Pathologic 2's difficulty is nightmarish. If this statement doesn’t stir in you the masochistic desire to try it out for yourself, then it’s not the right game for you. If, on the other hand, it piques your morbid curiosity, you will experience the best narrative pay-offs modern gaming has to offer.
Difficulty is a complex topic. Video games that make right use of it tend to score highly for gamers, less for critics. Such has been the case for Rain World, survival horror titles, and even more mainstream ones like Sekiro. The problem is that consumers attach themselves to an image of a “hardcore” gamer and defend their achievements religiously, which is off-putting for casual players who are browsing the market in search for interesting experiences.
It’s common to see how Pathologic 2 is portrayed as lesser when played on an easier difficulty, which, in turn, works as a counterweight, against the developer’s intent, who, needing to increase their sales numbers, introduced difficulty modifiers. It’s a strange conundrum. In the case of this 2019 title developed by Ice Pick Lodge, the hard survival mechanics and soul crushing decision making is intertwined with the narrative; so much so that playing on anything other than the Imago difficulty will lessen the emotional impact of your in-game choices. Trading your boots, which are supposed to protect you from catching a deadly plague, for a loaf of bread, which will only keep hunger at bay for a couple of hours, only makes sense if you’re feeling desperate. Pathologic 2 aims to create a sensation of hopelessness, and hopes to drive you to the brink of desperation, otherwise, how could you possibly feel what the characters are feeling?
The meta narrative of the game focuses on the concept of roleplaying. A game is when people pretend, so your main character is an actor roleplaying a surgeon whose father has died right before the outbreak of a plague that will kill thousands of townsfolk. If you die, your character is taken to an “actor’s room” where the director of the play passive-aggressively encourages you to try again from your last checkpoint, but this time, with more punishing survival metrics.
The game doesn’t shy away from telling you your main task isn’t to save everyone, but to survive. To avoid death, while death takes its toll over the town. Day-to-day survival is complicated by rapidly increasing food prices and a dwindling supply of clean water. In your first days, water is plentiful and food prices are somewhat reasonable, assuming you even manage to make some coin. As the game progresses and the plague spreads, you’ll find that what you once took for granted, like sprinting everywhere and fast-traveling via river boats, is a luxury you’ll most likely not afford. The game gradually tightens the noose around your neck, and never fully lets go until the proper ending.
But the question is: when designing difficult experiences, how do you keep the player from disengaging with the role they’re supposed to play? While Pathologic 2 allows you to fail and not complete your quests, resulting in the meaningless sacrifices of important NPCs, that is not the intended experience. You’re not supposed to bounce through the ordeal, but to find enough intrinsic motivation to push forward.
The game accomplishes this by providing you with a wide cast of important characters you should keep alive by administering immunity boosters, antibiotics, and, if you play well, cures. It’s impossible to not look on the list of characters you interact with and not attach to at least one. You care for orphans, rich kids, stuck-up idealists, lunatics, normies, criminals, and artists. Your main wards are seven children who represent the future of your town, but you’ll also form allegiances with the rulers, and re-kindle friendships with people who care for you but do not want to show it.
Caring for everyone is mechanically possible, but you won’t do it. You’ll not have enough crafting materials, you’ll forget to eat, you’ll do a meaningless quest, you’ll waste your time, and NPCs you like will catch the plague and pass away. In my first playthrough, I had to stop my session at around day 6 after Lara, a compassionate friend of your main character, caught the infection, and I just didn’t have enough to cure her. My best friend died during university, and I had to put the game down. I couldn’t go on. I returned to the game almost two years later, and finished it on Imago, and what I felt returning to the town with my first cure in hand, the elation, the pain… it’s difficult to describe, you have to see it for yourself, if the harsh survival mechanics don’t turn you off.
With your ever-expanding list of characters you need to keep an eye on, it would be easy for you to develop the impression that you’re roleplaying as a hero. In effect, plenty of video games delve into people’s power fantasies, and allow them to experience virtual realities in which they save the day, the princess, and even humanity. Pathologic 2 has to work hard to dissuade you from these notions, because the hero fantasy is inherently at odds with the sincerity of pure roleplay in a cruel setting. For the heroes of modernity, being heroic comes easy. Batman is a billionaire, Superman is a genetically modified bodybuilder, the Dragonborn was blessed by gods. Your character in Pathologic 2, the half-steppe surgeon Artemy Burakh, is just a guy.
