Pathologic and the Morality of Illness

Early on in Ice-Pick Lodge’s 2019 release Pathologic 2, your character, Artemy Burakh, dreams of his childhood home by a pair of railroad tracks. In each room of the house, there’s a crowd of familiar-looking people, but they each blink out of existence, replaced by black-suited, white-masked Tragedians, frozen in space and time as if they were never able to move.

In the back room, there’s a tall man, unmoving and expressionless, bathed in a red light you can’t see from the windows outside. You can do nothing but close the door again.

Lying in your childhood bed, there’s a young, dehydrated, fever-stricken girl — a plague victim, but one who can still be saved. You draw water from the barrel outside, and return to see the door to the back room hanging open and the man in the red light gone.

Where he stood, there’s only a coffin.

In the hall outside the girl’s sickbed, you pass the Bachelor and the Changeling, the other two protagonists of the first Pathologic. They shout at each other in pantomime before vanishing and becoming themselves Tragedians.

In your childhood room, a cloaked, bird-masked Executor stands by the girl’s bedside — an orderly, maybe, or the left figure in Death and Life. He towers over you, blocking the way to your patient, until she’s taken from you by the abrupt end of the dream.

Pathologic 2

What Blood Is

Hemophilia is an incurable condition that impairs the body’s ability to form blood clots. It’s usually hereditary, although it can also be acquired. When a hemophiliac starts bleeding, externally or internally, the normal clotting mechanism isn’t there to stop it. Hitting a joint can cause it to bruise and swell, and a blow to the head can cause a brain hemorrhage.

Hemophiliacs are missing one of two proteins usually present in blood — factor IX, in the case of hemophilia B, and factor VIII in the case of hemophilia A. The treatment for hemophilia, then, is to inject patients with the protein their blood lacks. Factor IX and factor VIII have been widely available in manufactured forms since 1992, but, before then, they could only be derived from human plasma.

I still remember waiting in a YMCA gymnasium while my aunt gave blood, a few days after 9/11. I think this stuck in my memory because it’s the first time I really understood what blood is, as an object: it’s communal tissue. A part of my body, but a part that can be donated, modified, and shared.

In the first Pathologic, two of the protagonists see blood as the origin of the series’ Sand Plague. At one point, Daniil Danovsky, a Bachelor of medicine foreign to the Steppe town, imagines the Plague as a deposit of blood from slaughtered bulls, festering deep in the ground. In another playthrough, the surgeon Artemy Burakh, a Steppe native, comes to know the Plague as the effect of a wound in the earth, inflicted by the sharp point of a deep, artificial structure. In the symbolist world of the games, blood might contaminate the Steppe town, or the town itself might bleed like a hemophiliac.

Before 1985, there was no test for HIV. Factor VIII, like other plasma derivatives, was considered relatively safe. It was filtered and heat-treated to prevent transmission of bacteria and protozoa, but, per Randy Shilts’ And the Band Played On, the filtration process didn’t account for viruses. At the time, Shilts notes, hemophiliacs had a high incidence of Hepatitis B and C, which are bloodborne.

According to Shilts, the earliest presumptive case of AIDS in a hemophiliac was an anonymous man in Miami, who died of Pneumocystis pneumonia “in the first days of 1982.” The face of this phenomenon, though, was Ryan White, a teenager who was diagnosed in 1984. He was neither gay, nor an injection drug user, and — along with Rock Hudson — became one of many reasons the U.S. could no longer ignore AIDS.

The Reagan administration was infamously slow to respond to the AIDS epidemic, because it primarily affected homosexual men and injection drug users. To the then-ascendent Evangelical right, AIDS was a perfect moral plague. In Reagan’s own words, education on AIDS prevention could not be considered “value neutral.”

Morals aside, HIV lives in blood, and blood is communal tissue. It marries the fates of gay men and the adolescent children of straight couples, and if the powers that be fail one of these groups, they inevitably fail the other. All of our fates are tied together, and if we let it, a Plague will take us all, leaving nothing behind but coffins and fighting Tragedians.

