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Over the years, a number of alternate reality games and transmedia experiences have used their storytelling platform as a medium for serious gaming. In Conspiracy for Good, many of the game’s live events were used as a lure to get players actively volunteering for non-profit organizations. In games like Indiana University’s Skeleton Chase and the American Heart Association’s Cryptozoo, the underlying purpose of the game was to get players more physically active.

To get a better sense of the evolving serious gaming industry, I attended the 9th annual Games for Health conference in Boston. Zombies, Run creators Adrian Hon and Naomi Alderman were there to share some insight into the success of their story-driven exercise app and announce their company Six to Start’s partnership with the UK government on a new project, coming next year. A host of game developers, medical professionals, and technologists added their own perspectives to the topic over the three-day conference. While the conference’s multiple tracks made a full picture of events impossible, I’ve attempted to share a few highlights in the world of serious gaming.

Zombies, Run: Escaping from the Zombie Horde

Since its release, Six to Start’s Zombies, Run has sold over half a million copies of its episodic audio adventures placing fans directly into the shoes of Abel Township’s Runner 5. To date, runners have traversed over 12 million miles in the real world, foraging for supplies through a virtual British countryside during the zombie apocalypse. A vibrant fan community has contributed fan fiction and videos to the universe: one of the members of the Zombies, Run writing team got her start writing fanfic for the game.

It all started when Zombies, Run co-creator Naomi Alderman joined a beginner’s running class. The instructor asked everyone taking the course to explain why they wanted to get better at running, and one woman blithely responded, “I want to be able to escape from the zombie horde.” This motivation resonated with Alderman, as it captured the heart of her situation. As a professional novelist, running isn’t something that helps her reach daily word counts or edit manuscripts. Alderman explains that for most people, running is more about being prepared for when things go bad. At its core, the impetus to run is the wish, “I want to be a healthy animal to escape from predators.” For Adrian Hon, an avid runner, that primal motivation was what was missing from existing apps, pedometers, and sensors on the market. No amount of metrics about heart rate, steps taken, or calories burned provides as much motivation during a run as the shuffling groan of zombies approaching you from behind.

Many design choices for Zombies, Run were made based on what felt right to the development team. For instance, the decision to make runners speed up their pace by 20% was based on Adrian’s decision that it “felt right.” However, one priority for the team was ensuring players could step seamlessly into the role of Runner 5. That meant making Runner 5’s decisions always feel reasonable to the player, especially since those decisions almost always involved running during zombie encounters. It also meant that Runner 5 would always be discussed in gender neutral terms: while it would have been possible to record separate audio streams that customized the experience for the player-protagonist, the team opted to strike out gendered language. Alderman noted that the gender neutrality allowed her to reinforce a feminist subtext into the narrative, as Runner 5’s gender has no bearing on how the story’s protagonist is treated, and is treated as largely irrelevant.

During their keynote address, Hon and Alderman announced that Zombies, Run was undergoing randomized trials to test its efficacy. Additionally, the Six to Start team announced their partnership with London’s National Health Services and the Department of Health in the UK to create a new narrative health app to tackle the obesity epidemic, set for release in 2014. Alderman describes this new app, tentatively titled The Walk, as a spy thriller that mixes elements of North by Northwest with The 39 Steps. You play the role of someone who needs to get a package from Inverness to Edinburgh while evading both terrorists and the police. The goal is to encourage users to go on to add just a bit more walking into their daily lives.

