Because I write this weekly column, I'm constantly looking for situations in which modern medical science can teach us something about how history worked and, as a result, the way that things might work in a medieval fantasy setting. Living as I do in one of North America's biggest and most cosmopolitan cities, I don't have much exposure to many of the major medical problems of the medieval era, but fortunately, the world of medical literature is a lot broader than my personal experience. When I'm looking for an idea of what to write about, I'll open up one of the major medical databases and just start typing unusual keywords until I find an article which gives me an idea, and that's precisely how I discovered this week's topic.

Let's talk about some of the ways you can get sick on a pilgrimage.

Pilgrimage was a big deal for much of human history. Not that long ago, when the journey of a few hundred kilometers was an ordeal as opposed to a day trip, it wasn't uncommon for religious people to risk life and limb traveling across country to a holy site. As one might imagine, there were countless ways to die on such a pilgrimage, but that's okay, because in many cultures, dying on pilgrimage was just evidence of how dedicated you were to your faith. In much of the Western world, the pilgrimage is no longer a very big deal, not because people have stopped going to holy sites -- although my understanding is that these days, Disney World sees rather more pilgrims than most sites of saintly doings -- but because the travel is easy and the rest facilities are plentiful. Of course, there's still one well-known pilgrimage in the world today: the Hajj to Mecca, which is undertaken by millions of Muslims each year (according to Wikipedia, the 2012 Hajj saw more than 3 million people). As is often the case with holy activities in the modern era, there's an entire tourist industry that's sprung up around it, so it's difficult to say that the modern Hajj is the same as it was in, say, the tenth century. Still, the Hajj stands as an example of what happens when a ridiculous number of people, many of whom are in ill health, try to travel ten miles on foot across inhospitable terrain. Research teams from across the world study the Hajj each year, because it's an amazing example of the health risks that come from packing too many people into a tiny space and then inserting a few environmental hazards (here's a hint: the effect is known as an "amplifying chamber for disease"). The last good review article on this topic came out in 2011, but as this article was in Dutch, I went to the most authoritative article prior to that, which was published by a combined team of American and Saudi physicians in 2006 in The Lancet, one of the world's premiere medical journals. For those who want to read the original article, it's Ahmed et al, Health risks at the Hajj, Lancet, 25;367:1008-15.

First off, there's infectious disease. In a medieval fantasy setting, this is likely the biggest danger for many, simply because most storytellers don't force players to keep track of how much water the characters are carrying. Mecca has seen a number of deadly outbreaks of diseases such as meningitis and the flu (in the Hajj of 2003, it's estimated that twenty four thousand people became infected by the flu; I couldn't find any data on how many actually died). The region sees a cholera outbreak every few years, which is a dangerous proposition in a region where dehydration is already a major risk. These bacterial and viral infections can spread like wildfire due to crowded conditions and poor sanitation. The problem got so bad that for many years, the Saudi government required all tourists at Hajj season to be vaccinated against the common offenders; when this requirement was lifted in 1999, they saw a major meningitis outbreak the following year. In 1994, tuberculosis was a major problem, and a large number of patients admitted to Saudi hospitals for respiratory problems were found to be infected; data collected since then has shown that Mecca has higher rates of treatment-resistant TB than the rest of the region because travelers from other parts of the world bring their local strains with them when they come.

Skin problems are one that won't necessarily occur to people. Many pilgrims walk the Hajj barefoot, which we can presume is doubly true in an era without mass-produced footwear. On top of the harm that can be caused by simple walking, the authors of this paper point out that people present to hospitals with severe burns from walking on scorching-hot marble and stone. Reportedly, this was enough of a problem that special, non-heat-absorbing marble had to be installed in Mecca.

Here's one that wouldn't have occurred to me: the spread of blood-borne infections due to shaving. Part of the Hajj involves shaving one's head. Saudi law mandates that local barbers must be tested negative for several diseases, but roadside "unlicensed" barbers are apparently a public health concern. A small number of such shady characters have been shown to carry infectious diseases such as hepatitis, but no data exists on whether they have spread it.

The most common cause of death at the modern Hajj is reported to be cardiovascular disease. This is probably actually much less of a problem in a medieval setting, but certainly wouldn't be non-existent.

Another major cause of death is trauma, but according to modern data, much of this is related to traffic accidents and probably doesn't carry over to a fantasy setting. Then again, it doesn't take much imagination to consider what a runaway chariot can do to people in a crowded street. Stampedes (of humans) have been recorded every three or four years, killing as few as 14 or as many as 1400.

Heat and dehydration kill some every year. In a game world, not every pilgrimage will take place in the desert, nor in the summer, but in the case of the Hajj specifically, temperatures can exceed 45 degrees Celsius, and rise above 30 degrees even in winter. It's easy to imagine how this interacts with the press of crowds and the confined spaces.

This article, written by modern physicians, doesn't discuss such things as animal attacks, snakebites, and banditry. I couldn't find any good, reliable numbers on this from the less civilized eras of history, but they were certainly recorded problems for pilgrims in other parts of the world.

All of this applies to a lot more than just pilgrimage, of course. Personally, I feel that any holy site that's more than half an hour or so away probably isn't worth the trouble, but I vividly remember sustaining a moderately severe knee injury one year while making a pilgrimage of sorts, from my hotel room in London to 221B Baker Street. Our characters spend a lot of time walking along some very unsafe roads, and all of this just goes to show some of the things that can happen as a result. 

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 16, 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.