Eric Lis

June of 2014 was an interesting time for anyone who wanted to see how the world reacts to the outbreak of a new disease. Let's talk about Middle East respiratory syndrome and how it can inform how we run our games.

MERS is a syndrome, meaning that as opposed to being a discrete disease, it is a collection of symptoms which commonly occur together in a predictable way. In the case of MERS, the syndrome is a respiratory illness which is believed to be due to a virus known as MERS-coronavirus (or MERS-CoV). MERS is a fairly newly known disease, having been "discovered" only in 2012, although efforts to identify the virus go back to around 2010 or earlier. A handful of cases were reported early on, many of which ended in fatalities despite optimal medical care. The disease didn't make big news in the West for two years because, and there's no gentle way to put this, Westerners often don't really care what happens elsewhere. In early 2014, however, a few cases were identified in Southeast Asia, probably due to someone who had gone to work in the Middle East and returned home infected. In the months since, hundreds of new cases have been reported, mostly in Saudi Arabia. In May, the first confirmed cases were reported in the US, and cases have since appeared in Europe. Hospitals and health care networks have been taking more notice, and the hospital where I work here in Canada has issued guidelines for what to do if a case is suspected, although none have yet been seen.

MERS manifests as several symptoms, which can range from nearly asymptomatic to potentially deadly. Sufferers experience several days of fever and cough, with build-up of mucus in the chest that can cause shortness of breath. As with many viral infection, muscle-pain can occur anywhere in the body. Gastrointestinal symptoms are seen in about one in every five people. What makes the disease scary is how quickly it can become life-threatening; approximately 70% of people who develop the disease end up requiring a ventilator at some point, and when death occurs, it's typically as a result of pneumonia leading to respiratory failure, sometimes complicated by kidney failure. We lack reliable data to estimate how deadly the disease really is, but as of June 26th, about 1 in 3 people (286 of the known 820 cases) have died of the illness. This is probably an overestimate of the lethality because many infected people presumably don't become sick enough to get diagnosed.

The disease seems to have a very limited capacity to spread from human to human. Even within the same household or section of a hospital, the disease doesn't spread easily. Viral particles are probably spread by aerosolization when people cough, and a face mask and careful hand-washing seem to be very protective. In gaming terms, the disease might also have a relatively low save DC. In other words, MERS is not the sort of illness that's likely to become a wildfire plague that ravages a nation. That said, two animals seem to play an important role for MERS and probably account for some of its spread. First, the virus has been shown to be carried by the Egyptian tomb bat, which is actually an otherwise completely harmless (and in my opinion, quite cute) insect-eating bat native to certain parts of Africa but whose name will immediately capture the imaginations of every player in your group. Second, the virus seems to be carried by camels. Camels in regions with the illness have been shown to carry the exact strains of virus that have been found in sick humans. It isn't yet clear how the virus spreads from camels to humans, but given the importance of the camel and its byproducts in many regions, and more so in any Arabic-theme fantasy setting, this is a significant fact.

Although some medical treatments seem to be effective in helping people with MERS, these treatments are based on fairly advanced technology which probably can't be replicated in a fantasy setting. Presumably the disease would respond well to magical healing, but understandably, there's no real-world data to prove or disprove that.

To simplify all that, here's the brief sketch of how it might look in-game if a character develops MERS. A character passes through a region experiencing an outbreak, and comes within 5-10 feet of a coughing humanoid, or inhales a cloud of bat guano while raiding a dungeon, or, I don't know, possibly gets spit on by a camel or something. The character rolls and fails a Fortitude save (we don't know enough about MERS to estimate a save DC, so use what you feel is appropriate) and becomes infected. 2d6 days later, the infected character makes a second save, and if this one fails,  the character falls ill. Depending on how nasty the storyteller feels, the symptomatic character may become Fatigued, Sickened or even Staggered, but most probably don't go so far as to become Nauseated or Helpless. If the character has access to magical healing, then a single Remove Disease spell is completely curative. Otherwise, probably about half of infected humanoids will go on to develop pneumonia and, given that most fantasy settings don't have advanced ventilators or interferon-based therapies, many of them will die. If a character recovers without magic, then 24 hours after the last symptoms disappear, the character is no longer infectious.

A disease like this leaves ample storytelling opportunities. A slow but deadly illness gives a storyteller ample time to let a group of adventurers feel mounting dread, or go on a quest for a cure. A disease that starts in one part of the world might become a convenient tool for nationalist or racist causes; a church might praise the gods for sending a disease that seems to target their enemies, right up until the moment their own members start dying. Or, given the disease's fairly lengthy incubation time, a group of PCs might find themselves the inadvertent cause of an outbreak after the dredge a lost-lost virus out of some catacomb or another and spread it to two or three towns, putting them in the position of having to fix their mess. 

More than four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on June 29, 2014. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system