Healthcare Is Broken?

Healthcare in the United States can’t be fixed. Can it be replaced?

Dandy, Fats, Deacon, Dopey, and Specks — the Crows in Dumbo (1941)

Not long ago, journalist Elisabeth Rosenthal wrote a book named An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (2017). She argued that healthcare in the United States is broken. In a newer book named Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation (2022), journalist Linda Villarosa makes a similar though more pointed argument.

Both authors convinced me, although anybody living or traveling in the United States should already know that our healthcare is broken. They should know, not because they read about it, but because they suffered the profound misfortune of experiencing it.

Healthcare in the United States is not just frayed around the edges or a little spotty in the interstices; it is fundamentally, structurally back-asswards. As in, SNAFU!

I noticed this for years before I started reading about it. As a crisis it’s not new news, but every time I think about the depraved system that we (as taxpayers and patients) pay for, my blood boils. I become incensed! Despite the quaint positivist “optimism” of authors like Rosenthal and Villarosa, I still haven’t found an (overpriced) prescription that yanks me back to 98.6.

My understanding of healthcare in the United States comes from direct observation of institutions and practitioners. It comes from vetted reporting like Elizabeth’s in Kaiser Health News and Linda’s in the New York Times. It comes from struggling to navigate labyrinthine policies concocted by the Red Queen in Washington DC and the Queen of Hearts in various State capitals.

Lately my understanding of healthcare has been burnished by Dandy, Fats, Deacon, Dopey, and Specks — the birdbrains on the US Supreme Court. I have also dabbled around the edges of the mind-numbing black hole of scholarly research on health disparities, health inequities, and health illiteracies. The research shows that natives in America are restless about their shitty healthcare but still “love” their wallet-vacuuming health insurance.

So you and I, we’ve already read or at least suspected that healthcare is broken, but what does that mean? In what ways is it “broken”? Let me name the few that stand out in my mind: each of them, coincidentally, evidence-based and incontrovertible.

  • Ethically — healthcare in the United States routinely violates the Hippocratic Oath
  • Practically — it yields grossly inferior outcomes compared to peer systems and other industries
  • Economically — it fleeces and bankrupts millions of patients who have the greatest medical needs
  • Morally — it barbarously discriminates against people of color, the poor, and the marginalized
  • Pedagogically — it takes much too long and charges way too much to train far too few healthcare workers
  • Qualitatively — it routinely makes innumerable medical and administrative mistakes and rarely admits them or accepts blame for them
  • Socially — it reinforces unjust health disparities and health inequities in favor of obscene profit margins on services untethered to outcomes
  • Technically — it exaggerates the value of biomedical and digital innovations that deliver indecent ROI to their funders
  • Structurally — it bewilders providers and patients alike with impenetrable complexity and lack of transparency
  • Administratively — it is run as a medical industrial complex rather than human services in the public interest
  • Financially— it bills for services like a vampire squid wrapped around the face of a hapless population
  • Organizationally — it is balkanized, greedily competitive, and grotesquely inefficient
  • Emotionally — it generates feelings of hope followed by fear, loathing, and helplessness in patients and their families

You may wish to quibble with one or more of these shortcomings of healthcare in the United States, especially if you’re a provider whose self-worth and net worth are derived from the broken healthcare system. Quibble away then, but not with me. Every point in my list is demonstrably true for enough people in the United States to make it true for all people in a civil society (if that’s what we are).

More important than quibbles, if you accept that healthcare is broken, then how can it be fixed? The answers so far are lame. They sum up to providing more healthcare. As in, keep doing what we’re doing no matter how miserable the results, but do more of it.

My view is different. I believe healthcare in the United States can’t be fixed. It must be replaced. I won’t go into the details here, because that will provoke a discussion of politics as stupid as it is fruitless.

My view is that healthcare in the United States must be replaced, not repaired, and in the meantime what we can do, as a society and more importantly as individuals, is promote self-care. By empowering each person, regardless of background, to recognize, understand, control, and improve the determinants of their own health.

Mind you, this is not a call to cure incurable diseases (a hobbyhorse of the NIH and nonprofit health associations). It is not a call to concoct drugs that lengthen life while decreasing life’s quality (a hobbyhorse of the health tech sector in Silicon Valley). It is not a call to attach bodies to digital nurses that monitor noncompliance with clinical regimens (a hobbyhorse of clinical entrepreneurs). It is not a call to tell people what they must do about their health (a hobbyhorse of health educators).

Instead, it’s a call to empower people to make their own choices and decisions about their health, and accept the consequences.

