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Pox and the City: Designing a Social History Game

Pox and the City is a role playing game prototype that explores narrative and game play strategies in order to focus on the social history of smallpox vaccination.


"History, real solemn history, I cannot be interested in... I read it a little as a duty; but it tells me nothing that does not either vex or weary me. The quarrels of popes and kings, with wars and pestilences in every page; the men all so good for nothing, and hardly any women at all - it is very tiresome." [1]

Luckily for us, things have changed in the study of history since Jane Austen’s day. From traditional studies in political and military history to Marxist and gender focused approaches, the study of past events can be analyzed through a multitude of well-established viewpoints. History games, however, have tended to be fairly narrow in their approach towards the subject. Commercial video games, such as the Civilization series, have abstracted political, diplomatic and military histories into a system so that players can attempt to build a civilization. Focused on empire building, the Civilization games are fun and allow players to simulate the impact of issues, like that of geography, on the success of the development of technology and successful military campaigns. However, Civilization shows us nothing of social or cultural history. Indeed, games made for heritage and history applications tend to ignore these aspects of the past. Instead, game designers in this space are encouraged to: “design rulesets that present their particular version of reality …” [2] even though this requires “reducing complex phenomena to simple rulesets…[of the]… phenomena [that are] not fully understood” [2]. Rules, or game mechanics, are a core component of game play – along with narrative. Games that explore social and cultural interactions require more emphasis on the narrative components. Getting the balance right between the formal (game mechanics) and dramatic (story) elements is a tricky business for educational history games. Pox and the City [3], a social history game prototype, explores methods for achieving balance between game mechanics and narrative to emphasize complex social systems that existed for doctors in Edinburgh circa 1800. 

To download Pox and the City and view project data like educational goals and project details, visit The Journal of Interactive Humanities.

Games about Contagious Diseases: A Review

A review of current games quickly reveals that Pox and the City is not the first game to be made about vaccines or contagious diseases [4][5][6][7][8][9][10][11]. Illsville [5] is a game that teaches the history of vaccines and is available on the College of Physicians of Philadelphia’s website. The game takes players “through the historical development of a society as it fights disease and tries to develop vaccines to protect the population” [12]. Illsville briefly touches on the history of inoculation but the player has no connection to social or cultural issues. The entire game is played from a top down viewpoint in which a number of dots, representing people or doctors, move around the town. The player mainly interacts by making yes/no decisions about research or treatment (Fig. 1).

Fig. 1: Screenshots from Illsville showing the abstracted, top down viewpoint that players interact with. Educational content and agency is brought in mainly through pop-up text boxes with yes/no decisions

This type of abstracted approach is common. For example, in the board game Pox: Save the People [13], players move pieces strategically around a board to stop the spread of a deadly contagious disease. Some games, however, bring in a stronger narrative component and role playing to help connect players to the game by placing them within a fictional narrative. Caduceus [7] allows the player to select a role and play mini-game puzzles to save the people of an imaginary land, Alterica. The game narrative is not integrated into any game mechanics but instead is contained in comic type pages that act as cut scenes. In PlayingHistory: The Plague, players control a character through a town in a point and click adventure with substantial dialogue and narrative. The player clicks on non-player characters (NPCs) to talk to them and carry out activities. For example, the player is instructed to go out and find knowledge of the disease. The game relies on players conducting small tasks, like finding a character and speaking to them, for the interactivity. Educational content is in the dialogue and text boxes that appear. In all of these games discussed so far, players are put into the role of “the good guy” trying to stop the spread of the disease.  Some games  however [14] [15], invert that approach by putting the player into the role of the disease itself. In Plague Inc. for example, the player infects patient zero and then must try to wipe out the human race by constantly evolving to stay ahead of advancing medical technology.

To summarize, there are many games that focus on contagious diseases and their history. These games encompass a variety of game mechanics and use different viewpoints. However, they tend to focus on the same content or understanding of contagious diseases: that is, a generalized overview of diseases and how they spread, for example Playing History. [9] These games also focus on the medical view of the disease, on the science of it. The most popular game mechanics have modeled a simplified version of contagion in which the player must move strategically to block the spread. Pandemic: American Swine  [8] was one of the few games to actually bring in a broader, cultural component, albeit in a contemporary sense. Pandemic explores the impact on current American society by incorporating game play elements of panic, media sources, and impact on business revenues.  

