Wellness
'Astrologaster' screensbots courtesy of Nyamyam
Games

'Astrologaster' Asks if Bad Medicine Can Make a Good Doctor

An historical comedy of astrological medicine in a time of plague has surprising insight about the problems of modern healthcare.
August 12, 2020, 1:00pm

Astrologaster is a game bookended by pandemics. It begins in 1592, when a wave of the Black Death sweeps London. The player takes on the role of Forman, an unlicensed doctor who swaps the traditional physician’s tools for astrology and fortune-telling. Forman catches the plague, but looks to the stars to decide which ingredients he should mix into a tonic. After drinking the resulting “strongwater,” he somehow survives. 

Eleven years later, in 1603, London has seemingly recovered. Forman has effectively marketed his strongwater as a plague cure and spent the last decade giving patients astrological readings (which is the game’s central mechanic). He even has a license. And then plague strikes again, leaving Forman shut in his house and ruminating on his legacy. He set out to use astrology as a medical tool, treating the minds, bodies, and souls of his patients, unlike the licensed doctors he distrusts. Forman’s ultimate question is also the game’s ultimate question: Has he made his patients better?

Scientifically speaking, probably not. Astrology hasn’t been an accepted part of modern medical science in ages. But the answer, and Astrologaster itself, is more complicated when you look beyond purely scientific questions to ones of health and care.

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Astrologaster is based on the casebooks and journals of the real-life Forman, a self-proclaimed doctor and meticulous record-keeper who lived from 1552 to 1611. “I think he [Forman] was just very used to writing everything down,” said Jennifer Schneidereit, the game’s creative director. I spoke to Schneidereit as well as Katharine Neil, who wrote Astrologaster, while the U.K.-based Schneidereit was staying at Neil’s home in France. “And I suspect the reason why he did that is because he wanted to tie everything that happened to him back to the location of the stars and planets.”

Forman is not a snake oil salesman, either in the game or in the annals of history. “Forman absolutely believed in astrology—he was his own best client,” said Lauren Kassell, a history professor at Cambridge, via email. Kassell is the head of the Casebooks Project, which digitized Forman’s meticulous patient charts. She also indirectly led to _Astrologaster_’s creation: Schneidereit saw Kassell present her research and was inspired to create a game based on Forman’s life. Kassell then served as historical consultant on the game. 

“For him [Forman], and for everyone else in early modern Europe, astrology worked,” Kassell added. “The question wasn’t did the celestial motions affect life on earth, but rather, how did these influences work.”

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In the game, patients describe their symptoms, and then Forman consults the stars to see which celestial body is responsible. _Astrologaster_’s first patient, Mistress Allen, suffers from a headache and vomiting. Does the constellation Cancer, ruler of the stomach, influence her digestion system? Or does Scorpio, ruler of the reproductive system, indicate that Mistress Allen is with child? The player then chooses which explanation is most likely.

Astrologaster came out last year, accidentally a year ahead of its time. It’s funny, it features an original choral score by Andrea Boccadoro, and it’s satisfyingly presented in the form of a pop-up storybook, with players flipping the pages between charts of the stars and Forman’s house. But what makes it most remarkable is its relevance in 2020. Playing the game in the summer of 2020 means placing “Dr.” Simon Forman’s concepts of health, medicine, and wellness in conversation with our own. His reality and our reality both show that when a medical system breaks down, its patients stop trusting that system and turn to the fringes of medicine instead.

Since the COVID-19 pandemic began, people have turned to alternative medicine (that is, any medicine that is not evidence-based) to treat or prevent the disease. Whether that “medicine” is essential oils, teas, colloidal silver, vitamins, or bleach, it doesn’t work. There is no cure for COVID-19, a fact doctors have repeated over and over. So why do people continue to buy debunked miracle cures?

