simple diagram of the infected area or the virus itself may prove useful. Instead of relying upon verbal communication exclusively, simple visuals may facilitate understanding leading to higher treatment adherence, improved patient satisfaction, and a nurturing clinician-patient relationship [3]. The use of visuals, such as comics, could also be a way to mitigate fear and help patients remember vital information. Along with aiding in the mitigation of fear, humor can also aid in recall [4]. Comics for example, may be more readily able to use funny phrases and mnemonics to explain conditions.

Health communication is not a new area of research; however, there is always need for improvement as doctor-patient communication may be correlated to patient health [5]. While not always the focal point of healthcare, health communication has been recognized as needing continuous study [6]. Medical communication is considered so important that the Accreditation Council for Graduate Medical Education has made it a priority, explaining that practitioners should be able to have the ability to effectively communicate with patients as well as their care teams [7].

Motivation for this study comes from the need to improve health communication through the exploration of under-utilized modalities, such as comics, as called for by the WHO. It is hypothesized that comics could be a workable modality for health communication, in general, as well as during public health crises. As effective communication may encourage the clinician-patient relationship, improve treatment adherence, and raise patient satisfaction—communication, including that of comics, may be considered a ubiquitous tool for pandemic containment.

#### **2. Communication and bioethics**

To provide context for the following methodology and how it relates to visual analysis, biomedical ethics, and health communication, attention will be given to the theories and principles from which they come. These theories provide the scope that is used to assess if comics could fulfill, in part or in whole, the WHO's call for continued study of health information in public health crises. One such theory is that of biomedical ethics. Ethical practice is of utmost importance in medicine—and not just in a scientific context, but in areas such as health communication. The four bioethical principles as defined by T. Beauchamp and J. Childress [8] state that physicians have specific duties to their patients. Everything that a physician does must show beneficence; it must be done in an effort to benefit the patient. All actions physicians and clinicians take must be non-maleficent; they must not allow harm to come upon the patient under their watch. Patients need to feel autonomous; that is, doctors need to allow patients' input and narrative in their healthcare processes. Practitioners must always act justly; patients of all kinds have the right to be treated equally.

While these ethical principles have been the standard in healthcare for many years, their scope is more often applied to medical procedures and clinical visits. It has been argued that all aspects of health, including communication, fall under the scope of bioethical principles [9]. Upon the bioethical groundwork laid by ethicists Beauchamp and Childress [10], continuous research is important. One outlet of continuous research is the application of biomedical ethical principles to health communication.

While health communication has been extensively studied, the direct combination of biomedical ethics and communicative maxims has yet to be exhaustively explored. One governing philosophy within the study of communication are the communicative maxims as defined by philosopher H.P. Grice, which serve

as dicta for effective communication [11]. Similar to bioethical principles, these four maxims describe what a communicator is obligated to do. Communicators must be mindful of quantity; that is, communicators should not give too much or too little information. The quality of the communication is important as well; it must be truthful. Along with truthfulness, effective communication needs to be relevant; communication should focus on the task at hand. Manner is also of huge importance in communication; the context in which one communicates must be reflected in manner. These four communicative maxims, when combined with the biomedical ethical principles, serve as a foundation for this analysis of health communication. Just as communication must be appropriate in manner, relevance, quantity, and quality, it must also uphold the bioethical principles of beneficence, non-maleficence, autonomy, and justice.

While extending the scope of bioethics to include health communication, it is important to note that communication comes in many forms including comics. The study of communicative value in visuals, such as comics, may be performed using a semiotic lens. This study will assess the effectiveness of a collection of COVID-19 comics as potential tools for health communication. There are three layers to visual communication [12]: the representational, which focuses on the people, places, and objects; the interpersonal, which focuses on the creator, viewers, and characters within the image; and the compositional, which looks at the effectiveness of the composition of an image as a whole [13]. Within the semiotics of comics, there are several modalities of communication, including but not limited to facial expressions, vectors, physical proximity, and ellipses. Each of these visual facets provides meaning to a comic.