Pathologic 2

Who May Live

In the first Pathologic, as Bachelor of Medicine Daniil Danovsky, you’re hobbled by something like bureaucracy. The first few ingame days outline what Harry Brewis calls “a pain simulator.” In the Bachelor’s playthrough, Pathologic lives on the subversion of heroic instincts, and Danovsky spends the game trying to save a town that, seemingly, doesn’t want to be saved.

I say Danovsky’s challenges are almost bureaucratic because they have an immovable quality, but they’re still unpredictable. After the death of the local doctor Isidor Burakh, the Steppe Town doesn’t have a central figure for guidance during a Plague. What’s left is a loose coalition of town leaders, each with their own ulterior motives. The impossible task of convincing them to work together falls to the Bachelor.

In the essay Necropolitics, Cameroonian political theorist Achille Mbembe describes a politics built on death. “This essay assumes,” he writes, “that the ultimate expression of sovereignty resides, to a large degree, in the power and capacity to decide who may live and who must die.” The power of a state, then, lies in its ability not just to kill its own citizens, but to expose them to death, even as it allows others to live.

I’m not the first person to tie Necropolitics to the coronavirus pandemic. Indeed, governmental responses to the ever-rising number of cases and deaths might seem like the most naked, universal manifestation of Mbembe’s theory in the West. In the U.S., for the first time this century, necropolitics are being exercised essentially without sleight of hand. This disease doesn’t limit itself to drug users, or to hemophiliacs, or to queers. Everyone is at risk for COVID-19, and if we’re all at risk, then our government’s inaction exposes us all to death.

Pathologic 2

In America, the troubling side of this is that it’s not only those in power who are exposing us to death. Our system of government is deeply flawed, but it is representative. Although it’s common to blame the botched coronavirus response on the Trump administration, our medical and public health infrastructure have been rotting since long before 2016. There is a reason for our inadequate supply of ventilators: it’s economic, it’s social, and it goes back decades.

The chaos wrought by the federal government’s belated pandemic response, then, is almost a self-inflicted paradigm. It’s imposed on us by the Trump administration and the Republican-controlled senate, but they’re both, in part, manifestations of our national psyche. As a nation, our value system seemingly doesn’t allow for a pandemic that isn’t a moral plague. But if everyone is at risk, anyone who can’t pay for treatment becomes a sinner.

In Necropolitics, Mbembe writes this: “Referring to both this ever-presence and the phantomlike world of race in general, [political theorist Hannah] Arendt locates their roots in the shattering experience of otherness and suggests that the politics of race is ultimately linked to the politics of death.” When a state exposes its population to death, typically, the most vulnerable are the most likely to die.

As the Bachelor’s run goes on, I’m fascinated at how many of his ideals he abandons out of what seems like necessity. In the beginning, he’s brought to the Town by a desire to overcome death itself — that’s what he had hoped to learn from Isidor Burakh. As the story goes on, though, he’s reduced to merely postponing death — for the townspeople, then only for the country beyond the town, and, eventually, only for himself and his immediate circle. According to the Pathologic wiki, the game’s design documents say that Danovsky is “so engrossed in his noble battle against death that he forgets to value the lives of those near him.” 

This is best illustrated by his final plan to save the world from the Town. While Artemy Burakh aims to create a panacea, Danovsky wants to create a vaccine. He wants to inoculate the healthy and allow the military to level the town with cannons, killing and burning the entire sick population. Even at its most successful, Danovsky’s is a bicuspid, necropolitical response: the world beyond the Steppe Town might be safe, but the victims of the Plague are left behind, exposed to death.

This unequal response is paralleled in Donald Trump’s now infamous rationale for denying the cruise ship Grand Princess entry into the U.S.: “I like the numbers being where they are.” To Trump and Danovsky, a solution for all matters less than a solution for a powerful few. And although this can seem expedient, we return to the idea that a group is only as healthy as its most sick member — in the Bachelor’s ending, even the survivors of are made more vulnerable by the deaths of the victims. In some playthroughs, this is further driven home by the revelation that the world beyond the town doesn’t need to be saved, and, in fact, it may not even exist at all.

In the end, anything the Bachelor can do is worse than useless.