His only real advantage is that people in power like him and trust him, for reasons of their own, but that advantage doesn’t manifest heroic ideals. Artemy isn’t good at fighting. He’s a mortal, who suffers from hunger and thirst, whose clothes wither against a couple of germs, who has nightmares after killing in self-defense, who doesn’t quip one-liners, and whose affections run hot-and-cold, depending on the player’s dialogue choices. Much like in real-life scenarios, the cost for Artemy’s heroism is often too great. But when the situation allows for it, and if you’ve played well enough, the sparse wins are exhilarating. The moments when you share warmth and compassion with virtual faces become a reason for living, and a talisman you’ll take with you till the end of your days. If you think I’m being pretentious, remember saving Murky from the plague, if you even managed to do it.
The fantasy you’re roleplaying as is that of an over-protective half-crazed man. While dying of hunger, you’re encouraged to play-act a role while the game reminds you of play-acting through the theater meta-narrative. This meta-narrative only works in the context of a video game; in film, it would make little sense, but here, it shatters the 4th wall to create a connection between the player and the player character. The theme Pathologic 2 imparts, in my opinion, is that of identity through sacrifice.
The theme of identity exists in its own simulacrum, where the characters, who are “actors” through the meta-narrative, play their part, and their role is that of someone who play-acts someone else, often a role super-imposed by tradition and the social order. Artemy Burakh play-acts the role of a steppe surgeon, a legacy inherited from his father, Isidor. Notkin and Kahn play-act the roles of Isidor and Simon Kain through their meaningless bickering, Grief play-acts the role of a criminal kingpin, and the children of the game play-act the preposterous acts of cruelty enacted by the modernized townsfolk against the steppe people.
The question isn’t one about change, but about sacrifice. In becoming killers, arsonists, and looters, and in engaging in pseudo-warfare, the NPCs ready themselves for violent change that comes through the sand pest. Their identity follows a linear progression, but Artemy has choice, something his situationship Aglaya comments on. The role of the meta-narrative is to remind the player of their choice, and of the meaning of their sacrifice: do they sacrifice the Kin, and their miracles, or do they sacrifice modernity and industrialization.
Artemy, being the only character with choice, gets to make one even if the player fails at fulfilling even the most basic of duties and sleeps through the whole game. Some players consider this a weak point in the story, but the theater play should remind you that, in the end, you’re roleplaying, an act that happens in one’s head, where there are no “real” consequences. Much like the children of the town, you’re play-acting cruelty and death to find meaning in suffering.
The suffering and stressful gameplay would not work without the fine-tuning of all survival mechanics. But much like Artemy suffers the consequences of his father’s actions, and is doomed to repeat them, Pathologic 2 suffers because of its prequel’s reputation. Pathologic Classic is a video game that YouTubers claim to suffer through so their audience will not have to. (I stole this from hbomberguy). Some people claim Classic is playable, but the amount of jank makes it difficult for even the staunchest of masochists to take it seriously. Much like Rain World, Classic's “bad parts” overshadow it to such an extreme that only evangelists will bother talking about it, leaving regular gamers with skewed perspectives that carry over the sequel. Classic is considered inhumane and janky, so people assume Pathologic 2 will be inhumane and “Eastern European jank.” (I stole this from Mandalore).
The audio-visual presentation of the game can be clumsy, indeed. The town is awkward to navigate because the streets are designed to make you take weird U-turns around blockages, to make you more stressed out about traversal, and the in-game street planner (Yulia, my heart) says it was intentional. The duplicated NPCs can break immersion, but consider that there are unique character models for each one of the wide cast of named characters, including Artemy. This is, quite frankly, an almost insane commitment to breathing life into the game.
