Psychoneuroimmunology

Producing outcomes without being a healthcare company.

Humaginarium is not a healthcare company. We’re unlike startups whose therapies heal or cure; also unlike those who manage medical service delivery. Nothing we do for patients requires access to medical records or histories; nothing we deliver to patients requires prescription, clinical control or reimbursement. In fact we rarely think of users as patients at all, but as regular folks.

Likewise Humaginarium doesn’t cater to providers, payers or suppliers of the healthcare industry. We don’t make things for them to buy or ask them to finance what we make for consumers. True, we are working to earn their versions of the Good Housekeeping Seal of approval, but not because it has monetary value. The effort to gain healthcare industry blessing will simply make us a better company.

All of the foregoing seems rather odd and uneconomical positioning for a health tech startup, but hopefully it’s rational. I’ll try to explain.

Humaginarium is an entertainment company. We develop video games and ancillary apps that amuse and inform. We use our programs to educate and empower people; not about everything, of course, but about their bodies and health; in particular about chronic illness they have or risk getting. Why? So they themselves can actually do something about it!

The foregoing category description rests on four functional pillars known as health promotion, health literacy, health education, and health equity. With a difference. Most programming within those pillars is behaviorist. It’s about conditioning: what, how and when to do things in order to become healthier. It’s rarely about learning: why something is and why it can be different.

Humaginarium is all about that why. As artists and educators we know there is only a dotted line between understanding and making a difference in real life. Our project turns those dots into a solid line with an arrow pointing to personal empowerment.

Yet as a high-tech artist and educator, am I certain that Humaginarium won’t heal or cure? I’m really not sure of that, so I don’t claim that it will; but I think it’s possible. Moreover likely.

I say this because I believe, from study and experience, in causal connections between mind and body; between mental and physical. The clinical term for such connections is psychoneuroimmunology (PNI). Everybody experiences PNI throughout their lives, practically every day and certainly when enjoying great entertainment, but science is only beginning to recognize and explain it. Clinicians by and large don’t have a clue. But it’s real.

A palpable example of PNI is the placebo effect, by which perceptions and beliefs improve health outcomes. Peer-reviewed research has proven (beyond any reasonable doubt) that the way people think and feel about themselves and their environment alters the biochemistry of their bodies. In plain English, our state of mind can actually make us well or sick. Everybody knows that, but why is it?

“Theorists propose that stressful events trigger cognitive and affective responses which, in turn, induce sympathetic nervous system and endocrine changes, and these ultimately impair immune function.” Did you get that? So for example, job insecurity or marital difficulty can, and often does, make people literally frail, vulnerable and symptomatic.

But what are job insecurity and marital difficulty? They are types of stress produced by the same thing: a lack of control. The same kind of stress that occurs with chronic illness. You have it, you don’t understand it, you can’t predict it, you can’t avoid it. It feels like a bewildering constant threat, like an asteroid heading towards your personal planet.

As such chronic illness is a self-perpetuating condition. The more fearful and anxious and angry the patient gets, the worse the disease may become. That’s fact, not fiction.

Humaginarium answers that fact with fiction. Literally, with fantasy in which users can face and understand and oppose and overcome illness in their minds. Fantasy of this kind is not merely an escape from reality, it’s an engine for belief in oneself; belief that “I am the master of my fate.”

When discussing PNI in the context of his long medical career, Sherwin Nuland wrote, “The question that remains is how these three major networks – the nervous system, the endocrine system, and the immunologic system – interact and, how, by understanding these interactions in precise quantitative terms, we can learn to predict and control them.”

That question is for scientists including positive psychologists, but not for artists and educators like me. We already know PNI works, though we can’t yet explain the molecular and cellular dynamics. If it works, we want to use it right now, not after decades of clinical trials, for the benefit of folks who have or risk getting a miserable chronic illness.

That is what Humaginarium is doing, and that is why I expect to produce meaningful outcomes without being a healthcare company.

