Hospital Design in Digital Games: St. Mary’s Hospital in The Last of Us
With the outbreak of the Corona pandemic, hospitals increasingly became the focus of public attention. Few news stories today, whether in newspapers, on television or on social media, can do without explicit images of occupied hospital beds in intensive care units. Bright lights, white and light blue clothes, tubes, electronic devices. A world that is foreign to us and yet familiar at the same time, since these media imaginings are not new insights into a formerly hermetic world for the vast majority of us. Not only have we all had our own experiences of illness or accidents that have given us a patient’s perspective on hospitals, we also believe that we have gained an insight into the everyday world of hospital staff through popular cultural imaginings of hospitals: In the early 1980s, it was San Francisco Memorial Hospital in Trapper John MD and the Schwarzwaldklinik in the series of the same name, in the 1990s, it was Chicago Hope in the series of the same name and County General Hospital in Emergency Room. In the 2000s, in particular, Sacred Heart Hospital in Scrubs and from the 2010s until today, of course, Seattle Grace Hospital from Grey’s Anatomygained media notoriety. In the examples mentioned, hospitals are staged as optimised places of efficient healing (and romance). The spaces medialised in this way often became the first contact with places otherwise foreign to us, beyond the outpatient clinics and sickrooms. They define a framework of the thinkable that can potentially also influence our later experiences with these spaces by conditioning certain expectations. Of course, we are aware that these are media fictions, and yet we develop a horizon of expectation here. In addition to the aforementioned positive stagings of hospitals as places of healing, there also existed terrifying stagings as places of dying and suffering, especially in the horror genre. While psychiatric hospitals in particular became popular settings for horror films from the beginning, we encounter general hospitals comparatively rarely in horror films.
The Hospital in Popular Culture
The situation is a little different in digital games. Here, too, we find translations of the efficiency topos, for example, in hospital management games like Theme Hospital and Two Point Hospital. Likewise, in narrative-heavy games, we find stagings of the hospital as a stage for individual dramas, for example, in Life is Strange: Before the Storm and This Dragon Cancer. In action games and horror settings in general, on the other hand, we almost exclusively encounter the dark side of the hospital: in Left4Dead it is the Mercy Hospital overrun by zombies, in Silent Hill 2 the disturbing nightmare world of Brookhaven Hospital and in Max Payne 2 a dark, nameless hospital in New York. Especially in action games in the broadest sense, hospitals become the stage for virtual threats. The corridors and treatment rooms become a labyrinth. The next danger could be waiting behind every door. The hospital becomes the staging of the threat. Mostly, however, hospitals are abandoned places in the sense that they are no longer used in the original sense, but are only a backdrop or stage.
The Last of Us
An impressive example of this, which – albeit unintentionally – also has strong resonances with the current Corona pandemic in several respects, is the game The Last of Us (2014). The game designs a post-apocalyptic world in the aftermath of a devastating pandemic that has led to the collapse of all infrastructure worldwide. In the game, the pathogen is an aggressive cordyceps-fungus that turns its human hosts into mindless predators. Even though they are not called that, these largely correspond to the topos of the zombie. A large part of humanity has probably died, most cities are now deserted and overrun by animals and the infected. The surviving military has set up a repressive police regime in individual US cities and is fought by rebels called “Fireflies”. They, in turn, have set up a research lab in the paediatrics and other wards of an abandoned hospital in otherwise deserted Salt Lake City to find a vaccine and cure for the fungal pandemic. In the game, we take on the role of a smuggler who, rather unintentionally, is supposed to escort a young girl from Boston to the aforementioned hospital on behalf of the Fireflies. It turns out that the young girl Ellie is immune to the fungal infection. Over the course of the game the two become closer, after months of travelling and fighting a father-daughter relationship develops. We can assume that the players also develop a para-social relationship here. Once at their destination, however, the father figure Joel has to learn from the Fireflies that Ellie would not survive the necessary surgery on her brain to investigate her immunity. While she would presumably have been willing to make the sacrifice, she was not informed of this by the doctors and is already being prepped for surgery when Joel decides to save her. To do so, he must fight his way through the corridors of the hospital now used by the Fireflies as a research facility. After long firefights, Joel finally kills the surgeon and his team and escapes with Ellie. The brief retelling of the plot of this game, published back in 2014, already reveals many unintended (but not accidental) resonances with current perceptions of the Corona pandemic and vaccination. In the following, however, I will focus on the staging and design of the hospital level in order to explore the question of which means were used to achieve which effect.
St. Mary’s Hospital in The Last of Us
The players get to know the virtual corridors of the mostly abandoned hospital at night. The rooms are usually only sparsely lit. The interior design of the ward is functional at first glance and – in comparison to other popular culture depictions of hospitals – appears immediately familiar.
The perforated ceiling panels are also familiar in Europe from mostly public facilities, as are the practical tiled and artificial stone floors. On the walls we recognise coloured lines that seem to serve as the hospital’s signalling system. In contrast to Until Dawn, where the signalling is used in the game to guide the players, here it only serves decorative purposes (at least superficially). Their purpose is not clear to us, if only because we can only enter and explore a small part of the hospital. Individual walls at the reception and in several hospital rooms are covered with wood veneer panels. The lighting mostly comes from clad neon tubes and halogen lamps recessed in the ceiling, less often from indirect light from shielded wall lights.
