Science Behind the Fiction: The horrible diseases that would kill you in Westeros

Everybody knows that the world of George R.R. Martin’s A Song of Ice and Fire and HBO's Game of Thrones is one of suffering and death. When building his story, the author pressed his finger all the way down on the pain scale. It’s basically a planet consisting entirely of Australia; everything wants to kill you in the most entertainingly excruciating ways.

When visiting Westeros, the options for misery are limitless. You can have molten gold poured on your head, have your eyes pushed in, be stabbed, or poisoned, or beheaded by a petulant child. And those are only the good deaths, the ones reserved for the upper crust. But the one percent aren’t the only ones having a bad time. In Westeros, there are plenty of woes to go around. Just because the deaths of the average Westerosi are more mundane, it doesn’t mean they are any less awful.

THE DISEASES WOULD BE MANY AND HORRIBLE

A Song of Ice and Fire is, for those of you not paying attention, a fantasy story. Which means — save for some mystical creatures, demonstrably real deities, and working magic — it’s basically medieval Europe. There are, of course, fantasy stories that take place in locales that aren’t medieval Europe. There are even locales within Martin’s story that buck the usual trend. But there’s a reason Westeros seems so familiar: It’s the court of Camelot, except everyone is hopped up on steroids and Viagra.

While all of that might sound super fun to experience, the everyday maladies were probably more trouble for the average citizen than the royals and their titular game of thrones. For much of our early history, disease was entirely misunderstood and, as with many things, attributed to god(s). In the Middle Ages, falling victim to some ailment or another was seen as divine punishment, and it was assumed a cure could only be obtained from the same source. Considering the wealth of gods present in Westeros, and the compelling evidence that they actually exist, it’s likely the populace had similar attitudes.

The text itself supports this notion. In A Game of Thrones, Robert Baratheon is gored by a wild boar during a hunt. It’s all the result of political intrigue at the hands of Cersei, and too much drink, but King Robert doesn’t see it that way. Instead, he blames himself for upsetting the gods. On his deathbed, while speaking to Ned Stark, he says, “The girl. Daenerys. Only a child, you were right … that's why, the girl … the gods sent the boar … sent to punish me.” He later dies as a result of his wounds, and probably at least a little infection.

Later, in A Storm of Swords, Tyrion is speaking with Oberyn about the ills of the realm, and of the Lannister family in particular, when the subject of divine punishment comes up again. Oberyn makes his opinion on the cause of all the strife — and the cause of Tyrion’s particular position — clear, saying, “Lord Tywin had made himself greater than King Aerys, I heard one begging brother preach, but only a god is meant to stand above a king. You were his curse, a punishment sent by the gods to teach him that he was no better than any other man.”

This sort of attitude, while justified in the context of the story, or in the context of the dark ages of our own world, does little to combat the actual causes and remedies of injury and disease. It might have been a dark age for us and for those in Westeros, but it was the Garden of Eden for disease-bearing microbes.

For those members of the noble houses, treating sickness usually involved the services of Maesters and too much milk of the poppy until the injury healed or the illness subsided. If they were lucky, they might get a wound cleaned out with boiled wine, poultices, or maggots. Fun! But the common folk did not have access to their services. Even if they did, those treatments were not always effective against the varied and malicious diseases the Seven Kingdoms, and the rest of the world, had to offer. And there were many.

THE BLOODY FLUX

The bloody flux is the name given to dysentery within the world of A Song of Ice and Fire. Anyone who’s ever played Oregon Trail knows you can die of dysentery, but while it is often relegated to the past, it isn’t the long-conquered disease many believe it to be.

The disease is alive and well today and can be caused by several strains of bacteria as well as the amoeba Entamoeba histolytica. While in most cases infection is treatable and subsides relatively quickly, it still leads to death in incredible numbers. In 2013, dysentery caused by the Shigella bacteria claimed the lives of more than 34,000 children under the age of 5. Three years earlier, approximately 40,000 people over the age of 5 died as a result of the infection. In Westeros, the bloody flux is even more virulent, probably owing to poor hygiene and an incomplete understanding of transmission and treatment.