Miracles

Belief in miracles is central to the mission of Humaginarium.

According to Merriam-Webster, the spiritual meaning of miracle is an extraordinary event manifesting divine intervention in human affairs. A miracle may also be a divinely natural phenomenon experienced humanly as the fulfillment of spiritual law. Can the miraculous, when candidly understood, really have anything to do with modern biomedicine?

Well, from the perspective of Humaginarium, the answer is yes. I am long known for saying (every time I get the chance) that “your body is a miracle.” No matter how young or old, how well or sick, how strong or weak, how happy or sad, how beautiful or ugly; our bodies are miraculous!

Oddly though, my claim has never been challenged. It’s odd because Humaginarium is scientific, technical. It leverages high-fidelity simulation of human physiology and biochemistry. Can miracles occur and be expressed in an environment like this? I say they can; moreover they must.

Belief in miracles is central to the mission of Humaginarium. You don’t have to believe in them when you first come to play; you don’t even have to believe when you tour homeostasis in the Arcade. However by the time you cut a path through the Morbid Frontier and killed or captured disease that haunted and persecuted you, you will gladly believe. And belief may change your life.

With miracles, am I referring to fantasy that overlays biology in our scientific entertainment? Are the miracles I speak of just figments of the imagination? They are not. They are tangible, objective and real. Rather than argue this point logically, I prefer to cite two authorities who come at it from different experiential perspectives: one a physician, the other a patient.

The physician is Sherwin B. Nuland (1930-2014), an eminent surgeon at Yale who wrote several books and articles about practicing medicine. In The Wisdom of the Body (1997) he reflected:

Centuries ago, when little was known of science, the mystery of the body’s internal machinery enthralled ordinary people and tantalized the educated. It seemed a miracle, this bustling edifice of thought and action – beyond the capacity of mere mortals to comprehend, and yet providing here and there a hint that the inscrutable might somehow be understood if only properly directed efforts were made. In time, the right direction was indeed found and the efforts were rewarded, yet the tantalizing and the mystery not only did not lessen; they actually grew. The more became known, the more miraculous seemed the intricacies of the whole and the more urgent the drive to expand our knowledge.

The patient is William Ernest Henley (1849-1903). At age 12 Henley was diagnosed with tubercular arthritis that eventually forced the amputation of a leg just below the knee; the other foot was saved only through a radical surgery. As Henley healed in the infirmary, he began to write poems, including Invictus (1875). This famously inspiring poem seems to be about many things, but in fact it is about one thing: a debilitating chronic illness that eventually killed him:

Out of the night that covers me,
Black as the pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.

The soul that Henley celebrated is the miracle that Nuland found in his practice of medicine. It is the courage that users unleash in themselves as they explore Humaginarium. Miraculous because science can’t explain it; unconquerable because medicine doesn’t eclipse it; courageous because it is the unfettered expression of the human spirit in our mortal, phenomenal bodies.

Scientific entertainment. Prometheus Creating Man in Clay (1845), by Constantin Hansen. Pictured with a swarm of microbes and viruses like those that swarm our bodies.

Literacy

Caring for a human body requires diligence, a force that is powered by health literacy.

My website says “Humaginarium is a systematic and evidence-based way to increase health literacy.” Let’s slow that down for a closer look.

For me at least, all literacy is a situated competency. There are no universal definitions and standards. Instead literacy is a personal, differentiated and evolving attribute. Yet somehow it always encompasses the same four generative acts: recognizing information, understanding it, relating it, and using it. If folks can reliably do these four things appropriate to their circumstances, they’re literate though maybe – probably – in dissimilar ways.

