Bad Air, Good Writing: An Argument for the Consideration of Medical History when World Building

Nature is weird. Let’s get that out of the way. The universe we live in is full of odd things growing odder by the day, but these curiosities aren’t confined to the ocean depths or deep space. The human body—and the fantastical history that comes with it—is a weird unto itself that rivals even the most outrageous-looking frill shark. It’s enough to make you ask the universe if it’s ever heard of internal consistency.

Which means that world building can be tricky. It’s not impossible, though, even if you don’t include frill sharks in your book. One of the major aspects of our world that occasionally is taken for granted or glossed over via the use of magic (and there is nothing wrong with that) is medical knowledge, and this is important because this knowledge not only shapes us but our world. Medical knowledge affects how we respond to epidemics, how epidemics affect population numbers, how population numbers affect the economy, how economies affect political structures, and so on and so forth. A small fact such as if your world has a working germ theory can alter something as conceptually different as your local political structures.

For example, the Great Plague devastated two continents. It killed so many people that when Europe began recovering from it, there weren’t enough people left alive to work. Those who were alive realized this, and they knew that laborers were scarce. Peasants and serfs were able to negotiate (sometimes successfully and sometimes unsuccessfully) for wage increases because if they didn’t do the work, there was no one left alive to do it. So many people were needed to work the lands that serfs suddenly had higher wages and weren’t bound to one lord. Previously, they didn’t have the freedom to move to a new area. Now, they could leave with the assurance that they would most likely be hired to work elsewhere. The wealthy had to make changes to accommodate the workers. This caused the standards of living to increase.

It also changed how wealth was implied socially. Since peasants could afford slightly nicer things, fashion rules changed so that everyone still knew who was wealthy and who was noble on sight. And on top of all of that, it eventually opened up new avenues of advancement such as peasant and guild revolts. With money came the means to fuel successful rebellions and create social and political change.

Similarly, we can see the vestiges of miasma theory in our current times. Miasma theory was the working theory of disease that most of the world had before germ theory was developed, and it simply refers to the belief that diseases were caused by the bad air given off by rot. It’s logical—infected wounds and bodies typically do have particular scents and many people caught disease from others whom they were within breathing distance of. Since people couldn’t see germs but could smell bad air, it made sense for bad air to be the cause. It wasn’t perfect but it was reasonable given the available information at the time.

And many societies arrived at the conclusion that miasma spread diseases. So they took appropriate actions. People wore masks filled with fragrant spices and flowers; good air was wafted through sick rooms and onto wounds; pregnant people stood over heated spices to ensure an easy birth; and nobles spent exorbitant amounts of money on perfumes and white linens so that they were “clean.” Cleanliness was a social concept—nobles were clean by virtue of their birth—and not a completely literal one in Europe. (This isn’t to say that people didn’t bathe or were dirty but that the idea of cleanliness was more than just physical. Nobles were cleaner literally—and those white linens not only proved it but proved their status—and metaphorically. Important social concepts often have more than one meaning.) These iconic concepts weren’t the only results of the disease theory of the time.

The Church, uncomfortable by the idea of midwives being in charge of infant souls, began regulating midwifery. With the advent of the printing press, physicians (and who, we must consider, made a socially acceptable physician in Europe—wealthy white men) compiled books on medicine and sometimes left out how to limit pain during childbirth which had been a standard part of midwifery. We must consider what drove these physicians to do that and what those omissions might have changed now that they had claimed ownership over previously oral traditions. Some doctors in the 1700s took offense at being asked to wash their hands because it implied they weren’t clean. Populations of people were destroyed by white scientists who used scientific concepts to justify racist agendas and prove theories.

Society and science are intimately entwined, and they must be considered jointly when world building because who society values often determines who controls medical knowledge. This in turn determines many things.

Consider who died during the Plague? At the time, mostly everyone with some exceptions, but as we look at other epidemics and major medical events, it becomes clear what the main exception is—money and social power.

Death is indiscriminate; medicine isn’t.

Medicine is decided by people. The education we receive and the biology dogmas we accept are decided by people, making their socialization matter immensely. Medicine as a concept may have no biases, but its applications do. Racism, ableism, sexism—all of these can be seen in not only our medical history but our contemporary practices.

To create scientific truths in a fictional world, we must dissect our own truths.

This creates some questions for you to answer in regards to your own world building and characterization. But before we can get into questions of medicine in a fictional world, we must ask who is in power. What groups in your world hold societal power, and what do they do with it? Science does not exist in a vacuum of objectivity, and scientists are not objective. They are shaped by their worlds. Our own world, science and medicine included, is built upon the graves of people killed in the pursuit of knowledge and power—the Flint water crisis, the high maternal death rates of the U.S., the countless experiments done on black people by white doctors, the dismissals and deaths of people from  marginalized communities. The answer to the above will affect the access, education, survival, and views of your characters. For much of English and American history, science was at the mercy of rich white men and our universal truths were not necessarily universal and true. What are the objective truths of your world and who said they were so? Even if nothing medical or scientific occurs in your story, your character have still been shaped by these concepts. If there is a plot related to medicine, does the plot reflect how these structures shape medicine? Perhaps not in a large way but in a way that doesn’t harm readers by minimalizing or erasing the violence resulting from our medical history?*

Now, the more general questions:

1. Does your world have miasma or germ theory? Is it a recent development or old news? Does everyone believe in this theory, and how does society as a whole view those who don’t believe it? Is there another theory of disease? What is it and why was it developed? If your world has magic or future technology, how does it fit into the leading theory? Is it a help or a hindrance to the leading theory? If you cast a spell that detects all forms of life, does the spell include bacteria? After the final, epic battle, do the healers watch for infection? Do those healers wash their hands? Do people balk at bad breath as unsanitary? Do they douse themselves in perfumes or antiseptics?