This is foreshadowed in the game’s first act, when Danovsky succeeds in instituting a quarantine. In doing so, he limits the spread of the Sand Plague to the Steppe town. Afterward, in the train yard, as he tries to board a train home, he’s stopped by a group of men. His own preventive measures have trapped him. Among the men, there’s a single, silent, black-robed, bird-masked Executor, like the one at the girl’s bedside in the Haruspex’s dream.

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Pathologic 2

Bound to a Stage

Both of the Pathologic games style themselves as performances of a single play, and this might be the most comprehensible part of their presentation. Characters speak in winding, tangled prose, and their cryptic lessons are delivered by costumed Executors and pantomiming Tragedians, illuminated and accentuated in harsh red. In the second game, as the Haruspex, you meet your childhood friend as an adult, and his shadow has, itself, become a Tragedian. He opens a safe in his hideout, and his shadow bows to you, motionless, as ever, and gesturing extravagantly at its contents.

The second game begins at the conclusion of the first, in a prologue called “Day 12: In which the Haruspex ends with a semicolon.” Pathologic’s story, then, isn’t written in stone. It’s a loosely scripted stage play — something meant to be rehearsed, reinterpreted, and performed again, changing with each repetition.

I don’t think it’s perverse to play Pathologic right now. Despite the darkness of its content and its themes, the game isn’t about despair. It’s about pain, but it frames that pain as a learning experience — for everything you get wrong in Pathologic, there’s a chance to get something right.

At time of writing, Dr. Anthony Fauci is a central figure in the U.S. COVID-19 response. That said, he’s served as the head of the National Institute of Allergy and Infectious Diseases since 1984, and he’s overseen various public health interventions, starting with the American AIDS epidemic. He isn’t profiled in And the Band Played On in any great detail — Shilts mentions him, but largely in passing, and largely to criticize a 1983 editorial Fauci penned for the Journal of the American Medical Association.

This criticism didn’t begin or end with Shilts, either. ACT UP founder Larry Kramer famously dragged Fauci in an open letter, accusing him of murder, comparing him to Adolf Eichmann and calling him “an incompetent idiot” (to this, according to the New York Times, Fauci said, “Wow, that gets my attention.”)

After the release of Shilts’ book in 1987, though, Fauci became an increasingly prominent figure in the fight against AIDS. After Kramer was diagnosed with HIV and hepatitis B, Fauci (again, according to the Times) became directly involved with his medical care, going so far as to get him a place in an experimental treatment program. Unlike most of Shilts’ sources (and Shilts himself), Kramer is alive today.

I can’t directly compare Fauci to a single character in the Pathologic series, but I see this story as a real-world analogue to its only real victory mechanic. In the first Pathologic, each playable character has a list of NPCs called their Bound. Each ingame day, the only real, material objective is to save one of your Bound from contracting to the Plague — and the more of your Bound you save, the more likely you are to get a good ending.

It’s mutual aid condensed into a game mechanic. In Pathologic, the key to winning is helping the people closest to you, and letting them help you in return. And in a pandemic, there’s essentially nothing else you can do.

At time of writing, I’m recovering from a presumptive case of COVID-19 — although I spent two weeks in self-isolation, I was never able to get tested. My family has a long history of autoimmune disorders, and they usually worsen with age. In a way, I’m very lucky that I caught this disease as a young adult. At 23, my COVID symptoms were already relatively severe, but at 33, I might have struggled to survive.

I’ve thought a lot about my older relatives, too, most of whom are at much greater risk than I am. Three days before my fever shot up to 103, my dad called and offered a ride to the rural town where he lives with my mom, so I could ride out the pandemic with more access to nature. I turned him down — I have plants to water and a cat to feed — but I can’t help but realize that if I took him up, I would have infected both of my parents with the virus.

For me, the coronavirus pandemic has thrown a lot into sharp relief, but I think this is the most important realization: even small actions can hurt or save the people close to us. This thought is as comforting as it is terrifying — but, like in Pathologic, for every chance we have to get it wrong, there’s another chance to get it right.

This play is unfinished. And when the curtain falls, we might all be saved.