Recognizing information is knowing what something is. We naturally recognize information when encountering the source of it. Understanding is discovering and pondering the meaning of information. For example understanding why Ingres spent decades painting The Source (shown at the bottom of this post) in his unique way; and understanding why it is perfectly beautiful like that. Relating is assigning context to information so that it fits functionally or imaginatively into one’s world view. I related (and distorted) The Source by inserting a concocted cellular view of water, in order to reveal dangerous bacteria supposedly living in it. Using is working with information. My job with Ingres was to bridge an aesthetic divide between art and science. I tried to embody “scientific entertainment” – and also have fun (respectfully) with a great work of art.

Since I haven’t mentioned reading so far, I’ll pause now for a confession. I trained and practiced as a professor of English. Before technology barged into my life I taught college students how to learn from the literature and history they read. This was my vocation: increasing literacy by means of text. To this day I enjoy and learn more from reading than anything else I do, yet I don’t feel that literacy is fundamentally about scanning text. Reading is only one way to recognize information, often not the best way, and certainly not the way that Humaginarium promotes health literacy.

My notion of health literacy aligns with the four-part model of recognize, understand, relate, and use. Health literacy is all of that, only situated in health. Sounds pretty straightforward, but it isn’t.

First there’s the wrinkle of “health.” By that I mean the condition of a human body, the physical thing one calls “my life.” Health is neither illness nor wellness, diagnosis nor treatment, scheduling nor adhering. Health is the sum total of a human body and health literacy is a person’s ability to recognize, understand, relate, and use information concerning the body.

Next there’s the wrinkle of information. Information about the human body is extremely hard to take in because most of it is hidden in layered systems so complex and mysterious that they’re nothing less than magical. I’m using that term literally. Our living bodies are miraculous no matter what condition they’re in. They’re just very hard to make sense of.

There are more wrinkles with understanding, relating and using information about the body. Few regular folks ever even consider most of that information; they can’t understand the scientific and medical rhetoric used to express it, and they have little or no idea how to use it. Let’s be candid: for most folks, using information about the body is limited to consumption, procreation and labor – and most of that can be done well enough without health literacy.

Then why bother with it? Well, I think health literacy enhances acceptance of what the human body is, how it works, what it needs and why it’s in each person’s practical self-interest to care – with gobs of curiosity and courage. Caring for a human body requires diligence, a force that is powered by health literacy.

As health literacy increases, so does medical efficacy and the capacity for self-care. Those are two horsemen of a long-awaited apocalypse that may bring a failing health care industry to its knobby knees and replace it with the best health care possible. The kind that every individual with a chronic illness, regardless of educational or socioeconomic situation, constructs for themselves. Those are the folks who may benefit most from Humaginarium.

Scientific Entertainment. Variation on The Source (1856) by Jean-Auguste-Dominique Ingres. Pictured with Vibrio vulnificus, a type of waterborne, flesh-eating bacteria.

Behavior

Without getting to the why there is no getting to behavioral outcomes.

Is scientific entertainment™ an offshoot of behavioral science or behavioral medicine? With the FDA approving video games as therapy for the first time, the question is hardly idle. The answer may explain how Humaginarium achieves meaningful outcomes.

Behavioral science is the study of human behavior through observation, modeling, and experiment. Behavioral scientists investigate why people do what they do, and how they might do better. The scientists have a voracious appetite for meaning, so they stir separate disciplines into a unified mode of inquiry, wrangling diverse epistemology in order to discern and use truth in more holistic and robust ways.

Behavioral medicine is likewise the study of human behavior with a unified mode of inquiry. Practitioners study why people are unhealthy or at risk of illness, prone to injury, difficult to treat, heal, or cure; why they’re frail or short lived, and how they can manage health with more than biomedicine. Having a voracious appetite for meaning, practitioners look beyond clinic to identify environmental, psychological and social dimensions, causes, or palliations of disease – and try to make good use of them.

I now think that scientific entertainment is indeed an offshoot of these correlates; that it’s “behavioral entertainment.” It involves depictions of human behavior derived from observation, modeling, and experiment. It relates why people do what they do, and how they might do better. For example, why they often increase risks rather than avoid or control them; and how they might act differently to produce more desirable outcomes.

