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What Red Dead Redemption 2 gets right about having a terminal disease

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When empathy comes from the last place you expect

Red Dead Redemption 2 - a man standing across from three men on horseback at sunset in a forest clearing Rockstar Games

There aren’t a lot of good examples of what it’s like living with a terminal respiratory disease out there in the world.

I actually learned to avoid characters I might relate to when I was growing up with cystic fibrosis, as they never seemed to exist as people. They were instead used as props, tragic plot points for the real hero to emote around. I had long given up on seeing anything close to an emotionally accurate representation of terminal illness in pop culture.

[Warning: The following contains major spoilers for Red Dead Redemption 2.]

I was only a few hours into Red Dead Redemption 2, Rockstar’s Western epic, when I discovered how it would end: not with our hero, Arthur Morgan, riding into the sunset, but with his slow, agonizing demise, as the gruff outlaw succumbed to tuberculosis.

That obviously wasn’t what I was expecting to find when I turned to the internet to help figure out how to trigger a money-lending mission.

I understood the grim poetry of such an ending, of course; that it would be both inevitable and ironic. I just wasn’t sure if I wanted to sit through a game with that particular plot point, having nearly died from cystic fibrosis myself. More than once, even.

It turned out my desire to pretend to be a cowboy, and revenge-murder every cougar I saw for what they did to my horse in the first Red Dead Redemption, proved stronger than my fear of being triggered into a post-traumatic anxiety spiral. Besides, this was a video game. How “real” could its portrayal of a fatal bacterial disease really be?

Red Dead Redemption 2 presents the most nuanced and accurate portrayal of life with a terminal illness that I’ve ever seen, in any medium.

The devil is in the details

The attention to detail in Red Dead Redemption 2 borders on the implausible. Even a “quick” run-through of the game requires the player to spend a solid 60 hours with Arthur and the rest of the Van der Linde gang; that’s roughly the equivalent of 20 or more movies’ worth of narrative. 60 hours is a lot of time to spend with a single character, and that space allows for many small moments of realism; the sorts of things that would be glossed over in other games or stories.

And when it comes to a terminal illness — the reality of an ever-present disease that reminds you of its existence daily — the devil is very much in the details.

Tuberculosis (TB) and cystic fibrosis (CF) are very similar symptomatically. There’s constant fatigue, a loss of appetite and inability to gain or even keep weight, difficulty breathing, persistent coughing, the expectoration of both mucus and lung blood, and, of course, a two-letter abbreviation. Both diseases are progressive, which means they will get worse over time.

They are also both fatal, if the disease progresses far enough. The two diagnoses resemble one another so much, in fact, that there’s still some confusion as to which one killed famed Polish pianist Frederic Chopin.

I am not dead, obviously, but I’ve come pretty damned close. I was about as sick as a human being could be without passing away. At one point, I only had 12 percent of my optimal lung function, I was unable to move from my bed to the couch without help, and I coughed up enough blood that it warranted an emergency surgery and a write-up in a medical paper.

Then I underwent a double lung transplant, and all that went away. So I may not know exactly how it felt to be a turn-of-the-century cowboy dying of consumption, but I’d argue that I’ve got a pretty solid idea of what it might have been like.

When you don’t have the luxury of forgetting you’re sick

The most striking thing about the portrayal of Arthur’s illness in Red Dead Redemption 2 was its constancy, and its utter messiness. Pop culture portraits of the chronically ill tend to present a romanticized and immaculate version of the experience.

Everyone’s still Hollywood pretty, after all, and the violent expulsions of fluids from their bodies are kept to a minimum, relegated to a scene here or there to remind the audience that this person is sick. Sometimes small amounts of blood are revealed in a handkerchief after someone coughs a bit, and we’re trained to understand this means that they are doomed.

Take Moulin Rouge!, for instance:

Red Dead Redemption 2, meanwhile, isn’t above showing Arthur falling off his horse or ruining a meeting with his hacking until he’s escorted away. But the real weight of his condition comes through his constant wheezing in later chapters, and the way he’ll simply sit and try to catch his breath for a painfully long time following certain missions. I’m not put in a place where I can forget his suffering.

The detail that hit the hardest, though, was one that can’t be explored in any medium other than a video game: Arthur is unable to adequately replenish his cores during chapter six, which is near the end of the game.

Cores are essentially Red Dead Redemption 2’s version of hit points or power meters. Arthur’s health core goes down when he takes damage, and he dies if it’s fully depleted. Exertion, such as important actions like running and fighting, drains his stamina core, and a depleted stamina core greatly limits what he can do in the game in general.

I know what this is like. I was eating maybe a handful of fish sticks a day when I was waiting for my surgery. I simply couldn’t eat anything more; my body didn’t want the food and couldn’t metabolize it. The only way to replenish myself — as best I could, anyway — was to sleep. Errands became all but impossible, and I spent most of my days napping to try to get some of my energy back. It was the only thing I could do to help myself, to try and restore my failing body.

