Tablet Games

How videogames be­came a weapon in the fight against child­hood cancer

EDGE - - CONTENTS - BY ASI BURAK AND LAURA PARKER

How videogames be­came a weapon in the fight against child­hood cancer

Ay­oung nurse stood on a chair in the wait­ing room of the Lu­cile Packard Chil­dren’s Hospi­tal at Stan­ford Uni­ver­sity, Cal­i­for­nia, on an over­cast Thurs­day morn­ing in late Oc­to­ber 2015. She was hang­ing Hal­loween dec­o­ra­tions from the ceil­ing. Cot­ton spi­der­webs framed two large win­dows over­look­ing an in­te­rior court­yard. Shiny black witch’s hats stood at at­ten­tion on tiny, pastel­coloured tables. Pump­kin-shaped string lights looped around fur­ni­ture cor­ners and light fix­tures. On the wall, be­low the per­ma­nent posters of Marvel su­per­heroes and Star Wars characters, some­one had stuck a life-size laugh­ing skele­ton.

A four-year-old girl with wiry blonde hair sat pa­tiently on the wait­ing room couch, a mul­ti­coloured sur­gi­cal mask over her mouth. Ja­cob Lore, a re­cre­ation ther­a­pist, walked in hold­ing a large folder and two iPads. The girl waved him over. “Hello,” she said, stand­ing up to greet him and putting one of her tiny hands on his hairy fore­arm. “Hey Maya,” Lore said, sit­ting down next to her and of­fer­ing her one of the iPads. “Want to play a game?”

Maya reached out for the iPad and, without an­other look at Lore, be­gan play­ing a chaotic-look­ing first­per­son shooter. A swarm of grotesque-look­ing crea­tures de­scended from the top and sides of the screen; Maya deftly tapped the screen in var­i­ous places, de­ploy­ing dif­fer­ent pow­ers to dis­perse them. “Wow, Maya, you’re do­ing re­ally great,” Lore said en­cour­ag­ingly. Maya ig­nored him. “What level are you on?” Lore tried again. “Eight,” she said, and kept play­ing. Lore looked amused. “Once they start play­ing, there’s no get­ting any­thing more out of them.”

As a child life spe­cial­ist in the hospi­tal’s on­col­ogy ward, Lore’s job is to help young pa­tients – who range from in­fants to late 20-some­things – ad­just to hos­pi­tal­i­sa­tion. This means con­stantly talk­ing to pa­tients about their di­ag­no­sis and treat­ment in a lan­guage they un­der­stand, and cre­at­ing an en­vi­ron­ment in which they feel safe. Lore likes to be pre­sent when younger pa­tients like Maya un­dergo a pro­ce­dure like get­ting an IV drip put in – he’ll of­ten sit be­side them, ask­ing them ques­tions or show­ing them pic­tures or videos to dis­tract them. The hospi­tal’s play­room – a brightly lit class­room space with toys, an art cor­ner, a small kitchen, and a re­cre­ation room with tele­vi­sions, videogame con­soles and iPads – is a des­ig­nated “safe space”, mean­ing doc­tors and nurses can come in and talk to the kids, but they can­not ad­min­is­ter medicine or dis­cuss treat­ment while in­side. There’s no talk of chemo­ther­apy or check­ups. “This is

the one space they can come in to play without hav­ing to worry about some­one com­ing in and say­ing or do­ing some­thing that scares them,” Lore said.

Be­fore the iPad, Lore used to use a felt board to teach younger pa­tients about things like chemo­ther­apy and red cells and white blood cells. “But when things like iPads came along, I was hav­ing real trou­ble pulling them away from the screen to get them to look at a felt board,” he said. In 2008, Lore was ap­proached by a pae­di­atric on­col­o­gist named Gary Dahl about a videogame Dahl was help­ing de­velop with the aim of in­form­ing young cancer pa­tients about di­ag­no­sis and treat­ment. The game was a third­per­son shooter in which play­ers pi­lot a mi­cro­scopic ro­bot named Roxxi through the bod­ies of fic­tional cancer pa­tients, blast­ing away cancer cells. It was slow to load and re­quired sev­eral disks (the first ver­sion of the game was re­leased in 2006), but Lore no­ticed it es­sen­tially ful­filled the same func­tion as his felt board.

This was the game Maya was play­ing; at least, a newer ver­sion of it: shorter, quicker, and avail­able on mo­bile and tablets. Af­ter an­other ten min­utes, she logged out of the game, and be­gan run­ning her small fin­ger across the iPad screen, search­ing for some­thing else. “What are you look­ing for?” Lore asked. “Angry Birds,” she replied. Lore sighed. “I’m al­ways los­ing out to Angry Birds.”