I believe the reason we put up with a healthcare system that is broken is because we like having somebody or something, other than ourselves as individuals, to blame for the consequences of our behavior. That’s bullshit and it needs to stop.

Are you unhealthy? Then you should take more responsibility by addressing the causes. If you’re delegating all the responsibility for your health to strangers wearing white coats, you’re putting yourself at the mercy of officials in black coats with matters other than your health on their minds. Good luck with that.

The Magic Circle of Simulation

Making complex, onerous and useful subject matter more accessible.

Our video games are scientific simulations that promote discovery and adoption of techniques for managing a chronic disease.

The simulations facilitate authentic recognition, understanding, control, and improvement of determinants of health. They reinforce a person’s autonomous ability to avoid, prevent, and mitigate risk. We call this ability constructive health competence (CHC) and describe it in a CHC Model for Metabolic Disorders.

Though our simulations empower people to practice self-care and participatory healthcare in real life, the experience they generate is unreal. It is interactive pretend-play that induces people to believe they can overcome real-world problems — at least in their imagination.

Thus our simulations are works of art rather than education or therapy. They are not used in classrooms or paired with textbooks. They are not FDA approved, dispensed by prescription, covered by health insurance, or recommended by doctors. People use them because they want to, not because they have to; and pay as they would for other entertainment.

In line with popular, commercial entertainment, our simulations are escapist flights of fancy. They let people defeat ineluctable threats to life with impossibly satisfying triumphs. The simulations are constructive fantasies in which players heroically fabricate their health and well-being in a magic circle of play. Such outcomes may be difficult if not impossible to achieve outside a magic circle, but the simulations develop the competence needed to try.

Normally, simulations take place in a facsimile of the real world to promote an illusion that they are true to life. Our contrarian simulations feature aesthetics of adventure, strategy, role-play, and puzzle. They are blatantly fabulous and for that reason more engaging, relatable, enjoyable, and aspirational.

The simulations are “scientific” because they harness evidence-based, mathematical models of determinants of health. Math forces our games to “follow the science,” but models (even behind a dashboard) are unfathomable to most people (even scientists). So we use models the way they do the most good: as puppet masters. Models do an invisible job in our simulations; they form a grid that transparently organizes content and modulates interactivity. Storytelling and stagecraft absorb people’s attention and labor during a simulation. Nobody sees the puppet master; if they did, it would break the circle.

By making science steer but not limit creativity, we gain the benefits of reductionism: the making of complex and onerous but useful subject matter more accessible to people who would otherwise be unwilling to consider or experience it, even with the payoff of greater health and well-being.

What, me worry about my health?

When the customer is a patient, the customer is usually wrong.

A typical patient with a muddled mind? Let’s not be cynical. (Wikipedia)

Daniell Ofri writes in Covid Vaccination, The Last Mile, that “The COVID vaccine engenders a unique obstinacy that seems to blot out conversation. We doctors and nurses are exhorted to listen to our hesitant patients and hear their concerns, but this is difficult to do when patients don’t even want to talk.”

Which begs the question: Is conversation with a doctor the right way for patients to become informed about their health risks? Since Warner Slack’s declaration of the patient’s right to decide, in the 1970s and perhaps even earlier, a prevailing answer has been YES. Clinician’s and patients are meant to collaborate in problem-solving and decision-making, in order to optimize health outcomes.

The practice of participatory medicine is based on such collaboration, but I wonder if it should be. My trusted advisor Merriam-Webster says that to collaborate is “to work jointly with others or together especially in an intellectual endeavor.” If it is nothing else, a conversation between a doctor and a patient is an intellectual endeavor. It’s a candid, probing, and nuanced negotiation that involves exchanging ideas and making agreements. Is either participant in that conversation normally qualified to have it?

By virtue of their training and experience, clinicians are purportedly qualified. Because of institutional, legal, and emotional constraints, they often are not. They typically don’t have the time or curiosity for intellectual endeavors with their patients. Their expertise is largely formed, not forming. They are doers rather than teachers, fixers rather than investigators. Probing the muddled mind of a patient is unlikely to improve outcomes, and may make them worse.

Patients on the other hand are dreadfully ignorant, untrained, inexperienced, opinionated, myopic; “obstinate” yes, but maybe a kinder way of putting that is self-determined. Many don’t like being told what to do; they don’t like the rigidity of a diagnosis or prognosis that’s been foisted on them out of nowhere; their default position is “I am different”; and they love being in control. And why not? Aren’t they customers in all healthcare transactions? Aren’t they paying, through taxes or an insurance premium or out-of-pocket, for services? Isn’t the customer always right?

