Dementia 21: Volume 1

Book Review by Kevin Wolf

Dementia 21: Volume 1 by Shintaro Kago is the first horror graphic novel that I’ve read that fits into the graphic medicine genre. Fantagraphics Books, Inc. (FBI), the publisher not known for manga, has published a couple dozen manga so far, including Fukushima Devil Fish by Katsumata Susumu (translated by Ryan Holmberg) with a story of cleaning up the Fukushima nuclear power plant after the tsunami, a real life horror. This is also my first manga review. It follows a home health aide (called home help aide in the manga) treating various patients under difficult circumstances. Though this is a horror manga, it shouldn’t be construed that this is a slight to actual home aides’ work; rather it’s often used as metaphor for other themes (e.g. anti-authoritarianism). Yukie Sakai, the protagonist, is a highly qualified home help aide whose positive attitude and professionalism allows her to often succeed in very difficult situations; rarely act unethically; and be ready to bounce back Wile-E-Coyote-like from a near broken state in one story to a fresh start in the next tale. If you want to learn exactly how real home aides work, then this is not the book to read. If you want to read stories that have home aide leanings with a lot of social commentary surrealistically presented, sometimes with humor and satire, then you’ve found a good source. With those caveats, I highly recommend Dementia 21.

Background on Manga

Manga is a graphic literary form in Japan that is similar to what is called graphic novels in the United States. It is widely read with up to 30% of all publications (magazine and book) being manga. It is typically first serialized in magazines before publication in book form. Since it is often serialized chapter by chapter, each chapter might be a self-contained story (e.g., Black Jack by Osamu Tezuka about a non-certified surgeon-for-hire; in 17 volumes with twelve stories per volume) form of entertainment or it might be serialized in book form (e.g. With the Light: Raising an Autistic Child by Keiko Tobe; in eight volumes; series was never completed because of the early death of the creator). The number of volumes produced for a particular story can vary from stand-alone one chapter/volume to 205 volumes, so far (https://en.wikipedia.org/wiki/List_of_manga_series_by_volume_count accessed on 3/7/2020).

Each volume can run hundreds of pages. The first few pages of a chapter or book are usually in color and have more shading while the remainder of the book/chapter is black and white with less shading. When translated into English the first few pages might not be in color, perhaps to save printing costs, so those pages will look different than the remainder of a volume. Though many audiences might read a particular manga series, some series target certain audiences, like men, women, children, science fiction, fantasy, military history buffs, and so on. According to Frederik L. Schodt in his classic Manga! Manga! The World of Japanese Comics (from third printing published in 1988), there were over 1 billion comics published in 1984 which were about ten for every person in Japan with bookstores possibly devoting over half their shelves to comics (pages 17-18). There is even a manga called in English Kingyo – Used Books by Seimu Yoshizaki about a used bookstore devoted to provide mangas; the Kingyo manga series has tales that relate to specific other manga. Frederik L. Schodt updated his statistics in Dreamland Japan: Writings on Modern Manga (published in 1996), where he wrote that in 1995 1.9 billion Manga was sold or “over 15 for every man, woman, and child in Japan.” This would have been a 90% sales growth in about 11 years! I could not find more recent statistics.

The English-translated manga are either presented in the original format of the Japanese comics, which means the only substitutions are the word translations for the hiragana or katakana Japanese characters or they do this substitution and flip the pages. In English we read comics from left to right starting the book with its spine on the left while the Japanese read and write their comics from right to left with the spine initially starting on the right. The “flipping” translation has led to problems because they often need to be double flipped. The initial flipping puts everything in the English reading style order, but right handed persons become left handed persons and vice versa and persons now look or enter a scene from the opposite direction as the author desired. The right hand Japanese page is now on the English left side. Within the English page if one wants right handed persons to continue being right handed and scene movement to happen as designed, then each panel needs to be flipped again within each page; but then the speech balloons might not be in the right order. Furthermore, if the panels are not rectangular the second flip may not be possible without redrawing the panel frame. These flipping complications have led many publishers to leave the manga in the original right-to-left Japanese format and ask the English reader to flip their reading style. Keeping the Japanese format makes the translation publishing process less expensive and faster. Though this doesn’t make one bilingual perhaps it could make one bi-visual. Such English translated Japanese manga often include instructions on the last page (the common first page of English books) that the reader should start at the other end and showing the right-to-left order of reading a typical manga page. One other translation note: Japanese names of people are given as Surname then Given name order; while translators put it in the Given/Surname order in English. Dementia 21 is published in the Japanese style format with names re-ordered.

Dementia 21

The premise of Dementia 21 is that Yukie Sakai, a child-like home health aide, is pushed into taking very difficult assignments. She always tries to be upbeat and helpful to her patients. She had been getting the top service scores every month from her clients and awarded bonuses (she says, “It’s never much of a bonus!”) by headquarters of Green Net: Home Health Care Support Center. Yukie is very humble about it (“Oh, it’s just luck.”). The aide who’s always getting second place, Ms. Ayase, is jealous. Ayase sleeps with the married, unnamed executive who hands out the awards and assignments. Ayase demands he do something. He manipulates Yukie’s complaint records, and tells her she’s been demoted and put on notice with a pay cut and given the difficult cases. The reader now watches Kago’s surreal imagination unfold.