Facial expressions can bear important information; there are certain facial expressions that are iconic and may be interpreted across cultural boundaries [14], including sadness, happiness, and anger. These expressions can be used in comics to make meaning and invite understanding. Furthermore, colors play a significant role in the interpretation of images [15, 16], as colors may be associated with different emotions or ideas across cultures. Characters within visuals may also reveal information through vectors and physical proximity [17]. Vectors are lines created through gazes and gestures that serve to direct the viewer's attention to a specific part of an image. The distance of a character's placement within a visual also tells a story: the physical proximity of a person or an object within an image allows the viewer to interpret different relations [18]. For example, a person portrayed with close proximity within an image may be inviting the viewer to create a closer bond with this character. Ellipses are another way to create meaning within an image. Ellipses are intentional blank spaces within visuals that may allow the viewer of an image to use their own imagination to fill that space [19]; allowing the user to fill the space inevitably creates a closer image-viewer connection through interaction.

All of these semiotic modalities within comics have a micro-cognitive effect. Regardless as to whether or not patients are aware of these modalities, they could help lead to positive outcomes. The SARS-CoV-2 pandemic has demonstrated that the control of health communication is just as vital as the containment of the virus itself. While addressing the need for a multimodal approach to health communication, this semiotic analysis studies the effectiveness of comics as a means of such as an approach.

#### **3. Analysis of communicative value and bioethical observance**

Now that semiotics, biomedical ethics, and communicative maxims have been reviewed, this research combines these theories to form a theoretical lens

#### *Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

for analysis. This theoretical lens analyzes communicative value or communication elements that aid in understanding, within this collection of COVID-19 editorial cartoons. These elements of communicative value will then be further assessed to determine if they can be successfully used within health communication in accordance with communicative maxims and bioethical principles. This research was inspired by the need to continuously study health communication in general as determined by the ACGME, and more specifically to explore new modalities that aid effectual communication during global health crises and pandemics, as called for by the WHO.

In the exploration of new modalities of communication during public health crises, this analysis examines a previously untouched data set, *comics depicting the SARS-CoV-2 pandemic,* in an attempt to describe any potential communicative value that may be adapted for health communication in the future. This collection of *Q&A* style comics are part of an internationally syndicated comic series titled *Health Capsules.* Currently drawn by Bron Smith, these cartoons were originally conceived by Dr. Michael Petti and illustrated by Jud Hurd. These cartoons can be found on the publisher's website [20]. In general, *Health Capsules* answers everyday questions about health and wellness topics, such as exercise, when to visit a physician, allied health practices, symptoms and illnesses, and cultural notions surrounding one's health.

This collection of *Health Capsules* contains four comics that illustrate the COVID-19 pandemic, its causes, and its symptoms. This analysis is founded on the principle that health communication must adhere to bioethical standards under the scope of communicative maxims to be considered effective [21]. With the hypothesis that visual modalities may be an effective means to adhering to such standards, each semiotic element contained within the visuals will be dissected to understand further such element's implicit meaning as may be interpreted by the viewer.

The analysis will begin using a semiotic framework to examine all meaningmaking modalities within the comics before proceeding to a bioethical and communicative analysis. Semiotic analysis of these COVID-19 comics will follow a visual analytic framework (**Table 2**) that questions the visual representations within, the emotional connections of, and the overall effectiveness of the visual. After this semiotic analysis to assess for communicative value, a biomedical and communicative analysis will be applied. This analysis will question whether or not the comics are appropriate in manner, relevance, quality, and quantity, and if they adhere to the beneficence of the patient, non-maleficence within medicine, a respect for autonomy, and the upholding of justice. This second step of the analysis is formed on the philosophies of the biomedical ethical principles and the communicative maxims described by H.P. Grice, T. Beauchamp, and J. Childress, and is summarized in a rubric created by J. de Rothewelle in 2019 (**Table 3**).


**Table 2.** *Rubric for Visual Analysis [22].*


and ethical standards within health communication?

#### **Table 3.**

*Analysis of Communicative Value & Bioethical Observance [23].*
