The Red Box Blog

Ramblings about D&D.

Diseases in D&D

Gestalt Gamer over at More Than Dice has a very excellent article about how to make diseases more potent in a campaign. But the thing that stuck with the most after reading his article was this line:

Never once have I played or DMed a game in which a character contracted a cold, a chronic illness, or suffered from a disease that couldn’t easily be removed with magic.

This, really got me thinking about disease in gaming, and in particular the lack of it.

The Real Medieval World Was Dominated By Disease

In the real world, medieval times was absolutely horrific with regards to disease. The average lifespan was just 30 largely because of disease being everywhere.

Poor sanitation hugely contributed to the spread of disease and a total lack of understanding of the nature of disease made most conditions incurable. Moreover, poor nutrition contributed to common diseases such as the flu having a much higher fatality rate than they do today.

Now, how much one wants his campaign to resemble the real world is a matter of taste. At the moment I am quite happy to have a game world that is clean, and as such disease is never more than the plot of a single adventure, not an issue that permeates the lives of every living thing in the world.

But what if you wanted a world with the feel of medieval times? What if you wanted disease to be a thing of mystery and a constant threat?

Make the Players Ignorant

I think the first thing you need to do is nullify the knowledge that players bring with them to the table. We live in a day and age where diseases aren’t really feared because we understand them too well. So you need to take that understanding away. The only way to do that is to change the underlying way that diseases work.

Forget about bacteria and viruses. Forget about malnutrition and cancer. A fantasy world needs a fantastic method for diseases. Either invent one of your own, or do some research on what people at the time thought caused diseases. One theory in Europe which could very easily translate into game play was Humorism.

The four fluids of Humorism.

Make Disease Omnipresent

Then, having taken away players knowledge, they need to be beat over the head with the idea that people are always sick and dying in this world. They need to see illness everywhere they go, and they need to see that people are both terrified by illness and unable to escape it.

As Gestalt Gamer points out, magical healing of diseases needs to be severely limited, either in availability or effectiveness. This could take the form of restricting spells, restricting the pool of casters, or just making Remove Disease and the like only affect conditions like Mummy Rot.

Finally, there needs to be a real chance each and every week that PCs will get ill. What that chance is and how ill a character might get would depend largely on how much of a focus you are wanting disease to be. But if you start every session with “OK everyone, time to see how sick you are.” players will come to really fear disease.

Disease Makes For a Gritty Campaign

I think introducing disease on this level makes for a far grittier campaign than I think my current group would like, so for now I am going to pass. But I could see great potential for this given the right players and atmosphere.

Have an opinion about this article? I love comments. Please feel welcome to leave your thoughts.


January 3, 2011 - Posted by | Dungeons and Dragons, RPGs | , , ,


  1. Well, if everyone is sick all the time, it dosen’t matter how much magical healing is available because at that point its self limiting. Plus, nobody knows when the case of the sniffle or sneezes is going to turn into the black plague, so everything is potentially serious. I think at least in a 3e standpoint this naturally limits what even magical healing can do. To treat more, you need to go oldschool herbal.

    If you really wanted to step it up from there in addition to what you describe.. every open wound has a change of getting infected. The larger ones are have a higher chance, and worse cases of it…

    Comment by Grey | January 3, 2011 | Reply

    • With regards to society as a whole there definitely aren’t enough clerics to keep back a plague. My line of thought though was that using traditional rules players can basically stop fearing disease once they have a cleric in the party who can cure them.

      And nice idea with the infections.

      Comment by The Red DM | January 3, 2011 | Reply

  2. Disease really shouldn’t be as overlooked as it is currently. I think that Pathfinder makes an interesting commentary on disease in the Curse of the Crimson Throne adventures (specifically #8). The disease spread isn’t hard to cure, but it spreads far faster than any cleric could possibly hope to cure it. The same should apply to 4E. Beyond that, the cost of a Cure Disease ritual is 360gp (market price). Even if a cleric were to do so for free, it still costs 150gp just for the component materials. I don’t know how many 1st level PCs have that sort of money kicking around, let alone the NPC populace of any given town. Disease should still kill people, but it doesn’t in the droves that it should do to our own lack of interest in participating in a setting of that sort.

    Comment by Jess | January 3, 2011 | Reply

  3. Interesting idea. Ich just wanted to add: My character did once catch a cold. It was the first session of Wheel of Time d20, level 1. We were hired to hunt down a hand full of trollocs and it was pretty cold but my character was to poor to afford a set of cold weather clothes (10 GP I think), because I did spent all starting money I had and we had to buy the cold weather stuff ingame. So I spent some evenings at the campfire freezing and coughing and lost 50% of my hp due to the cold. And there was no magic to cure it. That was terrible.

    Comment by TheClone | January 5, 2011 | Reply

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