Her first assignment is to help bed-ridden, at least at first, Eiko Koike (female, age 85, Required Care Level 3, unable to stand alone or do ADLs (activities of daily living: bathing, eating, dressing, toileting, walking/moving around, and transferring (moving from sitting to standing, chair to bed, etc.))). Yukie learns that Eiko’s five prior home aides died under ‘accidental’ circumstances (e.g., slipping in bath, falling from window, etc.). Yukie massages and exercises Ms. Koike’s atrophied legs. Early on Yukie trips and her cup falls from her hand and she cuts her hands on the shards of the cup. She bandages herself. Over the next few days there’s a shadowed creature that follows her sometimes and leads to: Yukie falling down the stairs, having bottles crash near her, even having the entertainment system fall on Yukie’s bed—she’s a live-in aide—just after she had fortunately gotten up and out of the bed. Perhaps it’s a yōkai (demon / ghost / evil) Japanese spirit. While working in the kitchen she accidentally pushes a panel on the wall to expose framed photos of the prior dead home aides and one empty frame remains. Suddenly the yōkai appears in reality, it’s her hissing patient who’s dragging her body around by her arms. Yukie is petrified and the patient suddenly starts to have a heart attack, hissing, “N-n –need m-my medicine!” The reader has a page turn confronted with powerful half-page panel of Yukie reaching out with her evaluation device “I’ll give you your medicine … in exchange for a high-score!” She gets the high score and is back on top of the service board. Dementia 21’s periodic disorienting twisted humor is demonstrated herein.

Each chapter has Yukie moving on to a different patient or set of patients. The tales often progress from difficulty to solution to going out of control to catastrophic resolution and Yukie hoping for a high service score. For example, the second chapter starts with Yukie taking care of three sisters alone. Yukie does it cheerfully and with aplomb. The unending repetitiveness plays out with mirror-like scenes within the same panel because more sisters, cousins, neighbors, … keep arriving. No back up aides are available. It reaches a sad but hilarious crescendo to show “the awesome might of senior power!!” to metaphorically fight those who treated them like detritus. Chapter 3: A woman literally erasing her past with her long dormant supernatural powers as she grows more senile, but is there a fix?

Yukie often has to work without support from the home office. And Yukie’s goal is often to get a high score from whoever she’s helping. There’s a story of the “C-1 Grand Prix … to earn the title of greatest home help aide in all of Japan!” That same story shows Yukie’s mother being angry with her because her mother had to quit working as a home help aide after Yukie was born. Mother’s mistreating their daughters (-in-law) is a common trope in Japanese manga. Yukie gets sent to home help aide training camp run militarily; clearly a metaphor against authoritarianism (e.g., they run 50 kilometers while pushing elderly mannequins in wheelchairs, crossing minefields with the mannequins, etc.). Another story is about an automated nursing home. Another covers war games between patients to be admitted to a very limited number of spaces in a CCRC (continuing care retirement community). Another amazing story has Yukie helping an aging manga artist sell his works at a “comic market” becoming Groundhog Day-like in a seemingly endless loop. The last story in this volume is how an adult daughter uses her mother’s wrinkles to smuggle goods out of retail stores and elsewhere.

Within the stories there are many home health care or other medical services provided in Dementia 21, like: toileting; temperature taking; medicine distribution; blood pressure taking; working with a senile patient; acquiring needed dentures; handling patient-parent/child bullying; osteoporosis and other debilitating issues; bed sores; cleanliness; elder and nursing home care; dealing with a germophobe; support groups; helping senior citizen with their driving; patient on life support; and death with dignity issues.

The illustrations are beautiful and very detailed. The chapter breaks are full pages of Yukie pictured surrealistically. Examples include: small Yukie heads bouncing upward out of her cranium; another shows childlike Yukie climbing out of a hole where her face should be; and being scared of her own image in a mirror; among many more amazing images. At the back of the book there’s a one-question-per-page interview of the author. Often the questions are longer than Kago’s response. Based on his answers, Kago clearly wants the reader to develop their own opinion of his work and not be given any clues as to what he might’ve meant. Salvador Dali, the surrealist artist, was a big influence on him. Along with those questions there are wonderful color surreal illustrations of Yukie. His style has been called “fashionable paranoia.” Though there’s nothing sexual in this work, Kago’s work is sometimes called “ero guro nansensu” manga which loosely means erotically grotesque nonsense. Gary Groth’s, FBI Publisher, writes at the back of the book: “Part dada, part surrealism, … ero guro emphasized depictions of grotesque combinations of sexuality and violence and often served as commentary about and opposition to social norms and taboos. … His persistent theme, at least in Dementia 21, is the totalitarian reduction ad absurdum [reduction to an absurdity; in mathematics forcing the opposite to be the real truth] of mass bureaucracies and technologies, whose limitless humiliations we suffer …are rendered with a mocking, abrasive contempt.” I’d rather call Kago’s work marvelously drawn twisted tales.