When the customer is a patient, the customer is usually wrong. And that is as it should be. They don’t know science. They don’t know medicine. They don’t even know their own bodies and minds beyond what’s visible in a mirror. They are unqualified to collaborate with clinicians and, for different reasons already mentioned, clinicians are unqualified to collaborate with them.

Humaginarium has thought about this conundrum and come up with an elegant solution. At least a partial solution that gets some of those “obstinate” (untutored, unmotivated) patients to a point where they want to talk to experts like Dr. Ofri.

Our solution is health simulation, in which patients get to play doctor, and play scientist, and play patient, all in a fantasy world where nothing real is at stake. In our health simulation, players aren’t told what to do, they’re asked. Players aren’t told what they have, they’re nudged to find out. Players aren’t threatened with consequences of not squashing morbidity, they experience the consequences of their own decisions and failures to act fast enough. If they get sicker in the simulation, they can go back and try again. If they die in the simulation, they can wipe the slate clean and start over. Better luck next time. Practice makes perfect.

Our solution has roots in the playground, where kids like to play doctor. Our simulation is not for kids though; it’s for adults who have to cope with serious chronic illness in real life. That’s about two-thirds of everybody. Playing with serious health conditions in a digital sandbox, working out the determinants of one’s health, is the right way to acquire a constructive outlook. As in: “I’m beginning to understand what happens, in and around a person, when they’re sick like me; I can practice dealing with this in a video game simulation where it’s fun instead of scary; I can enjoy the feeling of being in control, at least in my imagination; I can take my fantasy of overcoming disease back to real life and see how it works there.”

When our simulation gets done with recalcitrant patients, the next time a doctor like Danielle Ofri offers to hear them talk, there is more likely to be a genuine, two-way conversation that looks a lot like intellectual endeavor. You know what I mean?

Healthcare

Changing mental models of health from spectator to change agent.

My focus has been on determinants of health. These are the causes of chronic illness that regular folks can perceive in themselves and their surroundings.

Perceive — at a minimum that means to recognize, but it also means to understand because seeing is not necessarily believing. You need to believe something is true and meaningful before you’re willing to take risks and action.

(Precisely what you do is the raison d’être of Humaginarium. We won’t go into that here.)

Much study and reflection had brought me to a conclusion that the determinants of health occur in four categories. I believed all causes of chronic illness fall into one or more of these, but I was wrong.

One category of determinant is the somatic, which is basically your physiology and biochemistry. The somatic is what you see in the mirror and in body scans like CT and MRI. If you are one of the gamers entertained by Humaginarium, you perceive very little of yourself that is somatic. Instead there is fantasy, memory, or even nothing at all.

Another category is the psychosomatic, which is basically your thought processes and emotions. The psychosomatic includes the rational mind and imagination. It also includes feelings that have little to do with cognition and more to do with nerves and hormones. Most regular folks perceive the faintest glimmer of their psychosomatic self, though many may live and die for it.

Yet another kind of determinant is the social, which is basically relationships, dependencies, culture and community. Social determinants of health are not of you or another; they are all that occurs between you and others; all that makes us valuable or useful to each other. Politics, which makes many of us sick, is a social determinant of health that most can’t fathom, as usual for the category.

I thought that the final category is the environmental, which is basically the space that supports life. Metabolism is the cardinal difference between living and not living, but nobody knows how or why it started. We only know it cannot happen without an environment that sustains it. There are no martians and there never will be, Elon.

Now I realize there is a fifth determinant of health; a fifth cause of chronic illness that is painfully obvious but often overlooked. It is healthcare, which is basically the medical industry. It is your primary and specialty care, medical devices, drugs, clinics, hospitals and god almighty insurer. I hate to say this about an industry that vacuums up nearly $4 trillion a year from our collective human capital, but most of us do not understand this determinant of our health, no more than the other four. We perceive only the faintest glimmer of what medicine is — even when it’s being practiced on ourselves.

Five determinants hints at an analogy with Peter Senge’s five disciplines for creating learning organizations. Let’s see if it works. Here they are:

  1. Personal mastery is a discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively.” Check! That’s what Humaginarium does with and for folks dealing with chronic illness.
  2. Mental models are deeply ingrained assumptions, generalizations, or even pictures of images that influence how we understand the world and how we take action.” Roger that! Humaginarium is changing mental models of health from spectator to change agent.
  3. “Building shared vision — a practice of unearthing shared pictures of the future that foster genuine commitment and enrollment rather than compliance.” Our concept of commitment and enrollment is not in an employer health plan, but in the individual sense of well-being that comes with self-actualization.
  4. “Team learning starts with ‘dialogue’, the capacity of members of a team to suspend assumptions and enter into genuine ‘thinking together’.” Our program is 1:1 with and for each individual to become more comfortable in their own skin. That looks to me like a prerequisite for thinking with others.
  5. “Systems thinking – The Fifth Discipline that integrates the other four.”