Could it be that standup comedy on The Daily Show is also behavioral entertainment; likewise animation by Pixar, theater by Lin Manuel Miranda, painting by Banksy, fiction by Margaret Atwood, movies by Guillermo Del Toro, music by Bob Dylan, and video games by Will Wright? All of these make audiences feel good while moving them to create and use new meaning.

If scientific entertainment in Humaginarium is behavioral, it’s important to remember that behavior is more than how people act; it’s also why. As Robert Sapolsky makes abundantly clear, without getting to the why there is no getting to behavioral outcomes.

In humans, “why” leads through a morass of conscious choices and decisions, through nervous reactions of the senses, all the way to the tremulous molecules that compose our bodies and microorganisms that live in and on us – some keeping us alive and others just the opposite.

I’m claiming to be behavioral, but not behaviorist. I don’t suppose that humans are machines that can be programmed with external conditioning. More in line with behavioral economics, I think people should not be trained, conditioned, or forced to do anything they prefer not to do.

The job of scientific entertainment in Humaginarium is to help them recognize choices and make decisions in what they believe is their own self-interest. That’s our nudge to wellness™.

The nudge is what allows us to generate behavioral outcomes. As I have often heard the butterfly say to the fish, “the best thing in the world you can be is yourself.” People who find themselves in Humaginarium may grow more confident that they’re incredibly beautiful and brave and may become ever more so.

Fantasy

Transforming the body from oozing, sticky humors into a cosmic miracle.

A more explicit way of saying “scientific entertainment” is “biological fantasy.” Both may be rare enough to qualify for trademark protection, provided they actually make sense and are useful. Do they, and are they?

Scientific entertainment and biological fantasy are oxymorons that label customer experience in Humaginarium. Each should negate itself because everybody knows that biology is real and fantasy is fake; that science is momentous and entertainment is merely fun. Add two polar opposites together and logically expect a nil result. Does that mean we’re making zero-sum, inconsequential mind games for customers of Humaginarium?

I don’t think so because, in the context of learning, the whole is always greater than the sum of its parts. Look at it this way. Biology is the aspect of human nature that is real and tangible, but largely invisible and incomprehensible to regular folks. How do we know? Stop somebody on the street and ask a profound question about biology, for example, “What is a stem cell?” In most neighborhoods the answer may range from clueless to ridiculous, though every human life depends on stem cells and our species would go extinct without them. In this way biology is weirdly physical, immediate, deterministic, and largely unfathomable. (By the way, that lovely blob in the illustration below is a stem cell.)

Unlike biology, fantasy purveys intangible figments of the imagination that are nonetheless visible to the mind’s eye and fairly easy to understand. That’s partly why fantasy is a massively popular art form. People get it! To test this distinction, ask somebody on the street what a soul is, and you’ll likely get a devout or convinced or passionate response. Stem cells exist in and around us, yet folks know little if anything about them. Souls don’t exist anywhere, yet they’re a ubiquitous felt presence in real life. How can this be?

Probably because fantasy isn’t fake! Unreal yes, because it’s made up; but fully-conceived fantasy is at least as meaningful and truthful as biology; in fact more so for the vast majority. In scientific entertainment or biological fantasy, consumers confront what for them is unknowable and therefore frightening (the contests of the human body with morbid threats). They confront these threats with beliefs they can grasp and control to suit their longings and needs; and that activity is motivating. Though you may never hear the word fantasy in health care, I’m pretty sure it’s an uninvited guest at every medical procedure and sleepless night of worry. Patients leave the door unlocked because fantasy doesn’t negate science; instead it makes science believable, trustworthy, and useful to them.