A Spoonful of Gameplay Helps the Medicine Go Down

While encouraging fitness was a key concern at the Games for Health conference, many games were targeted towards helping patients manage their chronic conditions more effectively. However, Ayogo Games’ Michael Fergusson cautioned attendees that planning games that people will play for the rest of their lives is unrealistic. Rather, the focus should be on targeting key moments of change in patient’s lives known as “adherence cliffs.” For Diabesties, Ayogo Games partnered with the College Diabetes Network to pair college students together to find local support in managing diabetes tracking with someone else going through the same experience. The lighly gamified one-to-one social network provides diabetes patients with positive peer pressure to maintain care during a time of upheaval. For younger audiences, Monster Manor uses many of Zynga’s tips and tricks for generating micro-transactions to effect behavioral change through hyperbolic discounting. Fergusson notes, “micro-transactions work the opposite way you think. The game convinces you its currency is meaningful. Then, it pays you.”

With GeckoCap, a similarly gamified environment is used to encourage children to be more compliant in their asthma care. Asthma patients are typically treated with a maintenance inhaler for daily use, and an emergency inhaler for more severe cases. As a former physician, GeckoCap’s CEO Yechiel Engelhard saw that since patients would usually feel fine, children would often under-utilize the maintenance inhalers and overuse the emergency inhalers, putting their health at risk. Engelhard identified three main challenges: clinicians didn’t have an accurate enough view of actual inhaler use, parents had minimal control over their child’s inhaler use at school, and children saw no real incentive for compliance. To address this, Engelhard created special caps for inhalers that glow when it’s time for a new dose, and transmit usage data to inform parents and clinicians with when the inhalers are actually used, and how soon they’ll run empty. Parents can then use the system to set up rewards for proper use.

Even the act of gaming itself can help in treating disease. When patients are undergoing cancer treatment, many of the therapies designed to fight the disease leave patients feeling weaker. With Re-Mission, HopeLab aims to get kids feeling more positive about taking these medications by having them play games that let them hack, stab, slash, poison, and burn cancer. According to HopeLab’s Richard Tate, the team approached kids fighting cancer and asked them directly, “how do you want to destroy cancer?” To create the games, the team partnered with independent game developers to reskin popular pre-existing games on casual gaming platforms like Kongregate. Nerdook Productions’ Cat God vs Sun King game evolved into Nanobot’s Revenge, swapping out fireballs for bursts of ChemoBlast 6MP.

Gaming Through Tough Times

The most heartbreaking and inspiring game at the conference was That Dragon Cancer, an autobiographical interactive poem about Ryan and Amy Green’s experiences caring for their son Joel, who was diagnosed with terminal cancer when he was one year old. In Unwinnable’s review of the game’s demo, Jenn Frank captures the swelter of emotions, explaining “you fall into these cyclic, helpless loops of action, clicking on this hotspot and that one, fumbling for anything to alleviate your, Ryan’s, son’s cries – cries that start out gut-wrenching, then quickly turn into something more persistently awful, something you’ve got to quell as quickly as possible.”

As surprising as it is to say after such a harrowing scene, the game’s message is eventually one of hope and love. Ryan Green describes the scene as one of his hardest nights at the hospital, just after he learned Joel’s cancer was terminal. In his presentation, Green sets the personal stakes: “This game we play, this thing we call fighting cancer, it’s not a game for health. It’s a game for our very life.”

Crowdsourcing Care

A growing trend in medical research and diagnosis is crowdsourcing image analysis. The success of Foldit, a game that asks players to treat protein folding as a series of puzzles, has paved the way for a host of projects. With a single malaria diagnosis taking specialists up to 30 minutes to diagnose, Malaria Spot seeks to train interested visitors how to spot malaria in minutes. Cell Slider, which guides its users through historical cancer data, seeks to provide researchers with a richer data set on how different cancer cells respond to treatment. Cancer Research UK’s Citizen Science Project lead Amy Carton explains that her goal is to make image analysis research games that are indistinguishable from casual games, so that you could be playing a game without even knowing you’re helping with scientific research. In pursuit of that goal, the game’s next iteration emerged out of a game jam that tapped into the raw data to create 12 new prototypes for the next iteration of the game.