The Fifth Discipline is the title of Senge’s book and also an organizing principle of Humaginarium. Though we do not create learning organizations, we use systems thinking and dynamic models of health and healthcare for a far humbler purpose. To create learning individuals, one by one, millions at a time.

These individuals suffer with chronic illness that they do not control. We can’t cure their illness, but we can lessen their suffering by helping them perceive how much power they have, and can get, to live better.

I Saw the Figure 5 in Gold (1928) by Charles Demuth, bequeathed by Georgia O’Keeffe to the Metropolitan Museum of Art in New York. The painting is a mental model that illustrates The Great Figure (1920), by William Carlos Williams:

Among the rain
and lights
I saw the figure 5
in gold
on a red
firetruck
moving
tense
unheeded
to gong clangs
siren howls
and wheels rumbling
through the dark city.

Yin and Yang

Does Humaginarium make video games or health promotion?

“Do I have a split personality?” The question may arise when we hold two contrasting or conflicting beliefs, at the same time, and instead of trying to resolve or erase them, we let their differences flourish. Indeed, we may expect benefits from the tension.

There are different ways to perceive a split. On the one hand, we may cringe in the presence of cognitive dissonance, a symptom of unbalance and stress. On the other hand, we may proudly quote F. Scott Fitzgerald, who wrote “The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”

(He wrote function, not prosper. Just making that clear to contrarians in our midst.)

Oxymorons are beloved by folks with a split personality. Take the oxymoron serious games, for example. Games are played, and by definition gameplay is amusing, frivolous, entertaining, somewhat meaningless. A wonderful miniseries, The Queen’s Gambit, weaves an entertaining tale of struggle and conquest by a chess player, but chess itself is just a game. When you learn how to play it, the only benefit is that you now know how to play it.

(The miniseries has other ideas.)

So why pair game with serious, when serious is mindful, thoughtful, analytical, earnest. I once asked Clark Abt, who coined the oxymoron as the title of his book in 1970. He said that his editor came up with the title, it seemed catchy, and he didn’t think more about it.

When Oscar Wilde wrote The Importance of Being Earnest, A Trivial Comedy for Serious People, he had just this sort of oxymoron in mind. As an aesthete of the decadent fin de siècle, he thought a great deal more about it. Ultimately, it cost him his life.

Well then, there are two contrasting or conflicting beliefs whirling through my mind these days, not fatal but nonetheless twisty. They are video games and health promotion.

I believe in both. There’s even an oxymoron that I coined, scientific entertainment, in order to pace Clark and jolt readers or listeners into paying closer attention to my project. So far, I have preserved my ability to function, though I’m still striving to prosper.

So does Humaginarium create video games or health promotion? The answer is, both at the same time. Yes, I know that you can survey the field of health promotion and not find a single video game sprouting in its barren soil. You can likewise survey the video game industry and not find anything that quacks like health promotion. That’s because video games and health promotion have nothing to do with each other.

(Until now.)

While claiming that Humaginarium makes video games and health promotion, at the same time, and expects to benefit mightily because of it, I am challenged every day to put them in order, to prioritize, to say we do one in order to do the other (not the other in order to do the one).

This challenge was a damned nuisance until I referenced it to the concept of yin and yang, or dualistic-monism (another oxymoron): a “fruitful paradox.” Yin and yang are complementary (rather than opposing) forces that interact to form a dynamic system, in which the whole is greater than the sum of its parts.

Thus I arrived at the wheels within wheels of a conceptual breakthrough:

— Video games that are health promotion
— Art that is science
— Play that is work
— Freedom that is limiting
— Pleasure that is painful
— Silly that is smart
— Vulnerability that is strength
— Knowledge that is power

This list could go on. You probably have examples of your own.

The taijitu symbol famously depicts dualistic-monism. I chose a version of the symbol for this post, that reminds us, with markings around the circumference, that yin and yang are not reducible to this and that, subject and object, you and me. Instead it is a vortex of possibilities, in which every inferred possibility is accommodated and allowed to flourish. It is all-inclusive and balanced.

Not coincidentally, the quest of Humaginarium is for balance, or homeostasis. We are not trying to make sick people well, we are trying to make them happy. That may be the germ of our ultimate oxymoron.

Tai Chi Pa Kua Tu, the diagram of Tai Chi with Eight Trigrams, from Wikipedia

Literacies

Hey you, WHO, CDC, OECD: go stuff your endless texts!

