D&D and Disease

So I have this cold. This cold has plugged up my right ear in such a way that I can't hear a thing out of it. This also throws off my balance a bit. The closest thing I can describe to this effect is how one feels after getting punched hard in the ear. Rather than lasting for a few uncomfortable  minutes however this has been going on for days now and I'm starting to get a bit tired of it.

When grasping for RPG related inspiration, I am not starting in a good place today.

See Heroes don't catch the cold..

Never have I heard at the gaming table.  "Remember, Sir Gawain has the sniffles so he is at -2 on all his checks today."

I am totally at -2 on all my checks today... totaly.

The Dance of Death (1493) by Michael Wolgemut,

Sickness was a bit part of life in human history. Plague, Parasites, bad nutrition, bad hygiene, and general short life expectancy made most of human history a tough slog towards a quick death. A simple cold, could go to pneumonia then on to death pretty quickly back in 1330. We live in a golden age of health, compared to the past.

Lets just look at a few horrible things that happened to the  comon no hero types back in the day.

• The European Black Death, Peaked around 1348 to 1350, Killed some 75 to 200 million people in Eurasia. ***
• Lead to all kinds of social and religious upheavals, economic and trade break downs.
• Took 150 years for the population to recover.
• Returned again and again to kill people in pockets until the  19th century.
• 1826 to 1837 The European Cholera Epidemic, One of six Cholera outbreaks.****
• Killed quickly and gruesomely.
• Thought at the time to be a punishment from god.
• Carried by polluted water, the  warmer the better, would often strike seasonally.
• Smallpox: has killed hundreds of millions of people throughout history including 90 to 95% of the native populations in the Americas (Smallpox was the big killer, influenza and measles did their part as well.).
• Goes way back. It has been found in feces samples taken from Egyptian mummies. Including the mummy of Pharaoh Ramses V. way back in 1157 BC.
• Leaves survivors poclmarked.
• Seeds fear wherever it crops up.
• Is still dangerous to this day.

After doing some reading I start to wonder about the  myths we have in our head of strapping warrior's landing in long boats brandishing  large heavy weapons. No doubt the  average viking war party was in  great physical condition. Every moment of their lives was a physical trial, they had to be. Were they healthy though? By healthy I mean were they what we think of today as healthy? What with all kinds of epidemics, parasites and illnesses running around, how could the  average fotman be a strapping specimen? I mean  those intestinal parasites alone rob a person of important nutrients and  could lead to any number of conditions. Weight loss, vomiting, intestinal blockage, and fatigue are all possible and  none are good  conditions for your average warrior. Worse yet from what I have read the ancient world was RIFE with those sort of intestinal beasties.

I wonder what the true physical health of the average warrior might have been in antiquity?

Sure enough if a warrior were from the higher ranks of a society, he / she would have access to the best of the clans food and may spend a fair amount of time training. I would think this would  create an elite few, knights, Jarls guards, chosen companions, and such that would be  more fit than the average man at arms. Some exceptional specimens could even crop up, Not every ancient warrior was Ormur Stórólfsson whose log lifting prowess and  the  broken spine that resulted from it created a record that stood for 1000 years*. I'm honestly more interested in the  "50 mere mortals" who had to lift the massive 650 kg (1433 lbs) log onto his back. If we take the  Saga at face value and treat it as fact, Ormur was one strong fellow by any measure. Still I  imagine no less susceptible to all the  parasites, and disease floating around.

Not surprisingly,  a quick google search gave me very little in the form of information on the subject of health Vs brawn in our fighting ancestors. Shrug, will dig deeper at some point, but I'm pretty secure in my theory that that average health of people 600 years ago was not as good as it is today. Safe bet.

