Given powerful low-level Clerical healing, how can sick, crippled or otherwise unhealthy people exist?

Question

In my attempt to make a more harsh, uncaring setting, I’ve hit a stumbling block in terms of the ease with which even low level Clerics can treat the poor and the sick:

• A 1st-level Cleric can bring most commoners back from the brink of death (Cure Wounds), Detect Poison and Disease, and Create Water.

• A 3rd-level Cleric can completely eliminate a disease or a case of poisoning (Lesser Restoration), twice every 8 hours.

• A 5th-level Cleric can Create Food and Water, and treat most magical-related illnesses (Remove Curse, Dispel Magic).

This would lead me to believe that the presence of a single first level Cleric in a small community would render broken bones or debilitating injuries (accidental or otherwise) a non-issue. Nobody has to fear the result of falling off a ladder, mishandling an axe, or getting into a bar fight. At slightly higher level, a Cleric could ensure suffering from most diseases would be a thing of the past - the moment you start to cough you could just get the Cleric to magic your disease away.

Of course, Clerics may charge for their services, which would make them out of reach for the poor or average commoner. But this market would be rendered obsolete by a single charitable, "lawful good" type Cleric willing to offer his services for free. Furthermore, if a commoner suffered a broken arm, and a Cleric condemned him to life as a cripple by insisting on being paid to heal him (something that would take moments of his time and cost him virtually nothing), I don't imagine that Cleric would be particularly welcome in the community for long.

So in a nutshell, given that even a low level priest is probably not uncommon in most villages, let alone big cities, how can the presence of crippled, diseased or unhealthy people be justified? Are the streets in D&D remarkably absent of people with limps, broken bones, bad backs, the hungry, the blind and the sick?

Answer 1

You need not change anything about the default setting in order to have people "left out" of the benefits of clerical magic.

I don't think that clerical spellcasting is as easy to come by as you make it out to be. In other words: you can easily have your harsh and gritty world. In what follows I'll always lean toward the more-utopian interpretation of things, lean on the rainbows-and-unicorns end of numerical ranges, and I think you'll see there's still plenty of room for gritty/harsh living conditions. Obviously, then, if we dial back any of those happy-happy-joy-joy assumptions we can make things even harder for people.

Demographics

You've told us you want a harsh, uncaring setting. Luckily, much of our history on this planet has been conducted in that setting so we've got lots of data to go on. I'll point you toward my favorite such tool--Medieval Demographics Made Easy--which helps us imagine D&D's pseudo-medieval implied setting using the tax rolls of 13th-C France.

This gives a baseline of one "clergy" per 40 population, and one "priest" per every 25-30 clergy. For your purposes I'm going to interpret "clergy" as an unleveled acolyte, and a "priest" as a leveled cleric.¹ That means that we find a leveled cleric every 1000-1200 population.²

Villages/farmlands/wilds

Villages (according to MDME) top out at about a thousand people, so let's assume we've got a 1000-person village with one L1 cleric serving as its priest. That's two first-level spell slots per day for a thousand-person village.

In the case of illnesses remember that we can only cure two people per day. I don't feel like running a full S-I-R model here,³ but we don't need too-extreme of infection and recovery rates to overwhelm the "bonus" recovery from spellcasting. And curing an illness requires a second-level spell slot, requiring a third-level cleric!

In the case of extreme injury, just remember we only need three people seriously injured to overwhelm our poor country cleric. I've never erected a barn or taken down a tall tree, but I can easily imagine three simultaneous injuries. If a cleric can heal two but has to wait until the next day to heal the splinted broken ankle, there's your limper.

Accidental death. Let's talk size: sticking with medieval France we get a population density in arable lands of about 100 ppl/mi\$^2\$. So this village and its lands occupy about 10 square miles, or about a 3-mile (diameter) hex. Recall that without help you may only have 21 seconds of life left once you hit 0hp. The odds are not good that this accident happened within 20 seconds of our cleric =(

Cities

Cities (again, using MDME's classifications) range around 10,000 people.⁴ Using the same numbers as above we see that a 10K-person city should enjoy only ten leveled clerics.

