Pathologic opens with its three playable characters arguing on a stage. They present themselves and their cause, slander the others, then wait in darkened silence while the player chooses which to play as. Shortly after choosing, the player is visited by an otherworldly masked duo. These beings are terribly out of place, but somehow hold an unquestioned presence. They refer to the player as an actor, and inform them of the rules of the play (that is, the mechanics of the game). A theater is the very heart of this town, and is central to the game’s themes. Pathologic has a meta-awareness, that there’s a player, an actor, wandering around inside of it. It remains one of the least player-friendly experiences I’ve had.

Pathologic is a cutthroat survival sim set in a dying, infected town. The player is given the “simple” task of curing this more-than-deadly plague. As a mere human, the player manages their own health, hunger, exhaustion, infection, and immunity. This takes weapons, medicine, food, antibiotics, and time, all dwindling resources. Just to find enough money for food, players will be rummaging through literal garbage. Inside they may find bottles which they can fill with water and trade to a drunkard, or a sharp needle that a child may like to play with and trade for. Alternatively, the player can roam the streets at night looking for muggers to kill and loot. Or they can resort to stealing themselves.

As players are simply trying to survive through the days, they must also complete tasks to come closer to curbing the infection and understanding the town. Everyday a new quest must be done, or risk nearing a game over. The average day in Pathologic is mapping efficient routes to save time, money management, avoiding the disease, fights to the death, and deciding to heal health points or satiate hunger pangs. In later days players will likely stabilize with enough currency to at least consistently afford themselves food, if not other goods. However, the plague gets more dangerous to match. When walking through infected districts, clouds of plague will appear and obstruct the player’s path or fly directly at them, with rats chasing and contagious people wandering. Every third step in pathologic warrants a save as stress peaks and stakes rise.

Often I would save before initiating dialogue with a story character. They hardly act like traditional npcs, instead holding their own motivations and goals with a willingness to deceive for their own sake. Characters rarely tell you a pure truth; rather rumors as fact, lies, half-truths. It’s left to the player to decipher this web. Even ignoring the layer of deceit and sensationalism in dialogue, the player can be outright rejected. For insulting a character and their methods, they don’t applaud you for your wit; they cut you off and leave you dead in your tracks. This can severely hamper your success in the future, possibly even spiraling to a game over.

At the beginning of the infection, an institution was locked from the outside to prevent spread, leaving hundreds to hopelessly die. As the infection spreads regardless, it is later opened. The leader of the institution requests the life of the man responsible for quarantining them with no aid. The player has three options: offer the son who truly closed the facility, offer the father who will gladly take the blame to preserve his legacy, or a refusal altogether. To give the son is the player’s own demise, they need him as an ally in their mission. To give the father is to ignore justice, allowing politics to overcome truth. The refusal requires braving an infected house, a great risk, to retrieve an artifact. After this divine sacrifice, the player is denied their reward; the father turns himself in anyways. The game never intended to let you escape its cynical construct. Pathologic offers one solution and two ways to shoot yourself in the foot. By offering these dead-end choices, the game ludically puts the player in the same predicament as the Bachelor. They have a choice, but their hands are tied.

At the beginning of each day, a new pantomime is played at the theater. When the player enters, their character first reflects on what various people have said to them in the last 24 hours. Afterwards, a cutscene plays where executors, tragedians, and the three player characters are staged dramatically, representing the story progression. This short production at the center of the town is a reminder that the player is merely an actor in the story of Pathologic. Pathologic recognizes its player, which by itself isn’t unusual, as most media is at least aware of its audience. But in gaming, player awareness is often used to build power fantasies, streamline functions, and maximize fun. Instead, Pathologic wants to tell a story; a story of lies, survival, death, and disease. It does not wish to please its player, but test them, prod them, to see how they tick. It continually offers player agency, but extols heavy punishment when expressed.

Honestly, playing Pathologic is terrifying. I quit the first time I played, and only came back with a walkthrough and a list full of hot tips. It’s a grating experience that erodes player agency. As I play through the game I become more and more submissive in dialogue, I’m scared of making enemies. I’m presented with sarcastic remarks and scathing comments, but I’m much too paranoid to pick them. In the world of Pathologic, I can’t afford the pleasure of annoying somebody. I’m too busy stressing over making sure I have enough food for the rest of the day.

As it turns out, the bachelor, my chosen character, feels much the same. Fought by the government, manipulated by the townspeople, and continually within an inch of his life, he’s exhausted. Beyond exhausted – worn down, beaten. In fighting the player at every step of the way, Pathologic puts player and character closer than ever. In the end, me and the Bachelor are in agreement. Victory cannot be won without sacrifice, the town must be destroyed to preserve its magnum opus: the Polyhedron. The town and its filthy, foreign, and dishonest ways are not worth saving. The Polyhedron is the only beauty.

If they perform exceptionally, the player is invited to enter the Polyhedron and speak with the ubiquitous Authorities. Inside they find two children and a sandbox shaped up to look like the town. Talking to them reveals that in the Polyhedron, this magic structure that turns children’s fantasies into reality, the epidemic was conceived. To curb the plague, they sent three of their old dolls, each of the playable characters, to stop it. The Bachelor was a puppet saving simple dolls from a toy plague in a toy town. This is an inconceivable conclusion in its own right, let alone the implications for the game’s story and metaphysics. At the same time, it was always the most obvious. The player was always an actor, taking a role in the play of Pathologic.

After speaking to the Authorities, the player is invited to the theater to talk with the creators. Ice-Pick Lodge dons the mask of the executor and tragedian, the same masked duo from the beginning of the game. “These children [Authorities] are the same puppets as well, just like the hero [Bachelor]. The true game now goes on between you and us.” They ask why the player still wants to rid this toy town of its toy plague. They imply that the people living in this town made it real, for the Bachelor and the player, and that its reality only exists for the sake of the player. In one of these conversations the player must tell them they are not a puppet, and further clarify that it is the player (not the Bachelor) speaking. The player can reaffirm or rescind their role as a broken and worn down Bachelor. Regardless, Ice-Pick Lodge express interest in how the player will choose to end the story.

Difficulty is what gives Pathologic its texture. Only through lived, albeit simulated, experience can it communicate its vivid mortal struggle. In doing so, the player is worn as well, and the character’s struggle becomes their own, yet it doesn’t become their story. Ice-Pick Lodge skirts the line of soaking the player in its world, and yanking them back out. They want you to feel the Bachelor’s pain, but not tell a new story with it. Ice-Pick Lodge asks us why we still act as a ripped and torn doll for the sake of a toy town, something I suspect they know the simple answer to.