Why doesn't this kind of thing get much play in most Role playing games? **

My theory is because most role playing games are designed to tell stories about the mythical hero, and  not the supporting cast. Players want to be Jason, not an Argonaut. In fact most traditional games built around  troops of these heroes, traveling around in a party and generally being better than everyone around them. I don't think most folks want to play a character whose story ends when they die alone, under quarantine, suffering from some version of the black death. ***

So on to  D&D....I'm using D&D here as it's the world's most blahh blahh blahh blah..but also encompasses the  sword and sorcery style and time period I was thinking would be most affected by horrid festering plagues.

Lets start by sampling some disease magic. I'm sure there's more out there, I don't own every damn thing ever written, I'm going to sample some spells from various spells from various versions of D&D that have to do with disease specifically.

 In Basic D&D according to ye ole Rules Cyclopedia, disease magic is the sole domain of Clerics.

This cure disease spell cures one target of one disease with mummy rot and green slime infestation being used as examples. The duration of "permanent" leaves the player argument that the spell also imparts some kind of impunity open for debate. The basic D&D version of the  reverse "cause disease" is fatal over time which makes it deadlier than most other versions.

Though when talking about  disease in basic D&D and most of the other editions Purify food and water is where it's at. Even a low level cleric, if not busy  turning death at the local crypt or healing friends in some deep  hole somewhere, should purify every damn thing the party eats. Pure food and water would mitigate the risks of  parasites and disease straight away.

AD&D also had purify food and water, which looked like this:

Purify Food & Drink (Alteration) Reversible Level: 1     Components: V, S    Range: 3"     Casting Time: 1 round    Duration: Permanent    Saving Throw: None   Area of Effect: 1 cubic foot/level, 1" square areaExplanation/Description: When cast, the spell will make spoiled, rotten, poisonous or otherwise contaminated food and/or water pure and suitable for eating and/or drinking. Up to 1 cubic foot of food and/or drink can be thus made suitable for consumption. The reverse of the spell putrefies food and drink, even spoiling holy water. Unholy water is spoiled by pure water.

This version is interesting in that it's reversible, giving the  character the ability to spoil food and water one cubic foot at a time. That sounds kind of "meh" but cast in a  grain  silo or something, one foot of bad grain could  fester and poison a good number of  people. Honestly I prefer the basic version, because I don't want to argue over what 1 cubic foot of food might be.

AD&D also had it's own version of Cure disease:

Cure Disease (Abjuration) Reversible

Level: 3     Components: V, S    Range: Touch     Casting Time: 1 turn    Duration: Permanent     Saving Throw: None    Area of Effect: Creature touched

Explanation/Description: The cleric cures most diseases - including those of a parasitic, bacterial, or viral nature - by placing his or her hand upon the diseased creature. The affliction rapidly disappears thereafter, making the cured creature whole and well in from 1 turn to 1 week, depending on the kind of disease and the state of its advancement when the cure took place. The reverse of the Cure Disease spell is Cause Disease. To be effective. the cleric must touch the intended victim, and the victim must fail the saving throw. The disease caused will begin to affect the victim in 16 turns, causing the afflicted creature to lose 1 hit point per turn, and 1 point of strength per hour, until the creature is at 10% of original hit points and strength, at which time the afflicted is weak and virtually helpless.

This version of the spell has AD&D's penchant for wordy details and a sense of in  game time that some of the other editions lacked. The disease is cured in 1 turn or a week, depending out how sick the target is. The "cause disease" reversal of this spell is a spell in itself. Being this is AD&D you end up with takes affect after 16 turns, loose 1 hp per turn, and loose one point of strength per hour, so the  poor GM is stuck tracking  a bunch of  countdown timers until the head of the town guard is left shivering in bed.

D&D 3.5 has

Remove DiseaseConjuration (Healing)

Level: Clr 3, Drd 3, Rgr 3

Components: V, S

Casting Time: 1 standard action

Range: Touch

Target: Creature touched

Duration: Instantaneous

Saving Throw: Fortitude negates (harmless)

Spell Resistance: Yes (harmless)

Remove disease cures all diseases that the subject is suffering from. The spell also kills parasites, including green slime and others. Certain special diseases may not be countered by this spell or may be countered only by a caster of a certain level or higher.