But notice that the underlying numbers don't really change all that much. Travel times may go down, and with more casters we'll have some of higher levels (and more slots). But there are just so many people...

Again being generous, let's assume one cleric of each of levels one through ten, and that they use fully half their slots on daily petitioners. That's 45 spells to cast for ten thousand people, or 93 spell-levels for hoi polloi. All you need is more than one percent of the population to "need" something on a given day and you'll overwhelm the daily petitioning system. 2% would overwhelm the entire clerical-magic capacity of the city. One disease, a fire, even just a day when one of the high-level clerics is tied up in bureaucratic argle-bargle will leave some unfulfilled.

Turning the dials

Let me briefly summarize the assumptions made, and how changing them will change things:

• "Clergy" are not casters, only "priests" are. They are as abundant in D&D-verse as in medieval France. Obviously, in a world where the gods walk the earth there might be more priests. But keep in mind (a) there's also the lure of arcane casting; (b) clerics are also needed to deal with the undead hordes/curses/magically-fueled religious wars inherent in such a world; and (c) somehow the D&D-verse hasn't figured out any better agricultural technology than the moldboard, so we still need 90% of people to be involved in food production.

• Farmland is really rich so the region/kingdom/world is pretty densely-populated. Drop population density down to 30 ppl/mi\$^2\$ (like 13th-C. England) and one's proximity to a cleric drops commensurately.

• City-based clerics spend half their spellpower helping "commoners". This one I see as a fun dial to twist. If I know anything about bureaucracy at least one or two of them definitely aren't getting their hands dirty. Perhaps some orders are martially focused and so are embedded with a standing army and none of their clerical spells go to (directly, immediately) help common folk. Perhaps some order devotes 100% of its divine power to such works. Perhaps some order has grown world-spanningly-huge and spends much of its time maintaining its own bureaucracy. These are huge cultural differences that can really change how the world feels.

• The cleric in a village is a L1 caster. But one can imagine that a village where a L15 cleric has retired would be a little green patch of paradise: he attends all childbirths, so mother and infant mortalities aren't a thing. Droughts/blights? Create food and water'll sustain people and seed crops well enough to get through. Village festivals (to the cleric's god, obviously) come with a Hero's feast.

Bringing it back to reality:

The situation you describe isn't fundamentally different from our own world. There are people with physical troubles, and there are some with the power to alleviate those troubles. Why, then, do we see people in difficult circumstances? Proximity, access, cost, &c all play their roles. The same is true in the D&D-verse.

In some places charities step in. In some places social structures embody greater sympathy/antipathy toward the problem. But spell slots are a limited resource and so will evolve into their own economy, just like anything else.

---

^{1 - This, effectively, is exactly what @timster argues for in his answer.}

^{2 - If it seems I've queered the deal from the outset by declaring "priests" to be leveled clerics rather than "clergy" (and thus dialing back by a factor of 25 the number of available clerics), I urge you to consider the alternative: 2.5% of people are leveled clerics. Given twelve classes and assuming clerics are one-twelfth of leveled characters we see 30% of the population is leveled.}

^{Sticking with pseudo-medievalism we've got to have ~90% of the population involved with agriculture, though. So not only could you have every non-farmer a leveled NPC, one out of every five (roughly) farmers would still be, too! That's not really the setting implied by most published material. (But it's kinda a cool one, methinks. Every time you stop for dinner you've got to listen to the barkeep's old campaign stories, then the stablehand's old campaign stories, then the lamplighter's old campaign stories....)}