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In Astrologaster, part of the answer lies in class conflict. The narrative touches frequently on tension between the out-of-touch ruling class, who historically “went to the countryside” as a way of fleeing pestilence-ridden London, according to Neil. The working class, on the other hand, couldn’t go anywhere. Many of the city’s doctors joined the exodus, leading to the common folk of London distrusting the medical establishment. “[Doctors] were an exclusive fucking society,” said Neil. “They were of a certain privileged class. They were able to go and study at Cambridge or Oxford University.” But “[Forman] was lower middle class, sort of working class. He was an autodidact. He read lots of books,” Neil added.

Forman’s fellow medical professionals didn’t see his self-acquired knowledge as anything but  heresy. “Forman was an expert in horary astrology, that is in determining the significance of the positions of the stars at the time that the question was asked,” said Kassell. 

Kassell explained that Forman’s views were seen as dangerous because they went against the Christian doctrine of free will. “This sort of astrologer was often denigrated as a marketplace fortuneteller or quack. Forman, and others like him, insisted that they were misunderstood,” she added.

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It would be easy to equate Forman to elite wellness grifters like Gwyneth Paltrow (Goop) and Amanda Chantal Bacon (Moon Juice). But Forman doesn’t really fit that mold. Forman wasn’t rich, and he certainly wasn’t beautiful (according to Neil, he considered himself ugly). Any success he had was hard-won. He is the player character of Astrologaster because he is relatable, not because he’s the precursor to Instagram influencers trying to sell elderberry tablets.

The historical Forman was convinced he had identified a gap in the medical profession, and that he could help people by filling it. In this he neatly fits the mold for a lot of modern naturopaths, who trust in the products they’re hawking even if there’s no evidence their pills, teas, and treatments do anything. Denby Royal is a former holistic nutritionist and influencer who eventually realized there was no scientific basis for the herbs and supplements she sold to clients. In an essay for Self, she wrote that during her time as a nutritionist, she believed she was helping people. “I was drawn to holistic nutrition because I felt that mainstream western medicine by and large dismissed or just didn’t really take into account aspects of health I felt were important—diet, psychological wellbeing, and spiritual health,” she wrote. Her thoughts are like echoes of Forman’s, who didn’t think doctors paid enough attention to patients as people. 

Astrologaster argues that what Forman gives his patients isn’t what he thinks he’s giving them. He takes care to cultivate a rapport with his patients. He listens to them describe their pain. He sympathizes when they describe their anxieties and fears. When he’s found a diagnosis, he explains his reasoning. Whether he’s accurate is beside the point. His patients trust him because he believes in both them and the arcane arts he's studied. Forman has bet his career on the idea that all of chaotic reality unfolds according to a plan. Every illness and misfortune he and his patients have suffered can be explained by the order of the stars. If his patients trust him to raise the curtain between themselves and the realm of celestial bodies, they will survive.

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 The beliefs of the astrologers and physicians who criticized Forman have been about as thoroughly debunked as Forman’s. But there’s an argument to be made that, even if only by accident, Forman was in some ways an effective care provider.

Neil and Schneidereit think that Forman may have paid more attention to his patients than the average modern doctor. Schneidereit mentioned that at her doctor’s practice, appointments are only 15 minutes long. “If you have something that cannot be covered in 15 minutes, you have to book a double appointment,” she said. Fifteen minutes with a general practitioner is actually longer than the U.K. average, which is only 9.2 minutes.

Neil talked about a project she worked on meant to address possible breakdowns in communication between newly-minted French doctors and their patients. Because more French doctors now diagnose their patients via telehealth, she explained, new doctors sometimes struggle to develop their relational skills. “Doctors are actually getting worse at this, at least in France,” Neil said. “We’re losing people to quacks because we suck at the human side of dealing with patients.”

A growing lack of faith in doctors also exists in the U.S. Here, public trust in the medical profession has tumbled from 80% in 1973 to 39% in 2016, according to a Gallup poll. Shrinking appointment times, rising healthcare costs, and confusion over how insurance works may be some of the reasons why people look with suspicion at the medical field.

