Illustrating the benefits of tranexamic acid

Researchers at the London School of Hygiene & Tropical Medicine (LSHTM) have joined forces with professional artists to publicise the benefits of tranexamic acid (TXA) amongst medical professionals. The team utilised the Japanese manga comic style to convey important information about the drug to healthcare workers treating patients suffering from bleeding.

TXA was developed in Japan in the 1960s and helps to reduce clot breakdown. As such, the drug can benefit a wide range of patients including accident victims and women at risk of haemorrhaging during childbirth. Ian Roberts, Professor of Epidemiology and Public Health at LSHTM, devised a storyline in which workers at an emergency department treat injured people in the wake of two explosions. Professional artist Emma Vieceli and colourist Paul Duffield used the lively manga art style to set the scene. The team hope that their cartoon will effectively communicate the latest TXA-related research findings to doctors, nurses and paramedics working on the frontline of treatment.

I spoke to Professor Roberts to find out what led to the development of his manga-inspired comic strip. I began by asking him to explain more about the benefits of TXA.

"TXA can significantly reduce a trauma patient’s risk of bleeding to death," he began. "If TXA is administered within three hours of injury, it can reduce a patient’s chances of bleeding to death by about 30 per cent."

Whilst the benefits of a particular drug might be clear to see, disseminating the relevant information can be an arduous process.

"It is widely known that translating research into practice doesn’t happen overnight," explained Professor Roberts. "It is a very slow process of diffusion. You would hope that information concerning the identification of a safe and effective treatment for a life-threatening condition, would reach concerned parties immediately. Unfortunately, this is not the way that medical findings are distributed. Authorities begin by reading an article. They then debate its findings and have meetings in order to decide whether or not to incorporate them within their guidelines. These things take time.

"TXA is a treatment for haemorrhages, but consider the other end of the spectrum," Professor Roberts continued. Treatments for thrombosis, such as clot-buster drugs, took a decade to be implemented. Thousands of people died unnecessarily whilst this was happening. In my opinion, a lot of scientific dissemination is boring and nobody likes things that are boring. It’s all about getting a share of people’s attention in a way that is memorable. Of course, it is essential to be scientifically rigorous and to find out whether or not a treatment works. This is why we conduct randomised controlled trials (RCTs). What you are often left with, however, is a product that is scientifically rigorous and factually accurate, but as boring as hell. We are trying to package scientific truths in ways that are interesting and memorable."

Professor Roberts and his colleagues hope to communicate important medical information through lively and engaging storytelling.

"I think that humans are programmed to be receptive to narrative," he explained. "People are not so good at remembering facts unless those facts are delivered as part of a story. Throughout human history, stories have been used to pass on information. This is how the brain works. What if I were to tell you that the relative risk of death with tranexamic acid, within three hours of injury, is 0.72 with a confidence interval of 0.68? No part of the brain is ready for that."

Narrative is an integral part of Professor Roberts’s philosophy, but why did he choose the manga comic style as his medium of communication?

"TXA was invented around 50 years ago in Japan," he said. "It was originally used to treat heavy periods, and it is only recently that our research has led us down alternative avenues. We knew that it worked for minor bleeding, but we wanted to know whether it would be effective in more extreme cases. We found out that it was. This is our big news and we are now trying to get this news out there.

"The origins of the drug are really very interesting. I travelled to Japan to make a short film about the married couple that invented TXA. The husband is now dead, but his wife is still alive. She is 94 years old and she still goes to work; she is an extraordinary character. When I give talks on TXA nowadays, I don’t discuss RCTs. Instead, I show audiences a picture of this woman aged six. I tell them that her ambition was to become a medical student. I explain that she entered the field of medical research with her husband in post-war Japan and that they were so poor that they had to eat their laboratory animals. I then tell people that this drug reduces a patient’s risk of bleeding to death by 30 per cent and they tend to remember that information. The birth of TXA is a memorable story and manga was a novel way to retain some of its flavour."

Professor Roberts will now watch with interest to see whether his foray into ‘graphic medicine’ has been successful. However, his criteria for success might surprise some people.

"In my opinion, there could be two positive outcomes," he explained. "I want people to either love the comic or to hate it. If they love it, that’s good. If they hate it, that’s also good because it means that they will talk about it. Indifference is the real enemy."

Finally, I asked Professor Roberts whether or not he would consider graphically conveying the benefits of other drugs in the future.

"If the comic is shown to be effective then yes, I would," he replied. "However, if everybody started to do it then it wouldn’t be different. It’s all about being original. In previous attempts to stand out, we have made films and written songs. I play the TXA song to people at conferences and they laugh. Laughter is good because it represents an emotional connection. Emotional content makes stories memorable. For instance, when I teach students about clinical trials I begin by stating that I became interested in the field after killing a little girl. When I say this, you can hear a pin drop. I go on to explain that 20 years ago, my colleagues and I were treating a young girl who was bleeding to death. The things that we were doing weren’t evidence based. Now, we understand that some of our approaches would have been increasing her risk of death. Of course, this happens all the time in the medical profession. Doctors do some of the right things and some of the wrong things. In this case, we were doing a lot of the wrong things. Modern evidence suggests that at the time, we were probably doing more harm than good.

"This story elicits an emotional response from the audience. It is memorable. To this end, I would argue that narrative is good and scientific research is bad. Traditionally, when we present scientific research, we strip away all of the emotion. Research findings are very effective at identifying the truth, but they don’t make the truth memorable. This is the problem that we are trying to address."


Professor Roberts’s video, in which TXA inventor Utako Okamoto discusses her life and work, can be viewed via The Lancet.