"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." 
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 ..."  even though this requires "reducing complex phenomena to simple rulesets...[of the]... phenomena [that are] not fully understood" . 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 , 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 . Illsville  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" . 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, 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  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  , 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.  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  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.