Apart from these wooden elements, the colour scheme is light and tends towards greyish. At first glance, everything gives the impression of a plausible US hospital environment. In individual hospital rooms, there are upholstered armchairs, side tables and table lamps that are apparently intended to evoke a homely atmosphere. The impression is that the design had a positive effect on patients in a pre-apocalyptic world. This historicity, i.e. the emphasis on a closed past, is reinforced by the fact that the furniture and design already look outdated and are reminiscent of the furniture design of the late 1970s and 1980s. In addition, the walls are yellowed or full of damp stains, the rooms are untidy and have obviously not been used for a long time.
A normal hospital ward is followed by a children’s ward. This is distinguished by isolated colourful murals. In one corridor, the wall is designed as a sea horizon with sun and sailing boats. In the individual patient rooms, too, various colourful elements on the walls and floor are intended to provide the children with a more cheerful environment. Similarly, in the treatment rooms adjoining the operating theatre, the walls are painted with animal scenes and forests.
On the way to paediatrics, however, they first have to cross an improvised quarantine station. The entrance to this is marked by makeshift chipwood boards fixed to the walls and transparent plastic curtains as icons of the airlock, as well as an oversized warning sign for risk of contamination. The interior of the spacious quarantine ward is also marked by chipboard walls and gathered plastic curtains, which are meant to provisionally separate individual treatment rooms from each other. In fact, it is not clear what purpose the curtains are supposed to serve, as they cannot seal off the cordoned-off areas, but rather hang freely like shower curtains. In addition to mobile beds, these compartments also each contain tables with water basins as well as microscopes and test tubes, i.e. widespread iconic references to research (see fig. 6). Here, too, in contrast to the otherwise very thoughtfully furnished rooms of the infirmary, it becomes apparent that all objects have an iconic function in the game, but would be pointless in a corresponding reality.
However, it must also be said that such a thorough examination of the surroundings is not intended by the gameplay, as the stations only serve as a stage for continued firefights. So there is basically no time to take a closer look at the painted walls of the children’s ward. When I stopped briefly in the game to take a closer look at the surroundings, my avatar died almost instantly in the game. So, under normal game conditions, the hospital functions only as a stage. Its function is to further set the stage for both the battles and the narrative climax – Joel decides to save Ellie from surgery, even if it means accepting that no cure can be found – and to offer a course of obstacles and environmental demands on shooter gameplay. Ultimately, only the three-dimensional form matters here; the semantic design of the surfaces is secondary. 
The decision of the game character Joel is ethically fundamentally ambivalent: the narrative dictates that the main character / avatar puts the good of his family above the good of society. The decision is prepared in the course of almost eleven hours of play through a narrative convergence of the two main characters, but in the context of the final “level” it should appear, if not right for all players, at least comprehensible. Visual rhetoric is also used for this purpose.
On the one hand, the level design serves to make the scenario – within the bounds of possibility – appear credible (ethos), i.e. the hospital environment must appear plausible and meet the expectations of the players. This is evident in the attention to detail given to the hospital interior. Each patient room is slightly different from the others, right down to individual brochures and posters with hygiene rules. The environment is meant to appear at least latently familiar, also to make the taboo-breaking – the life of a teenager is to be sacrificed by doctors in order to find a cure – seem even more serious. This brings us to a second function of level design: the emotional activation of the players (pathos). This is most evident in the choice of a children’s ward as a level. Scattered toys, children’s drawings and murals of zoo animals suggest a safe place for children, a place of healing.
Apart from this narrative function, the visual design of the hospital ward also serves horror. Hospitals are very real spaces for most people because they are frequently experienced, but at the same time they are ultimately hermetic because they function according to a logic that is foreign to most people. As patients, we are at the mercy of people whose language and actions we do not understand. The unclear inner functional logic of hospitals is certainly one of the reasons why hospitals are often used as settings in digital games.
This rhetorical function of the environment is contrasted with the game-mechanical function. In other words, the level must allow balanced fights and at the same time orient the players in the right direction. This is shown above all by the fact that only some corridors and rooms are accessible – doors leading elsewhere are blocked, but above all by the fact that all rooms are far too large in direct comparison with real hospitals. Single-bed rooms are the size of six-bed rooms in the real world. The same applies to treatment rooms and offices. In the heat of the moment, the environment can only be perceived marginally by the players. What remains are fleeting impressions and a general atmosphere.
As shown, the hospital serves several functions here: it is a practical stage for the struggle, but it also supports the narrative and generally serves to maintain an unsettling and frightening mood of the game. But it also communicates an ideological statement: it shows the world of medicine as an alien world that acts according to its own ethical principles, which do not necessarily coincide with the ethical principles of the patients.
No matter how interesting such a close reading of a game level – even against the intention of the game design – may seem, there is always the question of the desired gain in knowledge, if it is not to remain just a description. In the absence of fundamental research on the question of knowledge transfer in digital games – such research is only just beginning to emerge – the above reflections mainly posed new questions rather than answers. Since we can assume that knowledge transfers take place in games, but that players are also always aware that they are playing, i.e. that they perceive the game critically, it is difficult or impossible – based only on the game description itself – to pursue the question of what form of framing is taking place here. For example, can such game scenes influence players’ attitudes towards hospitals in the medium and long term? Does an unconscious activation of the game experience take place when players later (have to) enter a hospital themselves? Empirical studies would be required here, which of course would also have to take into account potential socialisation moments in other media.
What can be said with certainty based on my observations is that hospitals work particularly well as levels in action-heavy games because we associate an immanent ambivalence (healing / suffering) with them even before the game.
 Many thanks to Arno Görgen for this thought.