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

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.

Market

Healthcare treats health literacy as noise on its uneconomical fringes.

The mission of Humaginarium is health promotion. Yet strangely, there’s no market for health promotion. People aren’t buying it.

According to the World Health Organization (WHO), “Health promotion enables people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure.”

The emphasis here is on “individual people,” meaning consumers or patients – those I call regular folks. They are the targets and beneficiaries of health promotion.

The emphasis is also on “control,” meaning medical self-efficacy among those selfsame individuals. Health promotion is not supposed to benefit the healthcare or wellness industries that sell services to consumers. It benefits the people who have or risk illness.

The specific pillar of health promotion that concerns Humaginarium is health literacy. WHO says that health literacy enables people to “acquire the knowledge, skills and information to make healthy choices, for example about the food they eat and healthcare services that they need. They need to have opportunities to make those choices.”

Thus health literacy is not knowledge or skill or behavior, and certainly not health outcomes. It’s merely the ability of regular folks to learn, in order to make sense and use of their own choices.

In effect health literacy is a competence rather than an outcome, and it’s one that never comes naturally. It must be learned, and there’s the rub. Most folks may be educated, but few have even the most basic health literacy. They didn’t learn it in school. They didn’t learn it in clinic. They didn’t learn it from friends and family. They didn’t learn it by surfing the Internet. Why is that?

Well, I know of two reasons. One is biology as a second language. We must dismiss the advertising we’ve seen and remember that healthy choices are not consumer packaged goods in the supermarket. They are expressions and perceptions that employ the semantics of science. Healthy choices are really hard! The second reason is the information itself: the intelligibility and utility and consequences of choices even after you know what the words mean.

For example, you probably know the word bacteria, but what good is that without knowing how certain pathogenic bacteria got into your mouth and throat and lungs; and how they managed to thrive; and what they’re doing there; and how your body is coping with them? You cannot gain health literacy – you cannot become an individual who exercises control – without some level of scientific acumen that makes you aware of things like this going on in your body.

Mundane health promotion doesn’t make you aware in that way. It typically doesn’t increase your ability to understand and use scientific information. That privilege is reserved for denizens of the laboratory and clinic. Consumers get to pay the salaries of those professionals, with taxes and co-pays and health insurance. That’s mostly where their role ends, for now.

Taking a new approach, Humaginarium promotes health literacy by helping folks experience and play with science of the human body, so they can discover their own truth and make meaning personal. Few health promoters have inspired regular folks to believe they can do that. Maybe Humaginarium has found a way.

However there’s a problem. Remember what I said about the market for health promotion: there isn’t one. Humaginarium can’t go selling health literacy where nobody is buying it. We’ll have to sell it where customers are likely to show up and pay.

That isn’t in the healthcare industry, which treats health literacy as noise on its fringes. Healthcare rarely addresses or prevents the root causes of ill health, but focuses on treatment and cure. That’s understandable; it’s how companies create shareholder value. As a healthcare executive once said to me: “We’re not interested in wellness; we make money from illness.”

Thus the fringes of healthcare are littered with low-budget crap like self-help books and infomercials. Humaginarium doesn’t like fringes; we want to be the center of attention. So we turn to entertainment, where there is a huge market of individuals seeking to exercise control: the market for commercial video games.

In the video game market we know we can render scientific health information visually and dramatically, without bewildering language. Not to teach but to inspire many individuals with the experience of discovering and controlling healthy choices. First in enjoyable, escapist fantasy chock full of risky adventure; then with the real and persistent challenges of their own body and life.

Scientific entertainment. Male Nude, with Arms Up-Stretched (1828-1830), by William Etty. Pictured with small polymorphic bacteria which cause pneumonia, genital and urinary infections in stressful situations like this one.

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.