There are many kinds of literacy. One that we all recognize is the ability to read and write in a native language. The average adult literacy, of that kind, in the United States, is utterly abysmal.

So bad, in fact, that health information should be written at no higher than an eighth-grade reading level (13-14 years old). That’s according to the American Medical Association, the National Institutes of Health, and the Centers for Disease Control and Prevention, as reported by Wylie Communications.

You might say: it is what it is, we do the best we can. But publishing health information, at the level of younger adolescents, is bound to reinforce health inequities. The reason for that? Even when information is dumbed-down thus, about half of all adults still won’t understand it. Not because they’re morons, of course, but because they lack reading skills.

This is a problem for anybody who produces health information, health education, or health promotion. Those are three pillars of self-determination, for controlling and improving health. They are meant to empower people. Problem is, most of what gets published under those headings is text. It must be read rather than watched, heard or experienced.

Ergo: no read, no learn; no learn, no improve.

There’s an additional problem for those who have proficient reading skills. Shown text that is written for juvenile eyes, they are more than likely to be bored. People tend to check out when boredom occurs. They don’t pay attention. They don’t engage. They don’t learn.

If we add the 50% of the adult population, who can’t understand the basic text of health information, with the 15% of the adult population that gets bored reading Golden Books, that leaves only 35% in the crosshairs of epitomic health information, health education and health promotion. No wonder the pillars are wobbly!

(Literate persons reading this may have noticed that health care is not listed as a pillar — for obvious reasons, to anybody who has received health care on a regular basis. It doesn’t empower through self-determination. Just the opposite, with rare exceptions. For better or worse, usually for worse, health care is a system of command and control.

However, I digress.)

The ability to read and write is a foundational literacy. It must be present in order for other literacies to flourish. Two others that are particularly important to Humaginarium are health literacy and scientific literacy.

According to the World Health Organization (WHO), health literacy is the ability of individuals to access, understand and use information in ways which promote and maintain good health.

According to the Organisation for Economic Co-operation and Development (OECD), scientific literacy is the ability of individuals to engage with science-related issues (including medicine), and with the ideas of science.

Each of these definitions, in their contexts, requires proficient foundational literacy to understand. The language is tortured. But for me they refer, somewhat allusively but inevitably, to reading skills: in one case, reading the rhetoric of medicine, in the other, reading the rhetoric of science.

Professionals spend decades in school and training, acquiring health or scientific literacy. And the 85% of adults in the United States, who have less than proficient reading skills? They don’t have a clue or a chance. They are sitting quietly, in the last row, waiting for the bell to ring.

That’s a problem that feels like an opportunity, at least to me.

Humaginarium has an opportunity to solve that problem. After noticing that the literatures of health information, health education and health promotion are banal and ridiculous for adults who are not morons (i.e. almost everybody), we cut a new path to empowerment. We obviously can’t develop the reading skills of folks with chronic illness, so instead we made reading optional. In fact, we made reading unnecessary. To be clear, people who come to our brand read nothing.

Instead of reading, they do what comes more naturally, no matter what level or kind of literacy they have attained. They get to:

  • Look at beautiful pictures
  • Play with amusing things
  • Crush thorny brain-teasers

In other words, they play video games. Our novel video games are health promotion in disguise.

Nobody will recognize the health promotion, because there’s no command-and-control text on the screen telling them what to think or do. Instead there are persuasive voices asking them to explore and act according to their own self-interest, their intimate wants and desires.

And for what? To win the game. To control the illness. To increase their share of well-being.

So hey, you, WHO, CDC, OECD: go stuff your scrolling pages of text already! Read my lips. The work needs to be about much more than information. It needs to be about empowerment!

Nurse Nancy, a Little Golden Book, now available from Amazon, and others since the 1950s

Wants, and Needs

Don’t all patients participate in health care?

Wants and needs. The words are so close in meaning, they’re often interchangeable; almost synonymous — yet not quite. Humaginarium uses them to differentiate customer motivations, when it comes to playing our unusual video games; and also the payoffs that follow.

To be clear: Wants are desires. Needs are necessities. And both matter.

In the pragmatic world of tech startups — where Humaginarium occasionally visits and all problems are reducible to algorithms — wants are fluff and needs are raisons d’être.

Did you get that? I’ll elaborate.

  1. Wants are subjective. Needs are objective.
  2. Wants are “take it or leave it.” Needs are “gotta have it.”
  3. Wants are choices. Needs are imperatives.
  4. Wants are rewarded. Needs are met.
  5. Wants are pleasurable. Needs are painful.
  6. Wants are emotional. Needs are physical.
  7. Wants are fanciful. Needs are empirical.