The Re-Mis­sion games were de­vel­oped by HopeLab, a pri­vate non­profit based in Red­wood City, Cal­i­for­nia. The com­pany was founded in 2001 by Pam Omid­yar and her hus­band, Ebay founder Pierre Omid­yar, to de­velop apps and games that im­prove the health of young peo­ple. The orig­i­nal

Re-Mis­sion was the lab’s first game, made in the hope of en­cour­ag­ing young cancer pa­tients to get more in­volved in their treat­ment by tar­get­ing spe­cific psy­cho­log­i­cal and be­havioural out­comes, like mo­ti­va­tion and self-ef­fi­cacy. It’s not just the grim en­vi­ron­ment of hos­pi­tals that can neg­a­tively im­pact a young per­son’s abil­ity to fol­low treat­ment: it’s hard for young pa­tients to re­mem­ber to take their medicine full stop. Regular habits and con­sis­tency is not some­thing they are overly fa­mil­iar with. Pam Omid­yar be­lieved that help­ing young cancer pa­tients vi­su­alise their body’s re­sponse to cancer might help mo­ti­vate them to take a more ac­tive role in treat­ment. If they could just see how hard their body was work­ing to re­pel the cancer, they’d be com­pelled to give it their all.

It was 1989. Pam Omid­yar was a 22-year-old col­lege grad­u­ate work­ing as a re­search as­sis­tant in an im­munol­ogy lab at Stan­ford Uni­ver­sity. She’d moved to Cal­i­for­nia to be with her boyfriend, Pierre, who worked as a com­puter sci­en­tist. At the lab, her job was to grow dif­fer­ent cancer cell lines so that the scientists could ex­per­i­ment on them. Some­times, she as­sisted them, but her main job was to keep these cell cul­tures healthy. She spent her days star­ing down the bar­rel of a mi­cro­scope, watch­ing T-cells bat­tle cancer cells.

“The idea was to find cell-spe­cific mark­ers, mark­ers on the sur­face of cancer cells that cy­to­toxic T-cells could at­tack and kill in a very spe­cific way,” she said re­cently. At night, her and Pierre would play videogames on their Sega Ge­n­e­sis. On the week­ends, they’d go hik­ing or moun­tain bik­ing.

The pro­fes­sor Omid­yar worked for was a pae­di­atric on­col­o­gist. Grad­u­ally, she be­gan think­ing about the kids whose cancer cell lines she was grow­ing. “She could see this epic strug­gle tak­ing place in the body of cancer pa­tients, but she knew that cancer pa­tients didn’t feel like there was that much of an epic strug­gle,” Steve Cole, HopeLab’s VP of re­search and de­vel­op­ment, said re­cently. We were sit­ting in a small, func­tional board­room in­side HopeLab’s mod­est of­fices in Red­wood City. Omid­yar de­clined to at­tend – she pre­ferred to talk via email.

One day, Omid­yar pic­tured her job in the form of a videogame. She was the pro­tag­o­nist, track­ing down cancer cells and at­tack­ing them with T-cells from a cool-look­ing laser gun. What if there was a game that utilised the same prin­ci­ples, but fun­neled them into some­thing that re­ally mat­tered, like a young pa­tient’s at­ti­tude to fight­ing cancer? “She put those two things to­gether and said, ‘You know, if I can just show peo­ple cancer in the con­text of a game where they can bat­tle it, then they are go­ing to feel dif­fer­ent about it,’” Cole said.

But videogames cost mil­lions of dol­lars and hun­dreds of peo­ple to make, and Omid­yar had no idea where to even be­gin look­ing for those kinds of re­sources. She dropped the idea. Then, in 1995, Ebay launched. Sud­denly, Pam Omid­yar had every­thing she needed.

On a sunny af­ter­noon in the fall of 1999, Omid­yar wan­dered into Stan­ford’s de­vel­op­ment of­fice and asked whom she could speak to about mak­ing a videogame about cancer. She was shown to Gary Dahl’s door, the pae­di­atric on­col­o­gist. Dahl im­me­di­ately agreed to help and sent her to Pamela Kato, a Stan­ford health psy­chol­o­gist who shared Omid­yar’s love for videogames. Kato was wrap­ping up a post­doc at Stan­ford in pae­di­atric on­col­ogy. “I re­mem­ber Gary com­ing to me and say­ing, ‘There’s this lady that made a lot of money in Sil­i­con Valley and she wants to make some­thing for kids with cancer,’” Kato said re­cently. “And I said, ‘OK, Gary, does she just want to give the kids a toy to make them feel bet­ter, or does she want to do this right?’”

Dahl told Kato to shut up and just go to the meet­ing. Kato was im­me­di­ately taken with Omid­yar’s sin­cer­ity. “I’ve seen peo­ple waste money try­ing to help kids but they don’t know what they’re do­ing,” she said. Dahl told Omid­yar, “This may be the first time I’ll be able to of­fer my kids a sense of con­trol over their dis­ease.”