Pathologic Classic had a problem with quest structure, in which you’d receive your daily quests from letters you’d need to know you received based on a goofy sound. To fix this “sin of the prequel”, Pathologic 2 adds to its own impression of jank by re-structuring the advancement of the plot via random NPCs who spawn out of nearby buildings to tell you that the “story needs to progress, make sure to visit an NPC in the other part of town.” My favorite instance of this type of shit is when Artemy has a dream that tells him to go a couple of hours of sprinting outside the town, in a settlement called Shekken, deep in the steppe. Next day, on day seven, Artemy gets another quest marker, in the same place, still a couple of hours of sprinting away, because that’s where the developers decided to spawn the NPC who will let you inside the Termitary, where the Kin were held prisoners for the majority of the story. This particular instance is, in my opinion, crossing the line, even if the quests are designed to waste the player’s time. Your initial goal, to find the person who murdered Artemy’s father, becomes a second-class quest, and for a few days, the town’s governor will attempt to look good in the eyes of his peers by arresting murder suspects who are never the culprit. If you decide to follow this series of quests, you will waste your time. There is no other way to say this, but there is a fine line between designing deliberate quests that fuck with the player, and artificially adding annoying circumstances, like going to Shekken two times in a row. The latter undermines the player’s efforts in ways that feel artificial.
Balancing these possible quest outcomes is difficult, which is why Pathologic 2 doesn’t have much in the way of branching quests and dialogue. Plot points come linearly, and your job, if you decide that protecting the children assigned to you by your father is important, is to follow up on clues before the next quest marker pops up on the map. This is a weakness of the game’s narrative, because as comfortable as the developers were with fucking with the player, they don’t seem too comfortable with letting the player fuck up the main quest. This is why other NPCs will do your job for you, do it poorly, based on no evidence whatsoever, then die without much in the way of an epitaph. Granted, Artemy isn’t a very logical individual. His understanding of the world is half-based on the rationality learned from his training as a surgeon, and half based on the folklore of the Kin. His major clues come from dreams and intuition, which feels a bit jarring when you’re tasked with containing the plague, because at no point does Artemy need to make a case for his ideas. As much as Pathologic 2 is a trash-digging simulator, the powerful people in the town have a weird, unearned trust in Artemy, because otherwise the player couldn’t advance the plot. Artemy’s first conversation with Aglaya the Inquisitor is something like: "I found a cure.", "That’s great! Did you test it?", "Yeah, it works, but I don’t know how to make more.", "Are you fucking with me?", "No.", “Okay, cool. See me in my chambers from time to time.”
That, and the important characters could become infected and die. The developers needed to implement safety measures so that the game doesn’t end abruptly based on the infection’s RNG. The decision to include RNG for day-to-day infection is an… interesting one. It adds to the general stress, but this creates a subtle problem. Notkin, one of your wards, gets infected on day four. From there on, he’ll keep getting infected until he inevitably dies, and the way to keep him alive is to feed him Shmowders, which are “miracle” cures, aptly described by Dankovsky as a “monkeys and typewriters” type of situation. Okay. So it’s fine to introduce faux-cures in the game as a way of covering your binary RNG-based mechanic while you hold a firm grasp over my balls with linear narrative progression. Artemy discovers a cure on Day 6, and only gets enough to make more than a couple on day nine or ten. Shmowders suck. They are rare, needed, costly when trading with the kids, have no in-game explanation, and work as a get-out-the-jail free card to counteract the effects of RNG. They also diminish the efforts of the player, who might get fucked over by the survival mechanics long before the game says: “Okay, fine, here’s the cure dream.”
This is a classic problem of video game narratives. Flexible designs let min-maxers destroy in-game economies and bend the plot to their will, at the expense of the story’s themes. Rigid structures feel tacked-on and meaningless, leaving the player with a sense that they’re watching a movie. For the most part, Pathologic 2 keeps a good balance, but the most important moments come so out of nowhere that playing the game without a guide is sub-optimal, further discouraging new players from giving it a chance. Meanwhile, memory and experience with playing the game matters more than direct effort, which further disincentivizes engagement with the side quests, and in turn, makes side characters feel paper thin. I once had Andrey Stamatin get an “In danger” status because he was living in an infected district, but he showed up near the Cathedral to meet the inquisitor, even had a couple of new lines of dialogue for me, but I couldn’t give him an immunity booster because he wasn’t in his fucking designated map area. So when I saw him next, I thought to myself: “Fuck him, who even is Andrey Stamatin?”
I realize that keeping track of all these possible situations is impossible. But the game bloats itself with side content because it was meant to be a three-part campaign, seen through the eyes of three playable characters, leading to asymmetrical storytelling, which is not only rare, but almost never done well. Classic Patholohic does it well at the cost of a shitty campaign for Clara and too much jank. Pathologic 2 leaves a bunch of bread crumbs that go nowhere because they’re meant to be uncovered in the next installment. I’m not sure if this should count as criticism, though. It’s one thing to say “play through one of the most harrowing experiences for the story”, it’s another to say “play through three games that have half a decade in-between them to learn what’s the deal with a nobody like Eva Yan.”