People love what they want and hate what they need. I could go on like this for hourst. It’s a tense dichotomy in human nature.

Wants are addressed in art and entertainment, where they seek catharsis. Wants are addressed in industries like fashion and hospitality, that rely on customers enjoying themselves; that strive to please, since they know their customers have many choices and moreover control their choices.

Humaginarium makes art and entertainment in the form of video games. Not talking about serious games (grody) or gamification (gag me) or educational games (with a spoon). Talking about blockbuster, bestseller, AAA, dumbass games that are good for one thing only: escapism.

Except ours are not good for one thing. They’re good for two: escapism, and competence. Wants, and needs. Our games build skills called “constructive health competence,” which means the capacity of folks to take better care of themselves; to collaborate fully in medical decision-making; to participate actively in personalized healthcare.

Wait, don’t all patients already participate in healthcare? No, they don’t; no more than the chicken in your sandwich participated in agriculture and gastronomy. It’s not that folks don’t what to collaborate and participate, but they’re stymied: they don’t know how to begin or what to expect.

Humaginarium understands that health literacy, health acumen and medical self-efficacy are desperately needed by millions of people, but are nowhere available. Nowhere! So we address those needs in ways that are also desirable.

Because, let’s be honest, nobody likes healthcare. In this year’s presidential debates, when candidates said, “if you love your healthcare, you can keep it,” I wondered why they were talking to British or French or German voters — or practically anybody on earth other than patients living in the United States.

In fact, when we peel away the PR and bureaucracy, it’s clear that everybody in America hates healthcare, but puts up with it, because they have bloody needs. They put up with scary, clinical, patronizing, embarrassing, dehumanizing, baffling, riddled with mistakes, impoverishing, infuriating, futile — because they have unmet needs for control; especially control of chronic illness.

The problem is, putting up with healthcare isn’t fun. Even thinking about it is stressful.

The solution is, make it fun so folks want to think about it. Effective may follow. Health usually follows happiness. And that’s how Humaginarium performs its magic. By folding the wants of folks for escapist art into their needs for health competence, we have invented a way to empower. Empower is the opposite of telling folks what to do. It is enabling them to do for themselves.

Should you care about meeting your needs by satisfying your wants? Yes, most definitively you should care, if you’re a gamer. If you’re not a gamer, well, you can easily change that by learning how to play.

You’ll be glad to find that Humaginarium video games respect what you want, and respect what you need, and they don’t require a prescription.

Mind

The woke mind is a powerful ally of the wounded body.

Humaginarium is novel health promotion. With reverence for life science, it invites folks to discover how a healthy body works; and how the body may be induced to work better and last longer, despite chronic illness.

Okay the body, fine, but what about the mind? Does Humaginarium also revere perception, cognition, emotion, philosophy? Does it deem intangible mental phenomena as important for controlling and improving health?

The answer is yes, indubitably. Our novel health promotion posits that the mind is a lever of constructive health competence; that the woke mind is a powerful ally of the wounded body.

Moreover mental faculties, including the imagination, may be more practical and influential than dumbass regimens of behavioral conditioning. You know them: nudges, digital wearables, involuntary adherence, habits; the palaver of wellness. Easy to ignore because effective people rarely just follow instructions or accept manipulation. They seek to understand, and that’s especially true of those dealing with chronic illness.

Lately, my naive beliefs and assumptions about the mind have been sorely tested by COVID-19, likewise by the history of pandemics that previously obliterated swaths of humanity. In some ways, 2020 feels like 1520, when it comes to epidemiology. There is discouraging consistency, through all ages, of the failure by folks to understand, or even seek to understand, pathogenesis.

Of course, I’m not speaking of scientists and doctors, who administer remedies, who issue proclamations, recommendations, precautions. I’m speaking here of the untutored masses who tend to avoid, ignore, deny, resist, attack and refute health experts along with their intelligent advice. I’m speaking of neighbors whose leaden minds have empowered viral molecules to become proficient mass murderers, in the name of economic prosperity, political ideology, religious dogma and other cockamamie prejudices. I’m speaking about my customers.

Humaginarium promises constructive health competence to these same customers, knowing full well that human competence is based on critical thinking. Competence is the ability to control and improve your health, first by understanding it, then by skillfully — dammit willfully — mastering myriad determinants of health.

Competence isn’t calling a doctor for an appointment or a prescription; it isn’t subscribing to reminder text messages, or reading labels on vials. Constructive health competence is making informed, often brave, choices and decisions in order to minimize risks, in sickness and in health.