2. Based on the above, how do your characters interact with the world? Its blood? Its smells? Its germs? How do they view their own bodies? How does society view their bodies? How do your characters view disease and medicine, and how does society view disease and medicine?

  • Politics, economics, geography, society—all of these affect medicine and how we view it. Your characters’ backgrounds will affect how they view medicine. Do they have access to medicine and medical education? Why or why not? What are the implications of this? (i.e.: Are they suspicious of medical professionals and why? Are medical professionals dismissive of them? Do they trust medical professionals absolutely, and if so, what does this mean for them and the society they live in?)
  • If miasma theory is prevalent in your world, how are air elementalists/related magic users received? If your magic system involves a blood sacrifice, what do they do to the wound after? What information is available to them given the resources they have (i.e.: how does magic and technology affect that info?) and what conclusions do they make using that information?

3. How has the history of the world and its peoples been shaped by disease? If an epidemic occurred, how did it affect the economies, religions, cultures, and politics of those affected? Does your world inoculate against smallpox? Do only the rich have access to inoculations/vaccinations? Is a cold a death sentence or easily cured? Likewise, are flesh wounds easily handled? In a fight, is your character more afraid of what happens after if they’re stabbed, or do they know that a stab wound can be patched quickly and painlessly? Will they always have access to healers or healing supplies? Are clinics a thing? Where are they? Who can afford them? Does your world have healthcare plans? Why or why not?

4. Is menstruation understood? Is pregnancy? Is it dangerous? Is it only dangerous for certain people? At what point does childhood end and adulthood begin? Is there birth control? Who is it designed for and why?

5. Gender and sex are complicated, and a single blog post (much less only one question) cannot do them justice. I really just want to point out that some common medical terminology (and how we talk about medical events, such as menstruation and pregnancy) is very exclusive of many people, and there’s no reason for it to be that way. Be mindful of how the narration and the characters talk to and about each other in regards to biology (and in general).

Remember: First, do no harm.

Some more specific questions:

6. Is dentistry a thing? Do your characters have teeth and are those teeth straight and white? What does that say about them?

7. Do your characters have scars? What does that answer say about them and their place in the world?

8. I am not qualified to talk about disability, chronic illness, or mental illness, but many people are and have discussed it, so let me leave it at this: be careful of common SFF tropes that play into stereotypes and issues. For example, things that deal with bloodlines, genetics, and “perfect” societies. Eugenics is a very real thing that hurts very real people, and it can be easy to not realize that your world building is leaning towards the support of eugenics. (This isn’t to say never write about it but that if you’re not directly dealing with it, you should be aware of it.)

9. Likewise, bodily autonomy and reproductive health will probably affect how your characters interact. How does the world and your character view these things?

10. Allergies! They’re real, they’re complicated, and they probably, whether on the page or not, exist in your world. How might a knowledge or lack of knowledge about allergies affect your world building and characters?

And some completely different questions:

11. Human ears (sort of) developed from gills. Anatomy is often very weird and very specific. If your characters have gills, what happens to their anatomy? If your characters exist in a world different from our own, what happens to their anatomy?

12. Stressors can cause a person to experience time dilation, so yes, you can manipulate (your sense of) time. How might that come into play?

13. Trepanning worked. And we replaced skull fragments with metal. No question, only possibilities.

14. Goosebumps (the phenomenon, not the books) are an evolutionary holdover from when we had fur, so in your world, who feels their arm hair raising? What about non-mammalian species?

15. We got taller before we got smarter, and we (mostly) know this based on the positioning of the thigh bones and foramen magnum (that hole where your spinal cord goes through your skull). Bipedal creatures don’t have the skeleton or muscles for walking on all fours (or however many legs you’re going with). How might this affect werewolves? Other creatures or shapeshifters? Additionally, we gained and lost many things because of what was useful to our ancestors. What have the ancestors of your characters gained or lost in your world?

Now go forth and answer the questions you want or need or are too entranced by to pass up! Create your world and populate it!

Everything aside, the human body is fairly amazing if not intriguing. Each body is different and weird and wonderful. Not all of them work the same. Not all of them react the same to similar stimuli. We are all a delicate balance of biochemistry and environment, and we’re all spectacular. That’s the beauty of world building.

The world is yours, and how it functions is up to you.

*Please keep in mind that I am coming at this from a distinctly American viewpoint as well as a very privileged viewpoint. Additionally, some of my “consider this/consider not doing this” points hinge on the concept of your story not dealing with the points directly. Escapism in fiction is exceptionally necessary, and sometimes you have to gloss over history to do it. All I’m saying is, if you’re not writing a story about eugenics, try not to indirectly imply its greatness with your world building.

Miller_AuthorPhotoOriginally from Arkansas, Linsey Miller has previously been a crime lab intern and pharmacy assistant, and she is currently an MFA fiction candidate. Her debut YA fantasy series about a thief out for revenge began with MASK OF SHADOWS and ended with RUIN OF STARS. Her next book, BELLE RÉVOLTE, is a standalone YA fantasy set to come out in early 2020. She can be found writing about science and magic anywhere there is coffee.

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