^{3 - okay, that's a lie. I really want to run an SIR model incorporating a clerical healer and I did. Assuming the cleric (a) doesn't get infected ever, (b) can get to and heal two people per day, (c) healed people now have immunity and can't re-infect, and (d) the same epidemiological parameters as the SARS outbreak in Hong Kong in 2003\$^5\$, we get a peak infected population of ~15% the total population; 150 people have this disease on the outbreak's worst day. The cleric, healing two a day, just doesn't do very much for those people; there's plenty of room for some disfiguring illness to scar people. (The cleric does have a huge effect on ramping down the "long tail" at the back end of the outbreak.)}

^{Admittedly, the underlying SIR parameters may be badly constructed for this setting: people are less-densely packed and don't travel nearly as much. But then again, hygiene and sanitation are much worse and the population may be starting at a less-healthy baseline. In short, I'm not a medieval epidemiologist, just an amateur mathematician with a copy of MATLAB.}

^{4 - This may seem small to us--it's the size of the suburb I grew up in, for instance--but "a typical large kingdom will only have a few cities in this population range." (MDME)}

^{5 - Razum, Beecher, Kapuan, Junghauss. "SARS, Lay Epidemiology, and Fear." The Lancet, May 2, 2003 + analysis of these data in one of my modeling classes in grad school.}

Answer 2

True Clerics are rare

The Player's Handbook points out that not all a deity's clergy are "clerics" who have magical healing powers.

Not every acolyte or officiant at a temple or shrine is a cleric...True clerics are rare in most hierarchies.

(Divine Agents, PH, p. 56)

"Magic and strength of arms" (also PH 56) are not available to every devotee of a deity.

And that's just the standard guidance in the PH. Your world could be even grittier, where clerics gifted by their gods with magic are exceptionally rare. (One could see afflicted commoners beseeching the party for healing whenever they come into town.)

Magic powers in 5e are rarer than in older editions

This change in what powers the typical village priest might have is reflected in the published modules/adventures from the game creators.

Just one example, comparing the current introductory module to an older one, in (1981) Keep on the Borderlands:

The "Curate" of the Keep's chapel is a fifth level cleric. (p. 11)

While in Lost Mine of Phandelver :

The local "cleric" is a commoner (p. 15) with no magical abilities.

Answer 3

This is a common misconception that founders on the shores of how real life works.

There's Not Enough Healers

5e doesn't have any metrics on the distribution of leveled individuals. 3e/3.5e did (Chapter 5 of the 3.5e DMG, p.103), and there's not a lot of reason that would have changed, for the sake of argument let's use them. A 200-person hamlet would have a max leveled cleric of 1d6-2 (and then double each level under to build a pyramid, if you get lucky with a roll of 6 and get a level 3 cleric, you have 2 L2 and 4 L1's). On average, though, you have 1-2 level 1s and 0-1 level 2's.

Disease Spreads

This means disease has no check upon it, and a handful of injuries a day can be handled. In larger cities where you might have more casters, you also have infected people coming into contact with each other at a much higher rate than they have Cure Disease spells - in a major city, even 10 Cure Diseases a day won't stop any kind of disease. People aren't sure they're sick during the incubation period. Even worse, when people survive a disease normally they usually become resistant or immune; if magically cured they are just as vulnerable to their kid who's also infected but not showing symptoms yet. Note that germ theory is not understood in your usual medieval/Renaissance based fantasy society. Real severe illnesses greatly outstrip any reasonable level of spellcasting in their spread; I recommend you go read The Great Influenza (John Barry) for a great modern day example.

Not All Casters Care

Also note that you're assuming all these clerics are Happy Local Catholic Style Priest Guy - but 1/3 of them are evil and worship some god of spreading pain and disease anyway. Assuming they're all helpful is totally not justified. (Heck, those guys will be causing disease and blindness...)

Cure Wounds Doesn't Heal All Injuries

Let's take other injuries. First of all, Cure Light Wounds cures hit point damage, not crippling injuries. Broken bones, severed limbs, blinded, etc. - no help. You have to be much higher level. And with other injuries, if they are near fatal, you need to be very close to get help before you bleed out. So that limits it to "not quite fatal" wounds.