Conventional health promotion doesn’t share my worry about the untutored masses. It tends to leapfrog the mind anyway, as if folks don’t have one, rushing to pump procedural, behavioral bromides into their muscle memory. Don’t smoke. Just say no. Get more exercise. Cut out simple sugars. Eat more vegetables. Take your meds. Get tested. Fast after midnight. Buy health insurance. I could fill a blog with the most common commands of health promotion before getting to one that says something like, “seek to understand first,” or “begin with the end in mind.”

My objection to procedural and behavioral orders in health promotion is that they don’t matter and they don’t work. We have statistics to prove that. Yet my growing worry about getting folks to figure out health, and act accordingly, is that they seem averse to intellectual struggle. Thinking is slow and hard!

I want folks to make better choices and decisions, based on their own felt needs and understanding. To judge by the conduct of crowds who ignored copious, relentless public health information for most of this year, folks tend to act like they won’t think. So there is nothing there on which to build health competence.

Or is there? Remember that Humaginarium doesn’t promote health with pedagogy. It is not health education. It relies on art and entertainment, on learning from the experience of fantasy. Regular folks, the same ones who act like they don’t have a mind when it comes to their bodies, are able to shoulder fairly large cognitive loads when using their imagination.

Obviously, despite appearances, folks do have good minds, and moreover their minds are ready to absorb and use sophisticated concepts and techniques, provided that these are experienced in ways that arouse rather than stultify, engage rather than dictate obedience. Arouse and engage, as in video games.

Do you doubt it? Then you don’t know gamers. Want convincing? There is half a century of scholarly research awaiting your attention. If you lack time to review it, check out The Hole in the Wall Project for an epitome.

Still skeptical? Then close your eyes and recall when you learned more and better than at any other time in your life. If you’re like most of us, that was in your infancy and early childhood.

You learned then the way gamers learn as adults: by experiencing, practicing, pretending, figuring things out. If lately you’ve declined to wear a mask and social distance, your mind is probably AWOL and your body — your health — is on the line.

That’s bad, but things could be worse. Humaginarium wants you to make them better. By seeking to understand your body and health, first.

Scientific entertainment. Costume of a plague doctor nicknamed Dr Beaky of Rome (1721), by Paul Fürst. The doctor wears a face mask and socially distances, to avoid infection. NB that was 300 years ago, before the advent of modern microbiology.

Material

“I saw the angel in the marble and carved until I set him free”

The Italian Renaissance was the cradle of modern civilization. Is that because it freed people from medieval superstition? Not by a long shot: superstition continues to thrive right up to the present and shows no sign of waning. Something else happened to make that time and place consequential. It was the advent of natural science.

The Renaissance isn’t notable for reinventing religion. It merely stopped inventing nature and instead turned people’s attention from the imaginary to the existential. At first this code switch probably felt like a comedown, because the natural world seems uncomplicated and familiar; it’s all around us, there for everybody to see and use rather than a symbol of things mysterious, unseen and desired.

That rustic perspective may have preceded the Quattrocento but for sure it ended there, with the emergence of scientific acumen. Because when patiently and attentively considered, nature is not uncomplicated and familiar; it is not mostly palpable to the senses, not intuitive or logical or even fathomable at its extremities. Nature is an enigma so mind-boggling that relatively few people can or even want to think about it. Instead we take it for granted, and wonder what’s for dinner.

Nature is the material world, spanning particles so small that they pass through our porous membranes as though we aren’t there; and stardust so diffuse that we don’t know where (or if) it ever ends. Beginning in the Italian Renaissance, artists and scientists have investigated material in order to understand what it truly is, why it sometimes comes to life and lives on, how it may be controlled and used for practical purposes.

A celebrated artist-scientist of that era was Michelangelo. He wrote of his art that “The sculpture is already complete within the marble block, before I start my work. It is already there, I just have to chisel away the superfluous material.” What did he mean?

He meant that material is us and we are material. We may look at and into ourselves to discover the meaning of the universe; we may look at and into the universe to discover the meaning of ourselves. Fearful symmetry!

This insight came forcefully to mind as I surveyed human metabolism and asked myself, “What may people come to know or know about, that they didn’t already know, by the time they finish Diabetes Agonistes? And how much of that will be useful to them.”

The answers are pretty exciting. People will suddenly know that their life is their body: neither the soul everlasting nor the face in the mirror, but a unique and beautiful and transitory expression of their genes. They will know that the genes encode biochemical activities so numerous and subtle and complex and quick and precise and certain that miraculous is not an exaggeration.