This sensation that the game stretches too thin becomes apparent in the last few days. Side content becomes non-existent, leaving you with a wild goose chase across infected districts to administer panaceas to your surviving wards, each isolated in their own bubble, then do nothing of importance on day eleven. The dullness of managing the daily survival grind starts a weird loop of visiting either Var for organs or the bartender for herbs, then the kids for the map of the infected districts, then the Town Hall, then the hospital. After the hospital shuts down, and the Town hall stops handing out work, there’s not even a routine to ground you in the narrative, just menial runs between houses with checkpoints. I can’t help but feel that cutting out at least one of the canonical twelve days might have helped. On the other hand, it’s possible the development resources were just as thinly stretched, and that we might’ve seen more interesting content in the last couple of days. As much as I like the survival mechanics of the game, they work because of the superb story, and I feel that when the story loses steam, so does my motivation to keep pushing. Couple this with a few early deaths, and it’s easy for the player to consider “restarting” the playthrough instead of pushing through.
Pathologic 2 applies survival metric penalties for in-game deaths. This means that, even if you reload a save, your penalty will be applied. But the only way to get out of a bad situation (a death loop, as the community calls them) is to reload at least half a day prior to your moment of glory, when all your metrics flash red and you’re collapsing into Mark Immortel’s boots. In essence, it’s refined save-scumming. You might think that a game about shouldering the consequences of your choices will protect you from save-scumming, but… not exactly.
Before I delve into this, understand my bias: I see nothing wrong with save-scumming. Certain genres like metroidvanias, souls-likes, and inmmersive sims are built on the back of save-scumming. Pathologic 2 isn’t different, but looking under the hood undermines player efforts in unexpected ways. For example, you can (and in my opinion, should) save-scum administering antibiotics. The game seems to assign the “infected/in danger” and “dead/survived” binaries somewhere at the beginning of the day, and I have a sneaking suspicion it does the same with the needed antibiotic for infected NPCs.
Administering antibiotics happens in its own mini-game of using tinctures and pain-killers, which will consume a laughably large amount of both herbs and morphine. However, if you have the chance of saving right before administering an antibiotic, you’ll notice the correct one stays the same across multiple reloads. That way, you can rock-paper-scissor your way into the right antibiotic without losing tinctures or morphine. Is this cheating? I think it’s playing by the game’s rules: if Artemy can “dream” his way into the cure, he can intuit the correct antibiotic based on his “understanding of the Lines.” And since Mark Immortel doesn’t show up with a spatula to whack me over the head with because of my bad behavior, there isn’t anything to stop me, is there? I’m bringing this up because people tend to take save-scumming too seriously, and this is a meta-narrative game about an actor who tries the Artemy role as many times as it’s needed.
Knowing this “exploit” undermines the “sanctity” of the dice roll. What’s the point in not waiting the entire day until reloading to see which character needs help the most? And if some NPCs die no matter what, this brings us back to the Shmowder problem, which kind of renders the game of diagnostic useless. What’s the point in collecting herbs and brewing antibiotics when you could hoard Shmowders? Granted- I don’t see a better way of designing this, short of giving the player more resources for crafting cures earlier in the campaign. But that would also mean more combat, and, well… no.
Combat is designed for you to get around it, which is an achievement in restraint. Most developers plaster bad combat systems front-and-center, but Ice Pick Lodge had the bravery of making walking the primary game mechanic. This is not a jab, by the way. I hate bad combat systems super-imposed on video games without substance, and Pathologic 2 has both substance and enough mechanical intrigue to keep me going without worrying about the next fight. Combat is purposefully brutish and shit; you’re not supposed to think a fight is a solution to any problem. People will sometimes claim they’re fighting looters for organs, but I don’t see how that is a more functional way of making cash than selling some of the hundreds of herbs you’ll be gathering over the course of ten days. The only time when combat is required is when you collect blood samples to make a cure close to the final day, and I’m proud to say I’ve save-scummed sneak attacks to hell and back to minimize the chances of death. What’s the point of getting a penalty, if the reload is the same?
The more I think about it, the more I think Pathologic 2 is a game about finding ways to game the systems, rather than confining yourself to the inconsistent and arbitrary rules set by the developers.
