Death by gaming: an investigation into the Taiwan café fatalities

When the paramedics lifted Chen Rong-Yu from his chair his hands remained frozen in place, one clawed as if holding an invisible computer mouse, the other poised to tap out a shortcut on a vanished keyboard.

At 10pm the previous day Chen had taken a seat in the farthest corner of an internet café in New Taipei City, Taiwan. He lit a cigarette and began to play League of Legends. Chen played the online game for close to 23 hours, occasionally sleeping for a short while at his monitor before picking up where he'd left off.

While the popular café was half-full that night, the moment of the 23 year-old's death passed unobserved. No one noticed the melted ice-cubes in his overflowing cup, the ghostly pallor of his cheeks, the idling of his on-screen avatar. It was only when the girl on the front desk went to inform Chen his time was up that, with a gentle nudge of the shoulder, he toppled stiffly.

On 1st February 2012, Chen Rong-Yu's time was up.

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This Taiwanese news report shows graphic images of Chen's body as it was removed from the internet café.

Chen is not the only young man to have died this year while playing a game at his computer.

On 13th July 2012, Chuang Cheng Feng telephoned his grandmother to let her know he wouldn't be coming home. He was headed to stay with a friend in the Yujing District of Tainan, Southern Taiwan. He wasn't sure when he would be back.

Standing at five-foot-five, 19 year-old Chuang had a muscular body, a benefit from his time training for local Tae Kwon Do competitions. It was this competitive streak that fired Chuang's passion for his other hobby: online video games. However, this relationship was unchecked, and enabled by the local internet café where he would arrive most afternoons and play until dawn. Chuang's life revolved around game café culture. His parents were divorced and, according to friends quoted in local newspaper reports, he found living with his grandmother lonely. Here was a place where he could retreat from the isolation of the real world and take control of his circumstances - albeit within the confines of a video game.

He secured a part-time job at a nearby game café, but the pay was low. In early July he handed in his notice with plans to move to Yujing in search of something else to do. On 13th July 2012, Chuang's friend called to say he wouldn't be able to meet up after all. At a loss, Chuang fell back on old habits. He walked into the Big Net internet café and loaded up Diablo 3. Killing time.

Some 10 hours later Chuang shifted in his seat, mind fuggy from the thick cigarette smoke in the room, eyes stinging from the glare of the monitor. He needed some air. He groaned to his feet, took three steps, stumbled and collapsed, foaming at the mouth.

He was pronounced dead at the scene.

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The death by gaming story occupies a peculiar place in the modern news cycle. News of a fresh tragedy arrives every six months or so, usually from Asia and in 2012, most often from Taiwan. The circumstances are always similar, now familiar: a young man found dead at his keyboard in an internet café, the victim of an unhealthy relationship with a sedentary hobby.

For players it acts as a cautionary tale, the kind of story mothers might tell their children to warn them off playing Nintendo DS beneath the sheets after lights out: 'Look what could happen to you if you play a video game for too long...'

For the tabloids it provides vindication of a generational distrust for this grubby entertainment medium that has been steadily infecting culture for over 30 years: 'I knew these video games were bad news. I just knew it.'

With their grim regularity, these stories have become part of the texture of modern reporting on video games. It has reached the point where their significance and sting have been lost in the routine.

And yet so many questions remain. Is it possible to die from playing a video game for too long? Should games carry health warnings, like cigarettes or rollercoasters? Why does playing games seem more lethal than watching films or reading books? Why is the phenomenon largely limited to one region of the world? Could it spread, like bird flu?

Are we all at risk of death by gaming?

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A month after Chuang's death, the news spotlight has swivelled away from the Big Net café. Despite the name, this is a small business in a quiet town on the rural outskirts of Tainan. It's one of the only internet cafés in the area, which makes it easy enough to find the phone number in a local directory.

The owner answers the phone, sounding timid, unsure.

"Are you a reporter?" she interrupts, as my translator explains the purpose of the call.

"Yes."

"Recent events have been catastrophic for my business."

Big Net café owner

"I am afraid that recent events have been catastrophic for my business. It's suffered a huge slide. I cannot talk to you about what happened. I want us to stay out of the news now."

She hangs up. We try again the next day, pointing out that our interest is in the phenomenon, not the specifics of her business.

"No," she says. "Thanks but really: no interview."

Internet cafés are widespread in the region. For young players it's far more economical to play games at one of these establishments than at home. Two dollars buys eight hours of game time. Taking into account the cost of a broadband connection, a PC, electricity and the games themselves, playing in public becomes the only affordable option.

Big City is one of the larger café franchises in Taiwan. We call a branch in the Yongkang District of Tainan, 15 miles from the café where Chuang died.

"Yeah, since the news of that death, business has been different," says Lian, the 25 year-old staff member who answers the phone. "It's far quieter than usual. It seems probable to me that this downturn is somehow linked."

"Are you worried that the same thing that happened in Yujing might happen in your café?" I ask.

"Of course."

"Have you taken any measures to prevent a similar tragedy?"

