Mange, Morphine, and Deadly Disease: Medicine and Public Health in Red Dead Redemption 2

Spoiler warning: This essay discusses major plot points about the ending of Red Dead Redemption 2.

It’s dead midnight, there’s moonlight on the corn, and Thomas Downes owes me money. He protests he doesn’t have anything to spare, but I insist he does, and so we end up wrestling against the wood fence. Then, bruised and bloody, Thomas coughs directly in my face.

Back in the real world, where I’m a historian of all things dark and morbid in the nineteenth century, I recoil from the television. “Oh, no,” I mutter as my character, Arthur Morgan, flinches at the fresh phlegm splattered on his eyes, nose, and mouth. He wipes it off and keeps shaking down Thomas, but I’m frozen, staring at the screen. “That’s not good.”

For the uninitiated, Red Dead Redemption 2 takes place in 1899 in an imaginary region of the American frontier, where you play as Arthur Morgan, a lonely gunslinger in the Van der Linde gang. Red Dead Redemption 2 is an open-world video game, which means that, while there is an important story to be told, you can take Arthur Morgan across the map at your own pleasure and speed.

Most video games tend to be ambivalent about historical accuracy, partially so players do not have to confront the horrors of earlier time periods. Yet the designers of Red Dead Redemption 2 dedicated themselves to presenting players with an experience closer to reality than fiction. For example, leading video game critics lauded the realistic horse testicle physics.

Man in a cowboy hat sits astride a red and white horse, in a field.
Still from Red Dead Redemption. (Flickr)

Similarly, the National Audubon Society positively reviewed the game, noting how accurately it portrayed the “decline of bird populations, habitat loss, and environmental degradation.” Historians have also complimented Red Dead Redemption 2 for its accurate historical interpretation of slavery and Jim Crow segregation.

The game designers wanted to portray Arthur Morgan as a man trapped in the Wild West, naturally including terrifying adventures in the worlds of late nineteenth-century medicine and public health. Red Dead Redemption 2 incentivizes players to eat, sleep, shave, and bathe. However, the game does not concern itself with an essential issue of public health: waste contaminating bodies of water and spreading disease. While horses defecate at alarmingly frequent intervals, no other animals seem to do so in the game, including humans, leaving out a key feature of sickness and health in the West.

Ultimately, much of Red Dead Redemption 2 is about surviving relentless violence. As Arthur, you are the frequent arbiter of such violence, but you are often the recipient of it, too. As a member of the Van der Linde gang, Arthur Morgan attacks and defends himself against robbers, backwoods cannibals, bounty hunters, and enemy gangs.

Still from Red Dead Redemption II promo. (BagoGames/Flickr|CC BY 2.0)

Like most video games, Red Dead Redemption 2 includes healing: eating food, drinking certain items, or ingesting medicine will repair Arthur’s physical health. In this regard, Red Dead Redemption 2 aligns well with the history of the U.S. West: most folks on the mid-to-late nineteenth-century frontier utilized homeopathic medicine and home-crafted herbal medicine to solve a wide variety of ailments.

The rise of patent medicine at the turn of the twentieth century invades the game to some extent, as Arthur can both make his own medicine and buy similar products when he heads into town. The game admits that not everything is made equal: Kentucky Bourbon, cigarettes, moonshine, cocaine gum, and chewing tobacco may benefit Arthur in some ways but damage him in others. Notably, Red Dead Redemption 2 rarely includes opium or morphine, except for a few fleeting references, perhaps to avoid popularizing drug (ab)use during the current opioid crisis.

Red Dead Redemption 2 centers on one particular public health crisis: pulmonary tuberculosis. Also known as TB or consumption, tuberculosis is an infectious disease spread by transferring bacteria-ridden phlegm. Over a million people still die annually of tuberculosis today. In the nineteenth and twentieth centuries, the disease spread across the globe, affecting families, communities, and entire countries.

In the case of Arthur Morgan, the man that gives him tuberculosis is Thomas Downes, who he shakes down for money. By the time Arthur is showing the classic symptoms of tuberculosis — coughing up blood, high fever, weight loss, physical weakness — you’re late in the game’s plotline, but the screen doesn’t gently fade to black. Instead, Arthur collapses in the New Orleans-styled city of Saint Denis, coughing violently. After being brought to the city’s only physician, the doctor diagnoses him with tuberculosis, injects him with morphine, and says there’s nothing more to be done.