What sorts of fantasies are churning in Humaginarium? Obviously science fiction because we picture and animate human physiology; and simulate its progressions with computer models. Like the wings of a fairy, fantasy surrounds and moves with our biology – not in order to falsify it, but to simplify and disarm it; and make it coherent, responsive, and beautiful. The imaginative rendering of scientific subject matter is called reductionism. It’s an aesthetic at the core of all great art (including the medical arts).

Beyond science fiction, Humaginarium presents immersive fantasy that alchemizes the oxymorons into seamless perceptual experiences. Customers don’t experience science and entertainment; instead they experience scientific entertainment with breathtaking epistemic powers. We present liminal fantasy that reframes the human body, transforming it from a pool of oozing, sticky humors into the cosmic miracle that “in fact” it “really” is. We present dark fantasy marbled with infection, inflammation, deterioration, and death that is coming after you and may catch you unawares and unguarded. We present comic fantasy sparkling with cuteness and jokes that ventilate the struggle for survival with the laughter of relief. Our initial visual prototypes did this job with steampunk, which somehow works like fictional nonfiction. There’s another oxymoron for opening doors of perception.

So then, does scientific entertainment make sense? You bet it does. Is biological fantasy useful? Only for certain things, like having a happier and longer life.

Scientific entertainment. Variation on Working in Marble by Jean-Léon Gérôme

Visualizing

Our virtual human body looks and acts like an incredible video game.

Members of the Humaginarium tribe are called customers, consumers, patients, users, gamers, players, learners, and (my favorite) eyeballs. Each of the monikers emphasizes a different role. The special role performed by eyeballs is to view.

So what engages eyeballs in Humaginarium? The answer isn’t obvious. After all Humaginarium is scientific entertainment that’s not been done before at scale; has never been done for a mass market of regular folks. Members of our tribe will surely be astonished and amazed by what we show them. Will they like the show and keep coming back for more?

To increase the chances we invented an intriguing visual style in the confluence of medical and fantastical illustration. One depicts a natural, objective world of the senses. The other imagines a make-believe, subjective world of the mind.

Our medical illustration is state-of-the-art CGI of human anatomy (structure), physiology (function), and pathology (abnormality). This kind of digital visualization involves dimensional, colorful, high-resolution, high-fidelity, animated pictures. It looks sophisticated and technical, but the roots of medical illustration trace all the way back to pharaonic Egypt. It informed Classical and Renaissance science and art and continued to evolve in the centuries that followed. Modern medical illustration that leverages technology began with Spanish neuroscientist Santiago Ramón y Cajal and blossomed in American surgeon Frank Netter‘s Atlas of Human Anatomy. These artist-doctors rendered Homo sapiens in elegant and precise drawings that were (and still are) used by clinicians and educators.

New medical CGI renders Homo sapiens as discrete atoms, and complete organisms, and at every scale in between including molecular and cellular. Want to zoom a chromosome? No problem, have a look. Want to strum an auditory ossicle? Right this way, point the light. Our medical CGI prompts folks to view and manipulate every ingredient of a virtual human body without ever cutting into a real one.

This kind of visualizing is naturalistic, but is it realistic? My answer is no, because a realistic picture of anatomy, physiology, and pathology is extremely hard to parse and comprehend; and therefore not as useful. State-of-the-art medical CGI is very useful because it idealizes subject matter. The rendered biology appears true to nature, yet easy to see and experience; moreover it’s beautiful, no less than great works of art and architecture. To encounter awesome new medical illustration is to gaze in wonderment.

The beauty of medical CGI serves as a docking station for fantastical CGI. It allows actual organic matter to dovetail with absurd and ridiculous inventions; together they generate nothing short of visual magic. People have always experienced this kind of magic without thinking much about it. For example as children with a wishbone after dinner, a ringlet of hair in a locket, and a baby tooth under a pillow. In these everyday examples and in Humaginarium, the real body acts like a wardrobe that opens into Narnia.