How Do You Allocate Healing?

And here's the real problem - so if you have one Cure Light Wounds, and you use it on the guy who comes in that morning with a cut that needs 10 stitches and could get infected - what happens at 3 PM when someone gets a life-threatening injury? You don't have the luxury of hindsight. Do you do first come first served? Do you hold on and not spend it on anything that's not life-threatening? Do you prioritize those of your faith? Do you prioritize those who can pay? Same with diseases. Even the flu can kill someone, so do you just heal the first disease of the day you find? A 2009 Gallup poll found that 1-4% of people in the US had the flu on any given day. In a medieval setting without modern sanitation it would be much higher. There will always be more people that need healing than you can heal.

We have all kinds of technical marvels today, and it's the same thing. Why isn't the world all perfect? Why we have drugs that cure a bunch of stuff... But drug companies decide to charge $1k/pill. We have plenty of food and medicine - but not in poor countries, and even there aid shipments are captured and co-opted by local warlords. All these same factors apply to anything valuable. Consider how "Game of Thrones" world would treat one local guy who can cure wounds? He gets bribed/tortured and taped to the leg of the local ruler, with orders to only use healing on him. Unrestricted do-goodering is rare and even when it is allowed the resource allocation issue can make it ineffective.

In the end this is always a hard discussion to have because the answer is "you need to have more insight about how real world societies work," which is only gained through experience and learning, a single answer saying "that's a goofy question because societies and economies don't work that way" probably won't fix that for you. But in the end, that's the answer.

Answer 4

Cure Wounds doesn't cure wounds: it restores HP

From the 5.1 SRD, page 96:

Hit points represent a combination of physical and mental durability, the will to live, and luck.

Hit points are an abstraction: It is not the case that every lost HP represents a physical wound on the body. Make this explicit to your players, but it doesn't seem too much of a stretch to say that not every physical wound results in a loss of HP.

Logically, this could lead to a world where Joe Commoner falls off a ladder and breaks his arm, but the local Cleric can't do anything for him. In this world, divine magic is for making warriors ready to go back into battle. It can't relieve the suffering of the innocent.

Answer 5

Economics

Simply put, no one works for free. Doing minor miracles is certainly worth more than a secular healing as it is more effective, and instantaneous. As such y ou could easily expect to pay 10 times as much to have your broken leg cured as the doctor would charge you to splint it.

Religious Intolerance

You might find that some clergy will only heal their own flock; with multiple pantheons some might only be willing to heal followers of the same god. You could easily posit a situation where if you are a devout follower of the same god as the cleric they'll heal you for a reasonable rate. If you follow a different god within the same pantheon they'll only overcharge you a little. Sympathetic other pantheon followers might be overcharged a lot, and some opposing pantheons might be refused service at any price. In addition, assuming the power for the spells is coming from your god, the god may (temporarily?) revoke your ability to cast at all if you spend effort on one of those heathens or heretics.

Power already expended

A final possibility to consider is that clerics with power may be 'spending' it broadly on their congregation rather than specifically on individuals. It's not that far-fetched that there are more diffuse Bless spells that have a lesser effect on a greater number of people... giving a little bit of help to everyone in their congregation every day might not leave enough to cast that cure light wounds. Consider a spell that grants 50 people advantage on harvesting for a day. Not very useful or interesting for adventurers, but for an agri-based area it might be very useful. Just because it's not in the book doesn't mean it couldn't exist...

Answer 6

It can really be as simple as not enough time/spells. I won't be using specifics on spellslots and cost (in time and money) because this is an issue in most D&D editions, including pathfinder, and those things can change between them without changing the flavor.

Though there are low level clerics or their acolytes who can use magic, they have a very limited number of spells per day. So it could be simply "This person is paying me for my spells and this other person isn't, so I'm going to put the paying guy ahead of the non-paying guy" and then he's out of spells before getting to non-paying customers. This isn't even taking into account spells he would have prepared or used that have absolutely nothing to do with healing, like divination spells or protection spells.