The examination of contagious diseases by focusing on the disease is an effective way for exploring the subject from a medical or science viewpoint. The disease and its mechanisms can be considered in isolation so that the player may understand concepts such as the constant evolution of strains of viruses. However, there are many other important aspects about the history of contagious diseases which fall under the social or cultural nature of the topic. These diseases occur within social groups and doctors have to interact with individuals and with social hierarchies and organizations. It is appropriate, then, to consider contagious diseases through the lens of social or cultural history. Social history focuses on studying the lives of everyday people from the past and can be conducted on a very personal, rather than distant and abstract, level. In addition, social historians go beyond reconstructing and describing the historic events, the “who-what- when- where” of history, and instead focus on “why”. They seek to determine the underlying causes of historic events and the people caught up in them. To a social historian, contagious disease could be understood through the interaction of three different groups: the disease, the patient and the doctor. 

Pox and the City, an NEH funded project, was designed to explore the social history of smallpox vaccines and the early 19th century medical profession. This required that the design team experiment with different game mechanics and game play in order to bring out the social issues that influenced the topic. We began by thinking of the game as a system of three parts: doctor, disease and patient. The player would take on the role of the doctor and we really wanted to bring that experience to life. What choices would you, the player, have faced if it were you trying to start up a dispensary and stop smallpox? This focus required players to become personally involved within the narrative. However, there are no clear guidelines on how to do this. It is very difficult to create interesting and educational narrative driven games. Our solution was to create game play that incorporated branching narratives, multiple characters that spanned different social classes and mini-games that added action and “rounded” out the player character (PC), Dr. Robertson.


Pox and the city is, at its core, a point and click adventure game that takes most players about 2 to 3 hours to complete. Players must step into the shoes of a young doctor and try to both advance their career and stop smallpox. One of the temptations when working with historic narrative is to simply make it linear: the player clicks through set story parts and mini-games are brought in for interactivity. We wanted to explore ways in which we could fully integrate narrative and gameplay so that players could truly understand the complexity of choices that faced Regency period doctors. The first challenge was to decide on the final state, or win state, of the game. We decided to define the win state as a “no lose” situation. As in life, players make choices which will take them down different paths, each with merits and challenges of its own. Therefore, there are no wrong choices in this game and there is no losing scenario at the end. Simply different paths the player may take. Ultimately, the player is be able to set up their own dispensary for vaccinating the community but there are different ways of achieving the dispensary that depend on previous choices in the game. Players decide on several major life events in the game: career path, marriage, and dispensary location. Each of these decisions influences the game options available to the player.

Although the game is narrative and dialogue heavy, it is not linear and player choices will change the options and narrative available to the player. We did this by using a braided interactive narrative technique. In this technique, major game or plot points remain the same but the actions available to the player are different depending on 1.) level of the doc-o-meter scale ( a scale that tracks player choices), 2.) whether they married or not 3.) social and treatment decisions made in the game and 4.) the location of their dispensary. In order to allow players to explore the complexity of the situation, rather than expound a single narrative, gameplay was designed as a system that balances player choices between professional and social concerns. Choices made by the player that were poor business decisions but good moral or social decisions would mean they would have to do different activities (quests and mini games) to gain money and open their dispensary. In addition, as the game was made to be played in a classroom setting, allowing players to make different decisions and have different game experiences would open up discussion around the game. This would allow teachers to engage with students about those choices and different aspects of early 19th century medicine and smallpox. We believed that the game should not be used alone, but with other in-class activities and one of the primary purposes of the game was to help set up "teachable moments" in the classroom to foster discussion and student-teacher interaction.

The Role of the Player

Players take on the role of Dr. Robertson, a young doctor just starting out by taking over a practice in Edinburgh. The first choice they face is to decide whether they are entrepreneurial or philanthropic in nature. Historically, doctors could follow different paths in their career. For example, they could choose to open up a practice and cater to the wealthy or to live in the country and cover miles of territory. In Pox, these choices were simplified to two types of professional paths: entrepreneurial or philanthropic. The entrepreneurial path reflects a doctor whose focus is on building up his practice as successfully as possible. By concentrating on career, the entrepreneurial doctor could help more people by focusing on research and by investing in bigger projects and equipment. The philanthropic doctor, on the other hand, could do more good work in the community by helping people directly and working in a one-on-one manner. In the game, each decision the player makes costs or gains them philanthropy or entrepreneurial points. These points are tracked in the doc-o-meter and are used first to determine game play actions available to the player and then later, to describe the player’s life at the end of the game.