Note: Since the spell’s duration is instantaneous, it does not prevent reinfection after a new exposure to the same disease at a later date.

This spell cures everything the  target has, with the caveat that "Certain special diseases may not be countered by this spell or may be countered only by a caster of a certain level or higher." Which is saying "This works unless the DM say it doesn't or whatever, good Luck!" This version of the spell also has an instant duration and a section in it's description specifically to kill any permanent immunity argument left over from basic D&D dead as a door nail. Also notice three different classes can now cast this spell. Neat, my ranger can fill in for the Cleric where disease is concerned. No one is dying of dysentery this game.

4th edition has it's own version:

Cure Disease is a 6th-level ritual.[PH:303]

The Cure Disease ritual wipes away a single disease afflicting the subject, whether the disease is active or still incubating. The subject is completely cured and loses any negative side effects and symptoms of the disease.This ritual is physically taxing to the recipient; if used on an injured character, it can even kill him or her. If you know that your subject is suffering from multiple diseases, you must choose which one this ritual will cure. Otherwise, the ritual affects whichever single disease you knew about.

Heal Check:

Upon completing this ritual, make a Heal check, using the level of the disease as a penalty to this check. The result indicates the amount of damage the character takes. Assuming the character survives, this damage can be healed normally. 

You learn the disease level when you begin the ritual, and at that point you can choose not to continue, without expending any components.

  Effect on Target

≤0         Death

                      1–9       Damage equal to the target’s maximum hit points

10–19 Damage equal to one-half of the target’s maximum hit points

20–29 Damage equal to one-quarter of the target’s maximum hit points

30+ No damage

While I'm no expert when it comes to (anything) 4th edition D&D, this isn't half bad. I like that it is a ritual, only cures one disease, and still has some risk built into it, making disease still feel dangerous.

5th edition has:

Lesser Restoration

2nd-level abjuration

Casting Time: 1 action

Range: Touch

Components: V, S

Duration: Instantaneous

You touch a creature and can end either one disease or one condition afflicting it. The condition can be blinded, deafened, paralyzed, or poisoned.

Which is basically the briefest way of stating how sure disease works. It's basically the anti AD&D version of the spell.

Then we come to "Contagion" which gives a target a nasty disease.  This spell is pretty nasty in the  second edition of the advanced game. (First appearance?)

The penalties to three stats, penalties to combat, and  the necessity  of a cleric spell or bed rest makes this  spell quite debilitating. The idea that it works on a timer (1d3 weeks) makes it very "roleplay-ish."  This is not a thing a necromancer just tosses out in combat. Contagions is something a character uses then waits, much like the reverse of cure disease from 1st edition. Notice no save?  This spell will affect anyone equally, the plague knows no rank or station. Those symptoms though. That's a plagu , even if it only affects one target. Also that last sentence in the  spell description leaves the door open for the GM to be particularly brutal if the a player is like, "I gots contagion? so what?"

By 3.5 contagion looks like this:

Contagion

Necromancy [Evil]

Level: Blg 3, Clr 3, Destruction 3, Drd 3, Sor/Wiz 4

Components: V, S

Casting time: 1 standard action

Range: Touch

Target: Living creature touched

Duration: Instantaneous

Saving Throw: Fortitude negates

Spell Resistance: Yes

The subject contracts a disease selected from the table below, which strikes immediately (no incubation period). The DC noted is for the subsequent saves (use contagion’s normal save DC for the initial saving throw).

Disease                   DC   Damage

Blinding sickness 16   1d4 Str1

Cackle fever            16 1d6 Wis

Filth fever                12 1d3 Dex and 1d3 Con

Mindfire                  12 1d4 Int

Red ache                  15 1d6 Str

Shakes                     13 1d8 Dex

Slimy doom            14 1d4 Con

1 Each time a victim takes 2 or more points of Strength damage from blinding sickness, he or she must make another Fortitude save (using the disease’s save DC) or be permanently blinded.