Would you like to know an inconsistency that bothers me? Artemy can lockpick his way into poor people’s houses to steal their five marbles, but for some reason, not even with a fully loaded shotgun, can he rob stores. This bothers me because it’s an infinitely more intelligent solution to abject poverty than breaking into infected houses. And it wouldn’t take much to implement either: just make it so that if Artemy does something like this, no other shop in town will open their doors to him, not even the guy who will keep selling food for money after Aglaya’s arrival.
Aglaya is an interesting character. Her role is to solve the plot, whether or not Artemy manages to keep his children healthy. She’s the one who figures out the origins of the plague, and she’s the one who proposes a solution and who sends couriers in the last day to tell General Block that he should play “destroyer of worlds” with the spiral-looking thing in the western part of town. This particular plot point definitely feels like someone rushing a half-baked pie out of the oven; it’s blatantly clear Ice Pick Lodge ran out of resources for the last day of the campaign. I can’t buy that the intent was to make the player feel like their efforts were in vain because Aglaya could have solved the plague faster if she didn’t waste time day-dreaming about Artemy’s biceps or talking shit with Grief. It’s the one part in the game I genuinely despise, and hampers my motivation to push through the clusterfuck that is day eleven.
Obviously, all the criticism comes from a place of love and admiration. Pathologic 2 isn’t the type of game that people finish, judging by the Steam achievements. In 2025, only around 10% of people finished the game with any of the two main endings, either on default difficulty or not. More than three quarters of all people who even buy Pathologic 2 manage to get past day elevent, which, to me, highlights that: a) the game didn’t sell well, and b) it doesn’t seem that adding difficulty modifiers did that much to the reception.
I think, purely as a speculation, that the primary reason for Pathologic 2's sales flop isn’t the difficulty, but that it’s hard to classify it as any particular sub-genre. I’ll come back to this, but to prove that the difficulty isn’t that much, I’ll provide you with the simplest possible guide to finish the game on the default Imago setting:
To me, these tips are simpler to apply than it is to learn how to play Sekiro or Rain World or Cuphead. The game’s difficulty comes primarily from time management because you don’t have enough time in a day to complete all quests, and that’s by design, since you shouldn’t try to complete all quests.
Unlike the handful of YouTubers who reviewed the game, I don’t think this is something average players aren’t used to. Almost nobody completes all existing quests in a large RPG, for example. Pathologic asks you what do you think you should complete, then watches you as you choose poorly, die repeatedly, and become frustrated with the survival mechanics.
The survival mechanics tie the narrative well; unlike games that are about exploration, Pathologic is about sacrificing a quest to complete another quest, and your hunger meter is a reminder that you can’t do everything. Without the survival mechanics, people would expect to complete quests at their own leisure, but because the narrative can be heavy-handed, the devs need to treat the players like children and remind them they can’t. Preferably, gently. But Pathologic doesn’t do gentleness. There is a coarse and almost patronizing tone to the meta-dialogue, which prompts an aggressive response from critics who are used to more menial experiences.
Take, for example, Soma, which I also love. In Soma, you make interesting and heavy choices, but there are as many of them as there are in a couple of hours of Pathologic 2. Gamers were not used to this type of experience, and unfortunately, Ice Pick Lodge didn’t design from the ground up, but had to tweak a janky game into a functional campaign. If Dankovsky’s route in Pathologic 3 will be good, there’s a chance Pathologic can become a serious franchise and sell more copies. But as it stands right now, Pathologic 2 had to rely on niche YouTubers to market itself. Most of them don’t do a good enough job of “defining” the game’s subgenre, so people are left confused. I mean, what precisely are we playing? It’s not a survival horror because there aren’t enough zombies to shoot. It’s also not a “walking sim”, or a “visual novel”, or whatever insults we like to throw around now, because Pathologic 2 has gameplay mechanics. It’s also not an “open-world” game; the town is more akin to a hub area, like the one we saw in Thief: Deadly Shadow, than to… I don’t know, the Imperial jungle.
Possibly the best way I can conceptualize Pathologic 2 is as a “stress simulator”, but this isn’t a genre, and game designers don’t design good difficulty levels in general, so we’re left with a relic. I’m also unsure if 2019 was the “best” year to release a video game about surviving an deadly plague, either.