The game is divided, from a design standpoint, into two sections. The first section focuses on Jenner’s work with inoculation and vaccination. Edward Jenner systematically experimented and proved that injecting patients with cowpox virus would protect them from smallpox. Therefore, the first game section focuses on smallpox. The second quest of the game, for example, requires players to recreate Jenner’s first experiment. The second half of the game focuses on exploring the early 19th century medical profession by allowing players to build Dr Robertson’s, career. In the second game section, the player must earn enough money to open and run their dispensary either by treating patients or making connections with wealthy people who will invest.

World Building

One of the core educational goals behind Pox and the City was to show players the difficulties involved in convincing people to get inoculated/vaccinated. Ideally, the vaccine or inoculant is discovered and right away, the entire population rushes to take advantage of this new medical breakthrough to save themselves. But that isn’t what happened. The reality was that many groups resisted taking the vaccine for a number of reasons.  The doctor himself also had a number of other pressures to deal with, such as running the business of the practice. In order to show these social systems, we had to take the player back in time, into the world of Edinburgh around 1800+/- 10. The game was designed to allow the player to roam the game world through a map interface (Fig. 2). The map was an iconic overview of Edinburgh from around 1820 [16]. The player begins with three locations open to them that they can access by clicking on the map link. As they progress the game, more locations appear and become available. This was meant to support the game narrative of a newly arrived doctor slowly expanding his knowledge of the people and city of Edinburgh. Locations the player may travel to are marked in “ink” and circled, as if the doctor had marked the locations on the map himself.  Locations used in the game were those that would allow the doctor to experience different class structures within the city. Thus the doctor would have to travel to the Grassmarket to meet farmers and laborers. Alternatively, he would encounter wealthy folk in New town. The locations used in the game:

  • The doctor’s office
  • The Tavern
  • New Town
  • Grassmarket
  • The Napier’s
  • The Infirmary
  • The RCPE (Royal College of Physicians) 

Fig. 2: A digital copy of a well-known map of Edinburgh circa 1820 is part of the user interface. Game location appear as handwritten notes which are meant to show Dr. Robertson making notes to himself as he explores the city.

 Interacting with NPCs 

 Interacting with characters was critical to the underlying goals of the game. Through character interactions we could show players social practices and customs, differences between classes and some of the events current to the time. The player interacts mainly with two families: the Cochranes and the Napiers. The Cochranes were very wealthy and lived in New Town. The Napiers, on the other hand were lower middle class. The difference in wealth and opportunity between the two families was much greater than we understand today. In order to communicate this, differences were shown in the clothes, the furnishings of the room and, when invited to dinner, in the foods offered on the menu, the other guests and topics of conversation. In Fig. 3, the player talks to a wealthy family about politics and painters. This topic would not be available when interacting with non-wealthy families.

One of the first jobs that the programmers tackled during game development, as it was the core game mechanic, was the narrative engine. The inclusion of narrative puzzles, branching narratives and multiple dialogue options were critical to building a sense of exploration, of figuring the world out through interacting with others. This is really an important point. We wanted players to learn social history, that is, a medical history through the lens of people interacting with the profession and the developments in science. Therefore, "interacting/talking" had to be our primary game mechanic. 

Fig. 3: Conversation with the Cochranes (above) in New Town. Players select dialogue options which will impact the game in a number of possible ways. The second image (below/lower half of the image) shows the interior of a lower middleclass family, the Napiers

Jenner's Experiment: Quest Overview

In the first section of the game, the players were all required to recreate Jenner’s first experiment with cowpox (Fig. 4). The quest begins with the player receiving an update in their journal while they are in their office. The player is given the overview of the experiment and given a clue that they should locate some cowpox material at the Grassmarket. Players must then travel to the Grassmarket via the map interface.

Fig. 4: Players received new quests in their journals. This entry explains some of Edward Jenner’s experiments with cowpox and asks them to recreate it.