The immediate effects are worse, there's a neat list of  8 made up diseases so as to not offend anyone, and now there is a saving  throw.  I strongly prefer the 2nd edition version of this spell, mostly  because it can be interpreted more freely by the GM. I don't know what "Mindfire" is but I could totally get behind giving a character scarlet fever.

The takeaway:

It's important to note that from early on in D&D individual diseases can be cured "instantaneously" or almost instantly if the proper level cleric is hanging around. For this reason I imagine in games with a higher level of magic anyone of any inport would have a connection with a church, be a patron of the a church and or keep a cleric on retainer. Simply for purify food and water and  remove disease. When I think about it these are like biblical level miracles being cast at relatively low levels. You hungry? Create food and water. Have a crappy well, purify food and water? Have cholera because of your goat crap infested water? remove disease.

This goes a good way to explain why D&D heroes are THE heroes. If as an individual a character has access to something like purify food and water or remove disease then they have a jump start on surpassing the normal 0 level dregs of society. The character will have the very best nutrition, and be immune or at least have an answer for many of the subtle wasting diseases that afflict the more common folk. In effect a level 3 warrior with a party including a cleric could live a life that breeds specimens like Ormur Stórólfsson. This assumes the  game world is not set up in a way where clerics are handing out pure food to and casting remove disease on anyone who needs it. A game world that assumes clerics with  the  ability to cast such spell are a rare somewhat special exception.

Hans Holbein, Simolachri,(1549)

I also find it interesting that none of the diseases mentioned in the contagion spell description are communicable. What I mean is no one catches "Mindfire" from the  initial victim. So the rest of the party goes their merry way while Fifel the Punny staggers along bleeding from the  eyes until he can make a few Fortitude saves. My personal theory is this: Giving player characters the ability to create a communicable disease that may in fact wipe out a population if left unchecked is, in fact a horrible idea. On the other hand, having an NPC necromancer start an outbreak of  bubonic plague is a truly horrifying, logical story hook. Think of the undead army a necromancer could raise after his contagion wipes out 60% of a small city. (It's all part of his evil plot.)

As a DM I also understand that the  bookkeeping of a disease that may or may not spread between  characters with each case having its own duration and effects is a bookkeeping nightmare. Some GM's might embrace that sort of thing, but it's not my strong suit.

Some diseases for your game:

here are some diseases that cause public health concerns  today. Roughly built out for a "D&D" style game, your mileage may vary. My opinion is these disease are all bad enough to put a character in bed for period of time. Some of them like Ebola and Typhus are more than likely to kill a victim out right.