A specific outbreak of the disease manifests in A Dance with Dragons, leaving Daenerys at a loss. When she insists on her obligation to help the afflicted, Ser Barristan laments, “Your Grace, I have known the bloody flux to destroy whole armies when left to spread unchecked.”

In the same chapter, discussion of the disease cements the superstitious nature of the illness and its severity: "Afterward the Green Grace was impaled upon a stake in the Plaza of Punishment and left until she died. In the pyramid of Ullhor, the survivors had a great feast that lasted half the night, and washed the last of their food down with poison wine so none need wake again come morning. Soon after came the sickness, a bloody flux that killed three men of every four, until a mob of dying men went mad and slew the guards on the main gate.”

Daenerys is, in the end, convinced to keep the sick away, despite the desires of her heart.

Suffice it to say, when the flux reared its head, the brave trembled. The primary treatment for the disease was quarantine, separating the afflicted from the healthy and hoping it didn’t spread. Here on Earth, proper hydration is recommended, and, if needed, hospitalization.

GREYSCALE

Perhaps the most insidious of diseases in Martin’s novels, greyscale is a contagious disease spread by skin-to-skin contact. Sufferers experience thickening, scaly skin that spreads to adjacent tissues indefinitely unless treated.

The infection causes a loss of sensation, among other more terrible symptoms. Thus, those who have come in contact with an infected person are recommended to prick their extremities with a blade daily. This isn't a treatment so much as it's an early warning system. So long as there is pain, the individual is safe. This is what we call a lose-lose situation.

Once symptoms arise in the form of the appearance of greyscale on the skin, the individual should seek immediate treatment. Sadly, the effectiveness of various treatments are up for debate and include poultices, hot baths, and removal of the infected areas to prevent spreading. The first two of those sound like a nice day at the spa. The last, not so much.

As the disease spreads, it can cause blindness and eventually the hardening and failure of vital organs. And if that weren’t bad enough, most of those afflicted lose their sanity long before the disease takes their lives. But maybe that's a kindness.

While many compare greyscale to real-world leprosy, a dermatologist speaking to Vox had other ideas, suggesting that greyscale, if it were real, would likely be caused by something like smallpox or HPV.

There have been some reported in-world instances of greyscale being halted in its tracks. Afflicted as an infant, Shireen Baratheon received immediate treatment, which stopped the spread of the disease but left her left cheek and neck covered in the scale. While the child seems cured of the disease, not everyone is so sure. In speaking to Jon Snow, Val says, “The maesters may believe what they wish. Ask a woods witch if you would know the truth. The grey death sleeps, only to wake again. The child is not clean!”

In any event, those who contract greyscale have a hard road ahead. But there is one silver lining: They are immune to the more terrible, and swifter, version of the disease, the grey plague, which promises swift and certain death for you and everyone around you.

LIFE EXPECTANCY IN WESTEROS

If the contents of Martin’s books or the HBO series they inspired have taught us one thing, it is that death is always only a moment away, unless you know how to play the game. Even then, there are myriad reapers, shadow children, wights, and dragons waiting in the wings. Life in Westeros, Essos, or Sothoryos, the three known continents that make up the world of A Song of Ice and Fire, would be hard and, likely, short by modern standards.

In order to get an idea of what the average person might have been up against, we again must refer to our own Middle Ages, and the news isn’t good.

During the Roman Empire, average life expectancy at birth was a whopping 25 years. So those who had the good fortune of being born in the Middle Ages might have been grateful for the prospect of living to 33. That represents roughly a 33 percent increase in average lifespan. You can do a lot in eight years. Like watch all of Game of Thrones or attend the release of at least two A Song of Ice and Fire books.

Although, calculating life expectancy is difficult. You’re dealing with averages, and high child mortality drove the number down. According to a paper from the International Journal of Epidemiology, surviving childhood was the most difficult hurdle in the Middle Ages, and if you could make it to 25, you could expect to live another 23.3 years.

Considering all of the extra hurdles present in Martin’s world, the oppressive diseases and regimes, the constant threat of war, malicious gods, and magic, reaching 25 without the aid of noble protections or magic of your own might have been even more difficult. All of this amounts to the conclusion that, while Westeros might be a fun place to visit, you wouldn’t want to live there.

The eighth and final season of Game of Thrones premieres on HBO on April 14.