"Headquarters held a meeting after Chuang's death," Lian says. "After that, employees were issued with new guidelines, asking us to pay closer attention to customers. We have been told to issue a verbal warning if we notice any customer sitting at the same terminal for too long. To be honest though, I haven't noticed anyone behaving in the same manner as Chuang did."

A little farther north, 27 year-old Huang, branch manager of the Ingame Café, is more willing to admit that people playing games for prolonged amounts of time is an issue. "Our business has been mostly unaffected by the recent death," she says. "We do have customers like that, who stay here for a very long time. Not many, but certainly a few. But I'm not really worried that something like that might ever happen here. We have a system to prevent customers from sitting in front of the computer for too long."

"Really?" I say. "How long is too long?"

"We don't allow any customers to play for more than three days at a time."

"Three days?"

"Yeah. Once it gets past that amount of time we ask the customer to go home, rest and refresh. This is a well-organised internet café, you see."

Three days is an awfully long time, I point out.

"You know what? Don't even mention three days," she says. "In fact, I just asked a customer to leave who had been here for over 24 hours."

"Why? Was he beginning to look unwell?" I say.

"Other customers had started to complain about his smell. So I asked him to leave. In my experience, no-one tends to play a game for longer than a day and a half at a time."

I wonder who Miss Huang thinks is to blame for these deaths: the players, the cafés or the games themselves?

"I think all internet cafés start up with good intentions," she says. "The problem with this sort of addiction stems from those addicts themselves. It's probably their family or their education that's to blame. It's really a matter of self-discipline."

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In Taiwan, just as in Europe and the US, people are free to injure themselves through myriad forms of obsession and over-indulgence, from alcohol consumption to rock climbing. But these potentially dangerous pastimes come with mandatory warnings. If people are dying from playing video games to excess, it seems logical that game boxes should also carry cautionary advice, and game cafés should place limits on playing time.

Lin, section chief for the Economic Development Bureau of the Tainan City Government, isn't so sure.

"Ultimately, I agree that it's a matter of self-discipline," he says. "It is up to adults to decide how long they play a game. We cannot tell game cafés how to limit their customers' time. We have to respect the free market, so city government can't get too involved in this kind of issue."

"Ultimately, it's a matter of self-discipline."

Lin, Tainan City Government official

Lin's job is to help small businesses in Tainan flourish but also to ensure that these establishments are safe and regulated. I wonder, with young men dying in cafés, whether the balance is off?

"You're right. It is our duty to protect the youth from potentially damaging activities," says Lin.

"The police will routinely do spot checks after 10pm on cafés in Tainan to see if there are any under-18s on the premises. If so, they are asked to leave. And during the summer holidays we also run a Youth Project, which provides advice to young people on how to have healthy and safe summer holidays - including warning them about the dangers of playing games for too long.

"Right now we are actually working on a draft of new regulations for internet cafés. But these policies will be limited to teenagers and protecting them from the negative influences of online gaming."

So in Taiwan, for the foreseeable future at least, it's a matter of self-discipline. Over-18s are free to play for as long as café staff will allow them to, stench permitting.

Besides, before any game publisher, café owner or government official would be willing to issue a formal health warning about the mortal dangers of playing a video game for too long, there would need to be an understanding of what exactly is causing these tragedies.

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Dr Ta-Chen Su is the attending physician and clinical associate professor at the Department of Internal Medicine, National Taiwan University Hospital. While the number of cases of young men dying while playing games is too few to have inspired any specific research into the phenomenon, Su has a personal interest in the subject.

Chen Rong-Yu, the 23 year-old who died while playing League of Legends in February, was his patient.

"It wasn't reported, but last year Chen had a heart attack and was transferred to NTUH for evaluation," Su says. "During his hospitalisation the checks included echocardiography, 24-hour electrocardiography, cardiac catheterization, coronary angiography and cardiac electrophysiology.

"The results of all of these tests showed no signs of any heart problems that might lead to his sudden death. Nothing. The patient refused to accept our suggestion to implant a cardioverter-defibrillator. After hearing there was nothing wrong with his heart, he refused to have further cardiovascular tracking and never came back to us again.

"Three months after I last saw him, he died in the internet café. As we can eliminate any pre-existing heart problems from his cause of death, he must have died from another cause."

What was the cause?

"Acute autonomic dysfunction is the first potential cause of death," says Su. "Video games can generate a great deal of tension in the human body. The player's blood pressure and heart rate rise. If this excessive tension is maintained for more then ten hours, it can result in cardiac arrhythmia and sympathetic-parasympathetic imbalance, also called acute autonomic dysfunction."

Killing orcs for prolonged periods of time can be stressful enough to give you a heart attack?

"In a sense. Secondly, even if the game is not especially stressful in this way, simply playing for such a long period of time can prove fatal."

Dr Su compares playing games for days at a time to putting in unhealthy amounts of overtime at work - something that leads to exhaustion of the mind and body.