• Sleeping sickness
• Vector is Tsetse flies: African trypanosomiasis, also called African sleeping sickness, is a parasitic disease spread by the tsetse fly. Symptoms appear with in 1d3 weeks of the bite and include fatigue, high fever, headaches, and muscle aches. (-2 of CON)
• 1d6 weeks later the second stage kicks in with confusion, poor coordination, numbness and trouble sleeping.(-1 to Dex, Str, Con. and Wis each week until treated.)
• If the disease is not treated, it can cause death. (Character dies when any single attribute hits 0)
•  Tick bite fever
• Vector is ticks:  Symptoms usually appear within 1d2 weeks after a tick bite and often include fever, headache, muscle soreness, and a rash. At the site of the tick bite will be a red skin sore with a dark center. (-2 to Constitution and any Concentration checks. Long term: If untreated may cause reactive arthritis -1 Dex per year after 1d4 years.)
• Amoebic meningitis
• Caused by an Amoeba usually found in shallow surface waters. This disease and usually occurs in warmer climates. Salt water has not been associated with the  disease. Infection occurs when infected water enters the nose. This can happen when diving, jumping or swimming in fresh water. The amoeba then invades the brain and meninges through the nose. It is almost always fatal. This is real horror movie  shit. 1d8 days after infection the character will display sore throat, headache and pain in the forehead, hallucinations, vomiting, fever, neck stiffness and pain, seizures (fits).
• If not treated with remove disease that day the  character is dead by morning.
• Anaplasmosis: Vector, tick bites. within 1d2 days. 
• The symptoms are flu like and will cause 1d6 loss of Con for 1d3 weeks, the a period of remission. If the disease goes untreated worse symptoms can crop up like difficulty breathing (permanent 1d6 con loss) or Neurological disorders (1d6 dex damage) these symptoms will crop up  with in  1d6 months of the initial infection.
• Monkeypox: There was a recorded outbreak of this  nasty bugger in 2016 in Africa and an outbreak in America in 2003, not all plages are relegated to the history books. 
• The virus enters the body through broken skin (even if not visible), respiratory tract, or the mucous membranes (eyes, nose, or mouth) Human to human transmission  happens via large respiratory droplets being  spread in close quarters. (coughing , sneezing)
• 4d4 days after infection Monkeypox begins with fever, headache, muscle aches, exhaustion, and swollen lymph nodes. The victim develops a rash of lesions and pustules, often beginning on the face then spreading to other parts of the body.
• ( For 1d4 weeks the character makes a daily saving throw. IF the save fails the character loses 1 CON for that day. If CON falls to zero the  character dies. During this period unsightly pox and lesions cause the charaters charisma to be half and the  character will loose 1d6 charisma permanently.) During this time the character is generally bedridden from weakness and fatigue.
• Smallpox
• Smallpox is a human only disease.

• The variola virus is the only known cause of smallpox. The disease affects only humans. No animal reservoirs or insect vectors (insects that spread a disease) exist, and no carrier state (period when the virus is in the body, but the person is not actively sick) occurs.^

•  Smallpox is a diseases that excels in cramped living quarters  as the victim may spread smallpox via droplets when coughing or sneezing. Victims are contagious from the time they develope a rash to the time their last scab falls off. 
• After infection the virus will incubate for 4d4 days. For 1d4 days the victim will have vomiting, high fever and severe fatigue. At this point a character will be stuck in bed. After that the sores start on the  mouth and tongue, at this point the victim is the most contagious. The sores spread quickly to the whole body, usually within a day or so. Strangely as the rash appears the initial symptoms subside. That only lasts for a day ro so as the  sores fill with fluid the fever returns.
•  Game wise handle the  disease like  monkeypox above, lasting 1d6 weeks
• Tick paralysis: Vector: Ticks. Caused by a neurotoxin in the ticks saliva, not a separate virus or bacteria. Takes effect 2d4 days after the tick imbeds itself.
• Begins with weakness in the legs and progresses quickly to the trunk then arms and head.
• (-1d4 STR,) and Lethargy (-1 Dex.) per hour for the next 12 hours. If the character's strength falls to below 0 they suffer respiratory failure and die.
• Typhus: Vector, parasites, fleas, ticks, louses. (This is not Typhoid fever that's a different disease.)
• This disease has killed people epidemically over the years. In 1812 Napoleon's men retreating from Russia were decimated by Typhus . Over 100,00 Irish perished of Typhus between 1816 and 1819. America had an epidemic in 1837. Again this  disease thrive in populations cramped in filthy environments, like prisons, war camps, and the occasional fast food restaurant.
• 1d2 weeks after infect the victim gets laid low with  fever chills with a rapidly spreading red rash starting 1d10 days latter. During this time (2d6 +2 days) the victim is at 1/2 Con and must save each day or suffer delirium during. Once Delirium sets in the  character cannot cast spells, concentrate, or makes skill checks. During delirium in the  victim must save once per day or loose 1 additional point of CON. If Con falls to 0 the victim dies. This lasts until the victim makes the saving throw and pulls out of the  delirium at which time they will recover 1 point of CON epr day until fully healed.
• Viral hemorrhagic fevers This is a range of diseases, including the  now infamous ebola,  Dengue Fevers, and Crimean-Congo haemorrhagic fever
• looking at Ebola as our base disease.
• Vector: Not 100% known thought to be contact with an infected animal such as a monkey.
• When an infection occurs in humans, the virus can be spread to others through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with a victims (dead or alive) blood or bodily fluids (including sweat.)
• After infection it takes 1d20 days for the  symptoms to start.
• Symptoms include all of the normal suspects fever, weakness. these symptoms are serious enough to make the victim bedridden.
• The symptoms include unusual / unexplained hemorrhaging, bleeding from various orifices and sever bruising.. 
• The disease affects the victim's strength reducing it by 1d4 per day  and their Con reducing it also by 1d4 per day. This persists for 1d10 +6 days after the symptoms start. If either score falls below 0  the victim dies. A victim who survived Ebola is immune to the  disease for 1d6+6 years afterward.

