Dr Rajiv Kumar is not a computer gamer; "We accidentally stumbled into gaming." he says. Despite this, he's made a game that 2,000,000 people play – and which keeps them healthy, fit and happy.
He's just one of many people working in the strange crossover between healthcare and computer games.
In 2005, Dr Kumar was a medical student, when he saw the first statistics about America's obesity explosion. In 1990, 1 in 3 Americans needed to lose weight; in 2010, 2 in 3 did.
His research started to scare him as these adult obesity-related diseases were moving down the age spectrum - "what was formerly called adult-onset diabetes was now called 'type-2 diabetes'", he explained, because children as young as ten had started to contract it - with children as young as 13 having quadruple-bypass surgery.
Dr Kumar wanted to help – but his patients disheartened him. They were aware of their problems, what their solutions were and wanted to get healthier - but the majority seemed unable to do anything about it.
A few, though, managed to break the chain; once they came off their medication and had shaken off the type-2 diabetes they managed to keep their weight off. Dr Kumar was intrigued, and investigated further.
Corporate health games
Not everyone has this same strong social network, so in their spare time Dr Kumar and his colleague Dr Brad Weinberg (a self-taught programmer) started work on a mechanism to encourage this behaviour. The tool they chose was a social game, Shape Up, which they started trying to use with their patients.
They formed them into teams, and set them competing to lose the most weight, walk the most steps, exercise the most minutes, and so on. They created tools to track their progress, gave them a website and educational materials, and sat back.
They were hoping for 300 people in their first run; they got 2,000. Then 7,000. Then 20,000. Then the Governor of Rhode Island endorsed them and the project really boomed. Soon, they were overseeing 250 local companies employing 70,000 participants, who lost an average of 7.1lbs, and reduced their BMI by 1.2; 73% kept the weight off. "We're engaging populations who were previously unengageable by wellness programs," says Dr Kumar.
Today, the Shape-Up game has been widely adopted by major corporations, and its efficicacy is backed by five published papers. The company has more than fifty clients - totalling nearly 2,000,000 people covered. Dr Kumar's mother wasn't so happy about him leaving medical school to run the company – but as he puts it, "When my mother asks me if I'm wasting my life, I tell I couldn't have seen two million patients in my life as a practising physician, one a time. We're working on how to grow this number."
Health games for all
While Dr Kumar's focus is on the corporate-led side of behaviour-shaping, game designer Jane McGonigal is focussing on the personal. Following a serious concussion, McGonigal was struggling to motivate herself to get better. "Like any good game designer, I turned it into a game." The game is called Jane the Concussion Slayer, and she recruited her friends and family as characters to support her.
You can try the game at superbetter.com - it takes a very similar bent to Shape Up, except it's very clearly a Mafia Wars style social game. It doesn't focus solely on physical health, but on mental, emotional and social health, and aims to build up your strengths in all these areas, through actions as simple as searching for cute animals on Youtube.
Going even more focussed, the Orange Award-winning novelist Naomi Alderman has created a health-focussed Smartphone application to encourage runners. The old joke always runs, "I wouldn't run unless I was being chased"; Well, Alderman and her collaborators at developer Six To Start have taken that literally; Zombies, Run is an audio application which persuades players that they're being chased by zombies.
"Many's the time when, at the gym, bored, I've pretended I was taking part in an action movie," says Alderman. "In my imagination I'm Scully running from aliens, or Buffy fighting vampires - it's always good to have a kick-ass hero in the back of your mind as you puff away. Makes everything seem more exciting!"
The game interweaves story elements from the game's characters (written by Alderman) with tracks from your own music, and Zombie mobs, which require you to alter your pace to evade them. As you run, you collect supplies which can be used in a metagame, building a base and unlocking more missions.
What's in a game?
Why are games so good at encouraging avoided behaviour, like exercise? Firstly, many of these games are social. The pressure isn't merely from the game itself, but how it recruits your friends as tools in the game; think about how a Facebook game uses your friends, not merely to interact with, but as tokens that you have emotional attachment to. There's also a 'Halo Effect'; if you're healthy, your friends tend to be healthy, but if you're obese, your friends tend to follow.
Secondly, games are compelling. Dr Howard-Jones of Bristol university has explained how games provoke dopamine uptake, that is, focus the attention more effectively than anything else - they have a similar effect to stimulants like amphetamines or cocaine. Dopamine uptake itself encourages brain plasticity, which makes it easier to learn - which is why educational games are excellent at encouraging learning (and why gamers rarely forget much about their favourite games).
Thirdly, games are exciting in themselves. "We aren't collecting evidence." says Adrian Hon from Six to Start. "However, in the two weeks since launch, our players have spent over a decade running in the game, for a total of a 250,000 miles - more than the distance to the Moon. And anecdotally, we have literally hundreds of emails and reports from people who have said the game is motivating them to run more - or just plain run in the first place!"
Finally, games combine all sorts of media – Zombies, Run has a story, music, mapping program, health program, neat graphics and game, all on your smartphone. "We aren't solely using standard game mechanics like points, badges, and levelling to motivate people," says Naomi "instead, we're combining them with a great, immersive story that makes people want to run farther, faster, and more frequently, because they care about the characters and want to find out what happens next."
Alderman doesn't seem to think there are limits to what can be gamified or turned into a story. "There are certainly already game models for both prevention (quitting smoking, eating healthy and so on) and treatment (blood sugar control for diabetics, rewards for compliance with pill regimes).
"Essentially anything where you have to do a defined task is possible to gameify, and anything where that task is boring and intrinsically forgettable or hard-to-motivate will be ripe for giving meaning by a story."
Gaming in the NHS
Though it's taking a while, the NHS is slowly moving towards using the clinical aspects. Alderman tells us that, for example, the Blood Donation service keeps records of how often you've given blood, gives you different colour cards when you reach different "donation levels", has a 'leader-board' of donors and physical badges for people who reach certain levels.
As Alderman concludes, "It'll probably cause boring Daily Mail headlines like "NHS FUNDS VIDEOGAMES!!!!" or some such nonsense, but basically the NHS should be funding well-evidenced treatments and if there's good evidence that gameified health interventions work they should be funded like anything else." Which seems an easy conclusion to agree with.