That, remarkably, is exactly how the game handles Arthur’s illness. The actual quantity of food and drink allowed is suddenly limited in that latter chapter, as is its restorative impact. Arthur has to sleep to regain his cores. There is no other way. I’m forced to decide what’s worth my time if I attempt to do anything beyond the story missions. Obligations become oppressing, and saying yes to one thing means saying no to everything else for the rest of the virtual day.

I also notice that other characters comment on Arthur’s illness as it progresses, and not always in a nice way. Rockstar understands that relationships change after this kind of diagnosis, and some people might start to treat the afflicted individuals with either sympathy, scorn, or a combination of the two. That is, if they don’t react with outright fear. And other people may not be that interested in concealing those reactions.

I hid my disease as much as I could when I was growing up, back when hiding my disease was still a possibility. I never knew how someone was going to react. A harsh cough could make strangers wince and draw away, or they might rush over and ask if I was all right, always in the same coddling tone. Some people would become angry if I coughed too much, and tell me directly that I should have stayed home.

Maybe they thought cystic fibrosis, a genetic, noninfectious disease, was contagious. Maybe they thought I should have resigned myself to bedrest and giving up. Or maybe they thought I had something else and was being careless. What they rarely did was ask, or try to learn the reality of the situation before rushing to some kind of judgment.

Strangers weren’t the only ones who reacted poorly, either, which is something else that Red Dead Redemption 2 gets right.

Arthur’s fellow gang members change their behavior as Arthur became noticeably ill. Some mean well, like Tilly, but even she still seems to blame me for my condition. She will state that she’s concerned about my health when I tried to speak with her in camp, but she’s also upset that I’m not taking better care of myself.

Gang member Micah Bell, meanwhile, becomes more outwardly hostile toward me and throws out the nickname “Black Lung” at every opportunity. He views Arthur’s tuberculosis as a weakness, and Arthur as weak for contracting it. Gang member Javier Escuella suddenly becomes dismissive as well, telling me to stay out of the gang’s affairs and “just worry ’bout that cough.”

While there are obviously other plot points in play during this part of the game, it’s worth noting that both Micah and Javier turn on Arthur most aggressively after his diagnosis. These characters announce their turn to full villainy by reducing Arthur to nothing more than his disease.

The disease is a part of you, not the other way around

And that, really, is the crux of all of this: Red Dead Redemption 2 never defines Arthur Morgan by his tuberculosis. He is shown to be more than his disease, despite the omnipresence of his symptoms and the fully realized world reacting to his ever-worsening illness. He has power over his own life, and his personality doesn’t begin and end with his illness.

Arthur is allowed to be angry, even in the most egregiously, transparently “sick” moment of the game. Arthur stumbles into a doctor’s office at the end of chapter five and is told, in no uncertain terms, that he has tuberculosis. He curses the doctor, and it becomes clear that’s he’s still Arthur. He still needs to do what needs to be done. His disease makes it harder, but it doesn’t define who he is or what he has to do.

Red Dead Redemption 2 - Arthur sits by his wagon, contemplating what he has done Rockstar Games

Arthur’s narrative does not specifically hinge on his tuberculosis. He evolves from Dutch’s faithful lieutenant to his wayward rival over time, and that story could still exist even if there was some way for Arthur to avoid contracting the illness. Arthur’s tuberculosis is a detail in the story, not the story itself.

And that is the part that most other representations of chronic illness get wrong. A person doesn’t lose their agency because of a diagnosis of a terminal illness, and being forced to focus on your health doesn’t mean that the rest of your problems go away, or even give you a break.

Because as devastating as tuberculosis or cystic fibrosis can be, as much as taking care of yourself seems to take precedence, the world doesn’t actually stop simply because you’re not feeling well. Most of us do the best we can in situations that are often out of our control. Our lives continue.

I worked with less than forty percent lung capacity for years, sitting at a desk and answering phones until I literally couldn’t speak anymore. Arthur doesn’t get to take a day off either. There are still people that need saving, squirrels that need hunting, bridges that need exploding, and stagecoaches that need robbing. Arthur spends his last moments getting into a fistfight, buying time to help his friend escape. He’s still looking out at the world and thinking about what he can do in it instead of focusing inward on his own limitations.

I finished Red Dead Redemption 2 a few weeks ago, and I left Arthur on that mountaintop, bloody and broken. But Arthur Morgan is still with me. Me, a scrawny kid from the suburbs of New York City, saw myself in him, a weary, cantankerous cowboy, in ways I’ve never seen myself in anyone before.

Arthur will always be there to remind me that I am more than my disease. That there are still things left to do. That, while I may not always be here, I am for now, and that means there’s still time to get to work.