That also handles the "1 charitable guy" problem as well, he would most likely be a travelling cleric and any disruption he caused would be minor and temporary because, as I said before, spell slots and time are limiting factors. If that cleric stayed in one place too long, he would no doubt be inundated by requests for everything from broken bones to paper cuts because people don't need to pay him. And when he picks some people over others, the people who weren't picked would undoubtedly be angry.

In regards to people being angry at a cleric for not healing them for free, do people get that way at real life doctors? yes. But most people also understand that doctors time is not free and they are also human and need to eat/pay bills/get around. Good clerics might accept payment in trade or in a service after the fact, like some doctors now, but by just putting it out there that you don't have to pay for their services, you get a lot more problems than asking for payment from everyone.

Answer 7

It is not directly connected with the universe of D&D, but this subject is very well explained in Trudi Canavan's Black Magician Trilogy and The Magician's Apprentice, from psychological, economical and substantial points of view.

There are multiple factors.

• the people are distrustful of magic, as it is unnatural
• the people are afraid that the cleric might have wicked intentions
• magical healing costs a sum of money, unachievable for many
• the number of clerics is too small in comparision to hundreds or even thousands of those in need and they wouldn't be simply able to help everyone

In the universe of D&D it could be, that clerics may want to reclaim the folks during the process of healing.

Other thing could be regional infamous rumors about the gods, therefore complete distrust to it's clerics.

Answer 8

Gods have an agenda. They give power to their clerics to further that agenda.

You need to ask "does healing a peasant's broken leg further that agenda?"

If the answer is "no" then the god won't allow their cleric to cast the spell.

Answer 9

This is indeed among the logical problems with the D&D cleric class. I find that any time you try to do serious world-building, the cleric class is the one that creates problems such as this (and you can easily draft a list of over a dozen such problems).

One rather radical solution is to simply ban good clerics in your games. This is what I've done successfully in my games for about a decade now:

Delta's D&D: Primary House Rules

Answer 10

Good -vs- Evil & Law -vs- Chaos ... This is the Eternal Battle, the Great Game that the dieties of D&D are always engaged in. Humans are but pawns in this game and some will be cursed or blessed for the glory of the gods' goals. That is why there is suffering in a world filled with healing magic.

Sean C's answer ends with the sentence: "In this world, divine magic is for making warriors ready to go back into battle. It can't relieve the suffering of the innocent." This sounds like a M.A.S.H. unit's mission -- "Patch 'em up and get 'em back to the Front as quickly as possible!" -- a war god like Mars would certainly mandate his cleric's use of power in that way to perpetuate the fighting that he lusts for.

On the other hand a benevolent goddess devoted to happiness & joy would certainly have her clerics expending her granted powers to relieve suffering & death. Of course it is entirely possible that such a divinity would only prevent death if one of her followers would mourn the dying person's absence. This is not cruelty but consistency (lawfulness) since the death of a hated man or a friendless woman would not diminish joy and happiness, and might even continue the suffering of others if the dying person was greedy, abusive, vicious, etc.

On the third hand some truely chaotic evil entity would recruit clerics from the ranks of sadomasochistic worshippers who revel in all forms of suffering ... but they would be granted a special kind of temporary near-immortality (it would not prevent aging but every other kind of bodily decay would be averted) so to allow their fevered pustule-encrusted contagion-infested bodies to be racked by "wonderful" pain yet not be functionally debilitated in order to continue their dark master's bidding.

Answer 11

Or, as in real life, many of the people who hang out on the street begging are actually actors who pretend to have disabilities to twinge on the conscience of the passers by. So if a cleric passes by and heals them of any infirmities, it won't change their lifestyle at all, and there'll always be beggars on the streets. (Ref: Life of Brian)