EyeWire takes a similar approach with its attempt to map out the neurons in the human eye, but the specialized nature of the work (with an hour-long tutorial plus additional training for more specialized cells like the Starburst amacrine cell) leads to a tighter community of players, with 1200 hours a day spent playing the game. EyeWire encouraged the growth of that community with the EyeWire Games, challenging the social networks that provide the backbone of EyeWire’s playerbase to see who could map the most cubes in a week. The competition pitted EyeWire veterans against users from Facebook, Reddit, Twitter, and Google+ with naming rights for the first neuron mapped by players as the prize. Ultimately, Facebook came out on top, and dubbed the neuron “IFLS” after the popular Page I Fucking Love Science that periodically crashes the EyeWire site with new players. The session included an impromptu Q&A with players in the game’s chat.

Games Even Your Doctor Would Love

Physicians are increasingly turning to games to liven up their training and ongoing educational efforts. At Mt Sinai hospital, for example, Daniel Katz created a short simulation to help train the hospital’s residents in a more rigorous, standardized fashion, hoping to decrease the complication rate arising out of catheter placement. The simulation was developed by a small team, but showed promising results. Other games and simulations available to health care professionals seek to simulate the more social side of treatment. With the Lissette Arnott simulation, doctors can earn their continuing medical education credit by following the diagnostic history of a woman suffering from depression as an interactive case study. And as game engines like Unreal get increasingly better at realistically simulating the human body and real world interactions, the barrier of entry into the field continues to lower. Of course, there is still an undeniable appeal for games like Surgeon Simulator 2013, which applies intentionally unwieldy gameplay mechanics to brain surgery.

Next Generation Technology and Paving the Way Forward

Developers in the health gaming space are already looking to the next generation of gaming consoles as potential platforms for innovation. According to a study recently commissioned by the Entertainment Software Association, 20% of all video games released in 2011 were classified as “active games”. Panelists at Games for Health were particularly interested in the potential of the Xbox One’s Kinect 2 sensor, which is capable of more nuanced motion recognition and heart rate monitoring than its predecessor. Hardware advances like Bayer’s ViviTouch system, which allows games to provide more nuanced haptic feedback than the traditional force feedback systems, provide more targeted modifications to the developer’s toolbox.

Oculus VR CEO Palmer Luckey’s keynote session in particular helped spur renewed excitement about the use of virtual reality. Luckey focused on the intuitive nature of playing games with the virtual reality headset, while cautioning developers about the limitations of the platform. Citing Valve’s experimental build of their game Team Fortress 2 for the Oculus Rift as an example, Luckey noted that while beginner and intermediate gamers found the system to be easier than traditional PC controls, more experienced gamers were frustrated by the challenge in replicating their avatar’s superhuman feats on the PC. Controlling avatars with the click of a mouse or a tap of a key drives the pace of games to speeds that can’t be replicated by swift head movements. Correspondingly, games developed for virtual reality should ideally adopt a slower pace more attuned to real world limitations.

While technological innovations and solutions served as a driving force for the Games for Health conference, many panelists acknowledged that often, games set in the real world are just as effective at driving results. Hide & Seek‘s Mark Heggen discussed many of the core game mechanics and principles that help make social games more fun and inclusive. It’s tempting to look at the fancy new technology available to creators and claim that things like smartphones, tablets, and virtual reality are the future of the health games industry. There’s also an unmistakable allure to the belief that vast troves of data quantifying every aspect of our lives might be the key to our future health, well-being, and happiness. For me, though, the real lesson from this year’s Games for Health conference is that we need to be more comfortable with the idea that playing games doesn’t have to be something you do to fritter away the hours when you’re feeling bored. While some of the games featured at the conference targeted children, games and game-like experiences were on display that could effect positive change in the lives of older patients, caregivers, and health care professionals as well. Games still need to be fun, but they can strive to be more as well.

If you’re interested in learning more about the Games for Health conference, you can check out their website for future events. Archived streams of many of the sessions (including the Zombies, Run keynote) are also available online.