The Triumph of Death by Pieter Bruegel (painted around 1562) 

Gameification:

A good number of the diseases above are spread by "things". Fleas, lice, ticks, and what not. In a D&D sense, this lends use to a spell like "protection from insects." A druid notes many of the animals in an area where there has been illness are infested with ticks or fleas, he or she casts protection for insects as a safeguard. A generous GM might go away from the letter of the spell and decide that, yes that spell helps safeguard the Druid from catching an insect borne disease. 

Several of the Viral hemorrhagic fevers I read about are still contagious after the host's death. So now we have a necromancer who starts an outbreak and then raises zombies from the dead which are still contagious. The  people fighting the  zombies are forced to make saving throws after each encounter or contract the horrid disease. It's a fantastically morbid hook for a series of gruesome adventures.

Giant rats can carry disease just like normal rats. In fact a giant rat can host that many more fleas. A low level character contracting a flea borne illness could spark a quick quest to find and hire a priest high level enough to cast remove disease.  This is a two fold opportunity. One it makes giant rats relevant again, and a bit of a threat to even higher level characters. 

Second it's perfect for when one of the players doesn't show up for a game. 

"Remember when you fought those rats? Well, the thief (who is not here this week) contracted a sickness that has her laid up in bed and covered in blotches. The  local herbalist won't go near her, says it's plague. You have heard of a cleric in the  next city who is a talented healer, the herbalist says to go and find him, but you have to hurry!"

A fairly interesting side quest. Puts the thief in jeopardy, but if all goes well it will be ok to get the game back on track the next time the thief's player shows up. Make the getting of the priest the easy part. I wouldn't want to kill the thief when the player is not even at the game. Make everything around that objective complicated or at least make the trip a good opportunity to gather information  about, somehow advance the  main quest, or even new subquests. Another thing to think about. Once that thief is healed the party is going to owe some church a big favor.

Skaven (ratmen whatever your game calls em) are just big rats, they can carry disease to. They are also smart enough to weaponise this fact. Ratment go from  orc substitutes to another kind of threat altogether.

I think that's enough words about diseases  today.

Thank you for reading.

-Mark.

*The  record was broken by strongman / actor / competitive weightlifter Hafþór Júlíus Björnsson, he took 5 steps with the same  weight log and  his back  did not implode.

** When talking role playing games in this  article, in this context, I'm talking about  old school style sword and sorcery games.

*** Black Death

**** Cholera (this is a DOC, it will download.)

***** Smallpox 2 3

Intestinal Parasites 1 2

communicable diseases of public interest.

CDC used for  disease information.

^ http://www.emedicinehealth.com/smallpox/page2_em.htm

Plague art

In this article I referenced examples copied directly from texts of the various incarnations  of D&D, AD&D and so on. These examples are used editorially, No copyright violation is intended.