Disability

What ‘Joker’ Says About Our Broken Health Care System

To a fellow survivor like me, 'Joker' exposes our system's failure to properly rehabilitate people after traumatic brain injuries.

Directed by Todd Phillips, Joker—a possible origin story of Batman’s most iconic nemesis, seen through a more realistic lens—has won awards, broken box office records, and brokered controversy for what some have called its more fascistic streak. But I think such concerns are overblown. After watching Joker myself, I’ve never identified with a character more in my life… not because I have any sympathies with the alt-right, but because, like the main character, I suffer from a traumatic brain injury (TBI) that left me permanently disabled.

In Joker, the titular character—whose real name is Arthur Fleck—suffers from many of the afflictions often present in those with TBI. He has a history of head trauma, taking a sign to the head at the beginning of the film, as well as having multiple traumatic brain injuries previously due to systematic abuse. The world this character inhabits, with its bureaucracy and lack of resources for TBI survivors (which is partly responsible for Arthur Fleck’s transformation into a killer), is very real to me. And it is extremely believable to me that the failures in our existing system supporting and providing rehabilitation to people with TBIs could lead to a real-life Joker.

According to the CDC, in 2014 (the last year data was collected), about 2.8 million traumatic brain injury (TBI)-related emergency department (ED) visits, hospitalizations, and deaths occurred in the United States. In fact, the National Bureau for Biotechnology Information has been calling TBIs the silent epidemic for years. Historically, TBIs can sometimes result in the Jekyll-and-Hyde style transformations seen in Joker… but, crucially, this can be prevented with rehabilitation: something never provided in the film to Arthur Fleck.

Historically, TBIs can sometimes result in the Jekyll-and-Hyde style transformations seen in Joker… but, crucially, this can be prevented with rehabilitation: something never provided in the film to the titular character.

In 1848, railroad foreman Phineas Gage’s tamping iron shot through his jaw, pierced his frontal lobe, and exited the top of his head after some dynamite exploded prematurely. Immediately after the accident, he was extremely laid-back. My favorite detail—left out in most retellings—is that when the Doctor John Martyn Harlow finally arrived to treat Gage, his patient was waiting on the porch, and said, quite calmly: “Well, here’s enough work for you Doctor.”

But as famed neurologist Oliver Sacks notes in his 1995 book An Anthropologist on Mars and corroborates this account, this sanguinity didn’t last long. After his accident, he went from a respectable young man to a drunken sociopath post-tamping iron. It was only two years after the accident, when Gage moved to South America and became a stagecoach driver, that he recovered his previous temperament—and the peaceful routine of his new profession served as a makeshift form of the therapy and rehabilitation he had otherwise been denied, according to psychologist and historian Malcolm Macmillan.

Gage isn’t the only such example of a person with a TBI undergoing a violent personality change, as in Joker. Other examples of individuals suffering brain injuries without being given proper rehabilitation have an even clearer parallel to Arthur Fleck’s journey.

Consider John “the Killer Prophet” Frazier, a serial killer who hit his head in a 1969 car accident in Santa Cruz and then started hearing homicidal messages from God. He chose to follow commands by murdering an ophthalmologist and his family. Frazier’s subsequent behavior following his brain injury closely mirrors Arthur Fleck’s descent as portrayed in Joker. Abandoning his family, Frazier hid in a makeshift shack in the Santa Cruz Mountains and fixated on a hippie hangout within the city called the Catalyst, fixating on gentrification much as the fictional Fleck fixates on comedy and the fictional late-night host played by Roberto De Niro. When Frazier showed up at his first court hearing in 1971, he had shaved one side of his head and face while the other half remained overgrown and unkempt—he wanted to show the dual sides of the hippie identity and what was underneath the growth. Fleck painted on clown makeup to show his insight.

What stuck with me about Joker, as a person with a TBI myself, is how well it nailed the reality of healthcare today. The best outcomes happen for those people who have the resources to rehabilitate fully; for those who don’t, tragedy often results. We all know of comedian Tracy Morgan’s and social psychologist Amy Cuddy’s recoveries from brain injury, but what happens when the sufferer isn’t rich or well-connected? What happens when the injury only exacerbates an individual’s already troubled psyche?

We all know of comedian Tracy Morgan’s and social psychologist Amy Cuddy’s recoveries from brain injury, but what happens when the sufferer isn’t rich or well-connected? What happens when the injury only exacerbates an individual’s already troubled psyche?

After my accident, a medical social worker showed me a photo taken while I was in a coma, hooked up to machines. My reaction wasn’t what she expected: I began laughing maniacally. As I chortled like a ghoul, the medical social worker told my mother: “This is an effect of her injury. It’ll pass.” But my mother said no, I wouldn’t. I’d always been this way. My mother, much like the Fleck’s mother in Joker , decided what the narrative for my condition would be.

That’s why Joker speaks to me as a brain injury survivor. Thanks to family and friends, I got the rehabilitation I needed, but what if I hadn’t? What if, like Arthur Fleck, or John Frazier, or countless other disenfranchised, neuro-diverse people shuffled off without adequate support by our indifferent healthcare system? From that perspective, the premise of Joker becomes a glimpse at a possible future in which I wasn’t quite so lucky: not so much a comic book retelling, as an alternate reality.