"Looking at these cases over the past five years, we can see that a quarter of the victims suffered acute myocardial infarction and, in each case, they had slept for fewer than five hours over the three-day period before they died."

The third potential cause of death Su has identified is something doctors refer to as 'Economy Class Syndrome'.

"Many studies show that maintaining the same pose for hours at a time without moving your body, especially your legs, can cause deep vein thrombosis," he explains. "Moreover, if you don't drink and eat properly while in this position, your blood can become sticky, leading to a pulmonary embolism and sudden death."

The final cause of death is linked to the cafés themselves, specifically their conditions.

"Internet cafés often have poor ventilation and offer players a cramped space to play in. One recent study found that the air pollution index in internet cafés often exceeds safe levels. Most establishments have dedicated smoking zones on the premises but while air conditioners cool the air temperature, they don't improve its quality.

"Likewise, Taiwan is a humid country. Relative humidity usually maintains at 60 to 90 per cent, conditions that help fungi, bacteria and dust mites to flourish in a confined space. These can stimulate asthma and other allergic syndromes. Severe air pollution can have a devastating impact on a human's heart and blood vessels, increasing the possibility of blood clots, raising the heart rate and blood pressure, stiffening the arteries and having a negative impact on hemodynamics."

Chen and Chuang's cases are not isolated. On 2nd September 2012 a 48 year-old man named Liu died in Kaohsiung City following a seven-hour gaming stint. His was the third game-related death of the year recorded in Taiwan.

Game deaths don't just occur in Asia either. In 2011 Chris Staniforth, a 20-year-old from Sheffield, England died from deep vein thrombosis after playing Halo for 12 hours.

I ask Dr Su why there appears to be an increase in the number of these cases.

"It's because more and more internet cafés are opening and the number of people taking up online gaming is increasing," he says. "The content of online gaming is improving and growing more attractive than ever. I believe that, if café conditions don't change, we are going to see more deaths."

"If cafe conditions don't change, we are going to see more deaths."

Dr Ta-Chen Su

While Su won't comment on whether governments should include warnings about the dangers of extended game playing, he is eager to offer his own advice for players hoping to minimise the risks.

"Don't play for over eight hours at a time," he says. "The exhaustion one experiences by playing a game for this length of time is akin to driving a car for that length of time. Don't keep awake by chain-drinking coffee or energy drinks. Don't stay up overnight playing games. Many studies show that staying up all night increases the possibility of autonomous nerve dysfunction. We know that acute sleep deprivation slows blood pressure recovery and this can lead to acute cardiovascular events for gamers, either sudden death by stroke or other cardiovascular diseases.

"Also, don't sit in the same position for hours at a time. Stand up; exercise from time to time. Finally, be aware of the air quality on your game environment. If the café has poor air quality and no ventilation, go somewhere else.

"And please remember: online gaming is just entertainment. It's not a necessity for your life or happiness."

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Back at the Ingame café, Tainan City, there's an attitude among players that death by gaming is something that happens to other people, with bigger problems and deeper issues.

Ding Kuo Chih, 22, has been playing games in internet cafés for a decade. "I've never played for longer than 48 hours at a time. Nowadays I rarely play for longer than ten hours at a stretch," he says.

"Yeah, I heard about the guy who died. My friends and I were just talking about it, actually. We all think it's just ridiculous to play game to death. The guy must have had some financial problems or something. Perhaps that's what happened - he chose to spend all his money on gaming, so he had no money to eat and drink properly. Something like that."

The news of Chung's death did have an effect on Ding's playing habits. "I used to eat and drink inside this café," he says. "But now I go out to eat and get some rest during my break. And I drink more water to force me to leave my chair and visit the restroom more. But I still play for just as long, I guess."

All other players we speak to have heard of Chuang's fate, but his story appears to have had little impact.

"It's not really changed anything for me," says Chiu, a mousy girl playing Starcraft. "Maybe he had some problem with his heart? It wouldn't happen to me. I have a job."

Likewise, for 16 year-old Shih, Chuang's death seems irrelevant.

"Yes, I heard about that," he says, reluctantly turning away from his game. "Maybe he died because he played for too long? It's not changed anything for me. I am an infrequent gamer. I only come here once a week, so it's OK for me to play for a long stretch of time. I am just killing time."

Death by gaming is a first-world phenomenon. It derives from a perfect storm of technology, business, geographical conditions and game design craft.

As such, it's a story full of suspects but without a smoking gun. The player's responsibility is to play responsibly. The café's responsibility is to provide healthy and safe playing conditions. The game-maker's responsibility is to encourage the player to take breaks, even as their game's systems seek to hold attention. The government's responsibility is to encourage everyone to act responsibly. With so much shared responsibility, it's easy for any one party to shirk theirs.

I ask Huang, the Ingame café's branch manager, who she thinks is ultimately responsible for preventing further deaths.

"You know, I don't have any strong feelings on this issue," she says. "One way or another, everybody involved is just trying to generate business, right?"

Meanwhile, Shih goes back to his game. Killing time.

Special thanks to Lin Meng Ying for her interview and translation assistance.