It’s worth noting that race and gender play a large role in the quality of patient care. Patients of color are less likely to receive the medical care they need for problems as far-ranging as cardiac arrests, strokes, cancer, or AIDS. In addition, doctors are less likely to take women’s pain seriously, which leads to underdiagnosis of serious medical conditions. According to a 2013 article published in the Journal of General Internal Medicine, these problems might stem from implicit bias: “uncertainty and time pressure surrounding the diagnostic process may promote reliance on stereotypes for efficient decision-making.”

Compare this with _Astrologaster_’s Forman, who listens to his patients no matter how mundane their problems. He consults the stars over complaints as minor as rashes, upset stomachs, and hangovers.  He counsels anxious patients, depressed patients, and patients nervous about first pregnancies. Granted, his ethics are sometimes lousy – he seduces several of his women patients and stalks others. (“He literally did have sex in the consulting chambers,” Neil said.) But he is always available. And unlike the other London doctors, he doesn’t leave when plague strikes. No wonder patients prefer him.

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“Maybe fixing a broken arm is the same as repairing a car, but understanding pains and fevers should, I think, begin with a conversation between the patient and the practitioner. Even Forman, who trusted the stars the way a modern doctor trusts an MRI scan, knew this,” said Kassell.

Astrologaster isn’t a perfect analogue for anything happening today, which Kassell was firm about. “I would never claim that Astrologaster has lessons for the pandemic!” she said. And she’s right: you absolutely should not turn to a video game about an Elizabethan astrologer for medical lessons.

But there are parallels. You could say Forman was ignorant by default, that he gave people random ingredients passed off as cures because it was all anyone had In Ye Olde Days. In some ways, this is true. Germ theory was not widely accepted until the 1800s. Vaccines were not commonplace until the 1900s. In other ways, Forman is not that different from us. Recent work by New York Times investigative health reporter Sarah Kliff has shown that when it comes to COVID-19, our healthcare is not just expensive; it is hard to use, and impossible to understand even if it works. The same COVID-19 test might cost $199, or it could cost $6,408. There is no standard test result delivery process, and results often come by fax. For-profit hospitals in rural areas have closed, which means patients with COVID-19 sometimes die before they reach another hospital 30 minutes away. Fear, greed, and pressure turn effective and affordable treatment into a game of chance. Any Londoner stuck in the city during the plague, just trying to survive while authorities failed to curb the chaos, would understand this dynamic.

Our medical system is soil in which empathy cannot grow, and the arrival of COVID-19 blew it to dust. It’s not such a surprise, then, that patients would look outside it for meaningful help. Alternative or homeopathic remedies won’t prevent or cure COVID-19, but they give buyers a sense of control, maybe even of hope. It’s not so unlike Simon Forman staring at his star charts, feverish and sweaty with the Black Death, making a Hail Mary concoction of herbs based on the positions of the planets.

Modern medical science is capable of providing effective treatment that was unimaginable in Forman’s time. But Astrologaster also makes the case that treatment is only part of effective medicine. To truly help people, medical treatment must be not only accessible but also administered by someone the patient trusts. When the system works properly, those elements reinforce each other. When it breaks down, some people seek help and certainty from snake-oil panaceas or furious conspiracy theorizing. Forman’s story, Neil argued, shows how people instinctively reach for a fix, no matter how unlikely.

 “In a way, astrology is one giant conspiracy that explains everything. As we know, real science is imperfect,” said Neil. She paused for a moment, then uttered one of the more incisive observations about the pandemic that I have heard. “With COVID research, [scientists] keep on changing their guidelines because they're learning more things … And that's something people don't like about science because they think, well, people are lying to me. But no, that's science. Whereas astrology, it's a system that explains everything. While interpretations may change, it's a stable system. It's like God did it.”