On arriving at the market, players must solve two narrative puzzles (Fig. 5). The first will give them some cowpox material and will unlock the second puzzle. In the second puzzle, they must convince a man to allow his son to become their test subject. The narrative puzzles may be navigated through either by process of elimination or figuring out what would likely appeal to each character in order to make the best dialogue choices.  

Finally, after finishing the quest, the player must now recreate the experiment by inoculating the patient. This opens up the first medical mini-game (Fig. 6). In the medical mini-game, the player must choose the correct treatment options before they kill the patient. In this instance of the mini-game the player must go to the library and read an overview of Jenner’s experiment before they can successfully complete the quest. In addition, the doctor’s office contains a bookshelf in which they may read excerpts from Jenner’s original notes on his experiments.

Fig. 5: Conversation with a farmer in the Grassmarket. The player must solve narrative or dialogue based puzzles in order to progress the quests.

Fig. 6: The O/R mini-game. From this interface, the player engages with a new game mechanic. They must select the correct treatment options. Often, the player must access the library during the game in order to complete the quests, by pressing the button on the upper right. In the library, the player reads educational texts that explain aspects of the treatments.


Games have the potential for modeling systems that players can explore. However, systems are not just economic or military but may be social or cultural as well. The great difficulty in designing games for showing social systems is that the mechanics need to align with the content. In a social system, the mechanic is interacting with other people and thus the gameplay mechanic must reflect this somehow. Pox and the City approached this problem by creating a narrative game that was driven by narrative puzzles and branching interactive narratives. The narrative engine was balanced with mini-games that served to bring in additional game mechanics but also show different aspects of the doctor’s life. The O/R mini-game, for example, gave the players a different activity but also showed them a window into early 19th century medical practice. When making games about the past, it is important to remember that there are a variety of viewpoints, or lenses, to consider. Scholars shouldn’t have to find something “game like” in their content but rather designers should be able to design for the educational content. This is possible by making sure that core game mechanics truly support educational goals and outcomes.


I would like to thank some of the many people involved in this project: Lisa Rosner, Ethan Watrall, Lisa Hermsen, David Simkins, Jason Ferreira, Graham Berger, Jon Dymock, Tory Mance and James Winebrake.

The game, “Pox and the City” has been made possible in part by the National Endowment for the Humanities: Exploring the human endeavor. Any view, findings, conclusions, or recommendations expressed in this article, do not necessarily represent those of the National Endowment for the Humanities.


[1]   J. Austen, “Northanger Abbey,” 1817, p. Chapter 14.

[2]  D. T. Schaller, “From Knowledge to Narrative – to Systems? Games, Rules and Meaning-making,” presented at the Museums and the Web, Philadelphia, 2011.

[3] “Pox and the City.” [Online]. Available: [Accessed: 04-Jul-2013].

[4] “Herd Immunity — History of Vaccines.” [Online]. Available: [Accessed: 03-Jul-2013].

[5]“Illsville: Fight the Disease — History of Vaccines.” [Online]. Available: [Accessed: 02-Jul-2013].

[6] “Ndemic Creations.” [Online]. Available: [Accessed: 03-Jul-2013].

[7]  “Play Caduceus.” [Online]. Available: [Accessed: 03-Jul-2013].

[8]  “Play Pandemic: American Swine, a free online game on Kongregate.” [Online]. Available: [Accessed: 03-Jul-2013].

[9] “Playing History.” [Online]. Available: [Accessed: 03-Jul-2013].

[10] M. Flanagan, “Pox: Save the People. An interview with Mary Flanagan. |,” 10-Mar-2011.

[11]         “The Great Plague - Fling the Teacher - Interactive game -” [Online]. Available: [Accessed: 02-Jul-2013].

[12] “Activities — History of Vaccines.” [Online]. Available: [Accessed: 03-Jul-2013].

[13]“tiltfactor » POX.” [Online]. Available: [Accessed: 02-Jul-2013].

[14] “Plague Inc. - A free Android Game.” [Online]. Available: [Accessed: 02-Jul-2013].

[15]Killer Flu Game.” [Online]. Available: [Accessed: 03-Jul-2013].

[16]         J. Wood and T. Brown, Plan of the City of Edinburgh, including all the latest and intended improvements. 1823.


Original article in Lost Worlds: Exploration in Digital Humanities Game Design










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