What does our scientific Narnia look like? Well, there’s a substratum of idealized anatomy, physiology, and pathology; that’s the natural world of Homo sapiens. Pure figments of our imagination populate that world: things like gardens with unmarked paths, caves with cryptic messages etched on the walls, opalescent pools that ripple when they speak, supernatural humanoids and beasts, horrifying monsters, criminals intent on gambling momentary gratification for a lifetime of pain, immanent spirits, enchanting songs. Our fantastical CGI is overlaid on the natural kind and littered with tangible clues like those that Jules Verne created for his adventurers.

Much of the spectacle in Humaginarium throbs with attitude and nervous energy. Members of our tribe don’t stroll through an art gallery but work hard to find their ways through a maze of chronic illness, in an enchained world that yearns to be free. That’s why our virtual human body looks and acts like an incredible video game. It doesn’t invite eyeballs to observe and learn. Instead it challenges them to survive and prosper despite the odds. That is why they like the show and keep coming back for more

Learning

The most desperate problems emerging from chronic illness have a surname: Vulnerability.

Humaginarium is entertainment for consumers who have, risk, or wonder about chronic illness. Participation is voluntary. Nobody is forced or cajoled to join. Like a carnival barker, the only promise we make is fun. It’s important to say this because unlike presenters of classic health education, Humaginarium must offer art that regular folks like and want for its own sake, whether or not it solves their problems.

Thanks to art, Humaginarium probably has more in common with medicine than bland health education does. Truly? Well yes, because medicine historically is a mixture of art and science, with art doing the lion’s share of the job until the mid 20th century. Even today in the technical vanguard of biomedicine, art is a critical component of what matters to most people: healing and wellness. When medical arts are eclipsed by instrumentation and data, health care can begin to seem manipulative and futile, if not ridiculous, to the folks it serves.

Humaginarium likewise is a mixture of art and science. Though we don’t boast about solving problems, that’s actually why we exist. Real-life problems; often unacknowledged, misunderstood, denied, hidden, scorned, or ignored by the kinds of folks who buy video games for escapist fantasy rather than useful information. As they enjoy the experiences we prepare for them, their health issues are pulled through an aesthetic ringer I call catharsis. That’s pretty much the same ringer that doctors and shamans have used for millennia and still use today.

In my view all the most desperate problems caused by chronic illness have a surname: Vulnerability. By that I mean weak defenses against illness and the clueless pursuit of wellness. Vulnerable consumers don’t make themselves better; they let things get worse. They don’t relish the esoteric complexity of the body; they’re obsessed with appearances. They don’t ask hard questions they can’t begin to answer; they delegate that to experts who know everything. Experience eventually shows how little medical experts actually know and how risky and inefficient such delegation can be.

As a problem solver, Humaginarium is not paternalistic. It doesn’t tell consumers what to think or do beyond one simple command: win the game. That’s their mandate. Thing is, they have to figure out how to win. On their own. They can share ideas and experience with peers, but they can’t delegate.

Instead players build their own knowledge and make their own choices in their own self-interest; and health literacy emerges. This learning style is called constructionism. You’ll find it in healthcare simulations for medical students and physicians, but you won’t find it in health education for patients who need it just as much. Why? That doesn’t matter. It’s about to change.

Consumers initially come to Humaginarium not for information or simulation or education of any kind, but to be amused. To enjoy a virtual experience of the human body in its battle with unfair, unfeeling, out-of-control destiny. As in all their favorite video games, players must develop new competencies to win. But this time their gains deliver more than make-believe victories.

Capabilities learned in Humaginarium are wholly transferable. A fight for health in our fantasy prepares people for a similar fight in real life where, maybe for the first time, they’ll deeply understand and strive to control existential threats like diabetes, cancer, or heart disease. We want them to bring better defenses against illness and longings for wellness to the battle. Ones that fit their own circumstances more or less perfectly.

When that happens, Humaginarium may perform like a magical healing art of the 21st Century.