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The characters are modelled in quite a lot of detail and can suffer all manner of injuries and ailments, both physical and mental.
There are several 'story-teller' AIs that govern the type, rate and severity of what affects your colony.
Learning the tricks of designing a working colony can be quite in-depth. For instance creating a walk in freezer for perishable products is key, as is managing heat exposure in general.
There are some good DLC but this game really shines through it's mods.