When our game posits that the body is a miracle worthy of their greatest care and respect and love, they will not scratch their head and wonder how that can be. They will not sign up for a class or call a doctor or a priest to explain life to them. They will instead look out on the world – the seas, the mountains and valleys, the forests and pathways through the forest, and they will believe, “That is me. I can now find myself in the world where I live, and understand the world where I live as the body I inhabit. For a time, until the material that is me returns to stardust and finds another fascinating way to emerge and continue.”

“I saw the angel in the marble and carved until I set him free,” wrote Michelangelo about another sculpture. We know it when we view his art. We know that his genius was to let the human emerge from material; and for material to teach us something ineffable about the human that nobody before the Italian Renaissance understood, and which few of us today understand. Tomorrow will be different.

Scientific entertainment. The Awakening Slave (1530) by Michelangelo di Lodovico Buonarroti Simoni, pictured with a biochemical fantasy and cruciform suggesting any person’s intermateriality.

Pathways

We breathe, we metabolize, we live.

A pathway is a technique, a course of action, a series of steps, a way forward. Once a pathway is recognized it may be observed or used with predictable results. Until then, it’s just an idea.

Diabetes Agonistes introduces folks to metabolic pathways. Which folks? Adults with poor health and science literacy, who risk metabolic syndrome and diabetes type 2, and happen to like video games. About 87 million Americans fit that description at present.

Folks can’t see or feel their metabolic pathways, but can (and do) ignore them. Metabolism is autonomic, kind of like breathing, you don’t have to think about it. It just happens.

Metabolic pathways are exquisitely ordered chemical reactions in all 30 trillion cells of the human body: every cell, every moment, 24/7/365. They’re also present in 100 trillion bacterial cells that colonize the human gut, feeding each person’s metabolism like a vast supply chain, starting the minute they are born and continuing, never ceasing, for as long as they live.

You know without being told: if you stop breathing for any reason, your life will soon be on the line. You know this from experience, you didn’t have to learn it in school. Likewise if any of the chemical reactions churning through your cells quit or misfire, your life may sooner or later be at risk. You may become sick, but unfortunately you don’t know that, because unlike breathing, you haven’t consciously experienced it. You haven’t learned it. You’re allowed to ignore it.

Yet people who play Diabetes Agonistes are aware their metabolic risks, because they have consciously experienced them in a simulation, and striven to correct them, and vowed to avoid them, and practiced how to control them when faulty biochemistry wrenches health from their body, like juice from a ripe apple.

So then: we breathe, we metabolize, we live. To be frank, breathing is part of metabolism. The oxygen that flows into our lungs when we inhale, the carbon dioxide that flows out when we exhale, these are the gaseous fuel and exhaust fumes of our constant metabolism.

Metabolic pathways keep us alive. It’s been argued that they are life itself, the essential difference between a human body and, say, a marble statue. Life on earth began more than three billion years ago, long long before any human was conceived: in the toxic swirling tides of a cooling planet. What made life start in that chemical broth, after billions of years of cosmic deadness and nothingness? What made Homo sapiens eventually show up on earth with our big ideas about some ethereal spark? Was it God that started it? Nope. It was the earliest metabolic pathways randomly oxidizing compounds in a primordial muck. That was our real Garden of Eden, properly evidenced and understood.

Diabetes Agonistes is a video game about the modern incarnation of those pathways inside our bodies. The game is a complex scientific simulation, a stroke of genius for regular folks, helping them understand and enjoy something that may make them healthier and happier and live longer.

Diabetes Agonistes is also a pathway of a different kind, a new idea that is about to be proven with evidence, or dashed to smithereens in failure. We’re nearing that crossroads.

You see, Diabetes Agonistes is a cloud-based app that transforms people who play it. Makes them smarter without teaching them. Helps them create knowledge and intuition and skills from their own experience, from trial and error and deliberate practice and fooling around and making stuff up. It creates understanding as subtly and organically as their cells synthesize proteins. Not by telling them what to do or how to do things, but encouraging them to figure it all out on their own. Nudging them up the path. They can do it if they try.

Unlike any entertainment I know, Diabetes Agonistes challenges folks to figure out some of the hardest problems ever faced by scientists and clinicians and educators and health policymakers, and use their discoveries to change the quality of their lives.

Step by tiny step up a crystal scaffold that penetrates the clouds of not knowing, and emerges into sunlight and starlight of truth and beauty about the human body, about the mind, about the spirit, about the difference between existing as a lump of clay and living as a noble human being.

Diabetes Agonistes is a new and different kind of pathway: a technique, a course of action, a series of steps, a way forward, an engine of predictable results. It is fast becoming more than a cool idea.