Man suffering from pulmonary tuberculosis with the swelling of the lymph nodes on the neck known as scrofula which was a term formerly used to denote tuberculosis. (Illustration from Kranken-Physiognomik / by von K. H. Baumgärtner / Wellcome Library)

From this point forward in the game, you watch Arthur deteriorate: it’s the slow, gruesome tragedy of tuberculosis that the modern world still finds so appalling. Just like the historic reality of the American frontier, Arthur cannot be cured. Upon the game’s release, the Internet filled with panicked requests of “how do I cure Arthur??,” but his tuberculosis is an inevitable and integral part of the game. Like the thousands who struggled with the disease in the nineteenth century, Arthur has been handed a death sentence.

But Red Dead Redemption 2 lives up to its title: even as Arthur grows progressively weaker, coughing up blood, voice turning raspy and weak, he tries to be a better man. Ultimately, the game designers employ historic medicine and public health in the same fashion. If you as the player want to intervene on any number of medical and public health crises, the game will certainly allow you to do so.

There are mange-infested dogs that you can pet, although you can’t cure them of the disease. There are sickly, scab-covered horses in the countryside that you feed sugar cubes and ride across the world, even if you can never repair their ruined coat. There are countless men and women who are bitten by snakes, trapped under fallen horses and trees, caught in bear traps, or attacked by cougars and wolves and bears.

Red Dead Redemption 2 does something mystifyingly realistic in these random encounters: it allows the same choice and humanity that existed in the late nineteenth-century frontier. While many did not stop to help a stranger in the tumultuous 1890s U.S. West, others intervened with a helping hand, a homeopathic cure, or a sip of moonshine.

There’s one moment in the game where you encounter a frantic, bleeding man by Saint Denis who asks for a ride into the city. If you choose to be honorable, Arthur brings him to the same doctor who will later diagnosis him with tuberculosis. The physician assesses the injury and announces he’ll need to amputate the injured arm. He pulls out a bonesaw, saws through the limb, throws it in the trash, and waits for payment from the bloody, unconscious, now disabled man — all while Arthur watches in distant horror. It’s a good deed gone awry, but, then again, the game suggests the man would have died without your aid.

Similarly, Arthur’s TB diagnosis only occurs because an unnamed Good Samaritan brings you to the doctor in Saint Denis. Just like the amputee, you have to pay the doctor $10.00 for your diagnosis and a single shot of morphine. Red Dead Redemption 2 is unflinchingly vicious in its conception of the U.S. West on the cusp of the twentieth century, but it is certainly not so detached from historical reality to be called completely fictional.

American Frontier Life. (Arthur Fitzwilliam Tait/Wikimedia Commons)

Undeniably, there was no redemptive justice to be found in nineteenth-century medicine and public health. Red Dead Redemption 2 thrives in the brutality and tragedy of the time period. While the game blurs reality for convenience’s sake so we can follow Arthur Morgan through a fictionalized but fading American frontier, there is still a harsh truth to the world. Red Dead Redemption 2 operates in the macabre but theatrical shadow spaces of the nineteenth century, where most medicine was homemade, surgery was done fast for cash, and public health disasters could kill mangy mutts and main characters alike.

After learning that he would soon die from tuberculosis, I watched Arthur mount his horse, my mind in a daze. He looked out of place in the big city: a huge alligator pelt was tied up on the back of his mustang, dead blue herons and jack rabbits dangling from his saddle. He wandered out of Saint Denis, leaving behind the cosmopolitan residents snidely side-eyeing him for being a rugged, ragged cowboy at the turn of the twentieth century.

Only when Arthur looked up through the dense fog rising off the swamp to stare forlornly at the moon did I sense the finality of his fate: he really couldn’t avoid what was waiting for him. But, instead of falling into mourning, I squared my shoulders and muttered to myself in the real world, “Alright, Arthur, let’s live a little while longer,” and urged him forward towards redemption.

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