This past week, by virtue of some unusual free time and an inconvenient unavailability of the people I would normally spend it with, I've been spending some time playing Civilization V. I have a mixed relationship with Civ V, because its predecessor, Civ IV, is among my favourite video games of all time, and I can't help but compare them. I liked some of the changes they made in Civ V, and I disliked others, but there's one change that I find particularly interesting: the in-game effect of hospitals and health care.

In Civ IV, each city that you control has a separate measure of its health and happiness. As a city grows or as polluting buildings are added, its sickness score grows, and the player has to find ways to ensure that its health score grows at least as fast, if not faster. If sickness becomes greater than health, the city becomes sick and productivity drops sharply. A sick populace is slower to produce whatever you're trying to build and its food production becomes poorer. Early in its sickness, though, a city may still keep growing, with each increase in its population just making the city sicker and sicker. Eventually, the bloated and festering population can no longer support itself and citizens begin starving to death, which causes the population to drop back down. Buildings like hospitals and aqueducts add health points, which allows players to stay ahead of their sickness points; they don't necessarily reduce illness per se, but they do increase a city's capacity to tolerate illness without it interfering in productivity. This is a very realistic depiction of sickness in a society. As the population becomes more unhealthy, their ability to work and produce drops, but a city can become terribly ill and dysfunctional before the horrific over-crowding and insalubrious conditions actually lead to the population declining faster than it can grow. This is exactly the sort of pattern that we can see in many third-world metropolises, to say nothing of the poorer areas of many North American cities.

Civ V works a little bit differently. In Civ V, there's no sickness score and cities can't become overcome by ill health. Instead, a city's health is measured solely by the capacity of its population to continue expanding. To grow, a city requires that its food supply constantly be larger than the needs of its people; we can assume that the "food" resource in the game represents everything people need to live, such as medicines and housing and such. If a city doesn't have enough food, it can't grow any larger, and therefore can't become more powerful or more productive. Buildings like the hospital contribute additional food to the city, which enables it to grow faster and grow larger. Obviously, a hospital doesn't directly increase the in-game food supply, but we can imagine that as the citizens' overall health improves, the food that they have goes a longer way or becomes more nutritious, and furthermore, citizens who would otherwise have died live longer, so that the population grows faster than it declines.

What's interesting about this is that in both Civ IV and Civ V, the health of your population is represented in a very realistic way, but each do it in an entirely different way. In one game, health is measured by a population's ability to keep ahead of sickness, and in the other, it's measured by the population's ability to grow beyond its current size. In essence, both of these depict the exact same thing: when the health of a city is better, more people are born than die, so there are more people, so there can be more workers, so that the city can produce more goods and money. Without buildings that produce health, the population can't grow or produce; the fact that one game represents this by showing people get sick while the other depicts it by directly slowing down expansion is purely stylistic. Both games get it right, but do so in a very different manner, which just goes to show the eternal truth that there's rarely only one way to look at a situation.

When you get right down to it, in both gaming and real life, on a population level, "health" is really a measure of a population's ability to grow beyond its current size, or for the existing population to be able to work better, with fewer days off due to illness. This is a fairly cold way to look at health and suffering, but games like the Civilization series... to say nothing of real-life governments and policy-makers... tend to focus on the large scale, where an individual's suffering can't be measured and where the population's en-masse functioning is the only visible outcome measure. Is this is good way to conceptualize sickness? It may not be empathic, but it's certainly realistic and it does reflect precisely how health effects the world on a large scale.

On a totally unrelated note, I always thought that the plural of "metropolis" was metropoli," but apparently it really is "metropolises." Isn't it nice to be able to learn something new every day?

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 August 25, 2013. 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.