Ini­tially, Kato worked as a con­sul­tant, writ­ing pro­pos­als on how a game about cancer would look, how it would play, and whom it would ben­e­fit. She made con­tacts with game de­sign­ers and pub­lish­ers. “The game wasn’t in­tended to be clin­i­cal – it wasn’t a new form of chemo­ther­apy – but we be­lieved it could help kids while they were go­ing through this chal­leng­ing part of their lives,” Omid­yar said. She didn’t have an of­fice; her and Kato met in cof­fee shops to give each other up­dates.

While Omid­yar and Kato tried to come up with an ac­tual method­ol­ogy for devel­op­ing the game, Dahl, a hard-nosed medic, warned them the chances of suc­cess were slim: “There’s not a lot of ev­i­dence that this is go­ing to ac­tu­ally work,” Cole remembered Dahl say­ing. “But I can tell you one thing: if your game can help my kids take their main­te­nance chemo­ther­apy more re­li­ably, or help them re­port symp­toms at an ear­lier stage, that will make a huge dif­fer­ence.” Dahl knew that young cancer pa­tients died much too of­ten, pre­cisely for those rea­sons. If there was some way to help them re­mem­ber to take their treat­ments, or mo­ti­vate them to be­come more ac­tive and in­ter­ested in their re­cov­ery, it could trans­late to an in­crease in sur­vival rates.

That’s when Kato called an old grad school friend named Steve Cole, who was work­ing as a pro­fes­sor of medicine at UCLA Cancer Cen­ter. “Steve, you’re the only per­son I know who knows the back­story of the cells who can also speak the lan­guage of videogames,” she told him. “Help me turn this into a game.” Cole agreed and came on­board as a con­sul­tant.

The prob­lem now was the game it­self. Be­cause its pri­mary func­tion was not en­ter­tain­ment, it would re­quire dif­fer­ent de­sign and pro­duc­tion pa­ram­e­ters to make. No one seemed to know where to turn next. Omid­yar reached out to ma­jor game de­vel­op­ers “at the level of EA, Mi­crosoft and Nin­tendo”, although she did not wish to name them. But no one was in­ter­ested in tak­ing things fur­ther. “In a busi­ness con­text, they couldn’t jus­tify the ex­pense of cre­at­ing a game for a small seg­ment of the pop­u­la­tion,” Omid­yar said. “They didn’t have the imag­i­na­tion to see how we could make a game about cancer cool and beau­ti­ful.”

Omid­yar and Kato knew they needed videogame de­sign­ers, but it was dif­fi­cult to find any will­ing to work along­side physi­cians. Physi­cians didn’t un­der­stand the process of game de­sign, and game de­sign­ers didn’t al­ways want to in­clude the clin­i­cally rel­e­vant in­for­ma­tion that Omid­yar thought was im­por­tant to achieve the game’s pur­pose. “Game de­sign­ers are fab­u­lous at mo­ti­vat­ing kids to keep play­ing a game, and that’s what we wanted – we wanted a game that kept kids play­ing by us­ing the in­cen­tives and chal­lenges that make games so en­gag­ing. But we also needed to put con­tent into the game that would make it rel­e­vant to the cancer ex­pe­ri­ence and help kids bet­ter un­der­stand their dis­ease and how to fight it,” Omid­yar said.

Ad­her­ence to med­i­ca­tion is cru­cial in cancer treat­ment. Ide­ally, the game would help young cancer pa­tients to un­der­stand the cor­re­la­tion be­tween the amount of chemo in their body and the abil­ity of cancer cells to repli­cate the mo­ment they stopped chemo. Omid­yar and Kato would sit around cof­fee shops in Moun­tain View try­ing to imag­ine what such a game would look like. They thought it would work best set in the blood­stream. “What would it look like to ac­tu­ally nav­i­gate through the blood­stream in the heart? You’d have to wait for the valve to open, and you’d shoot through,” Omid­yar said. “Then you’d get stuck, and you don’t want to dam­age

“They couldn’t jus­tify the ex­pense. They didn’t have the imag­i­na­tion to see how we could make a game about cancer cool and beau­ti­ful”

the heart, so you have to hold firing and get to the next lo­ca­tion. We talked through all that.”

There was also the is­sue of videogames’ pub­lic im­age. At the time, games were more or less seen as the “enemy of civil­i­sa­tion”, as Cole remembered. Games had been blamed for the Columbine High School shoot­ing in 1999. Two years later, Rock­star’s Grand Theft Auto III gen­er­ated heated de­bate about the na­ture of vi­o­lence and sex­ual con­tent in games. There were claims the game glo­ri­fied, even en­cour­aged, crim­i­nal be­hav­iour. Vi­o­lent games be­came the sub­ject of fre­quent me­dia re­ports. On 25 June 2003, teenagers Wil­liam and Josh Buck­ner shot and killed Aaron Hamel and Kim­berly Bede.

They claimed they were in­spired by GTAIII. In Oc­to­ber the same year, Hamel and Bede’s fam­i­lies filed a $246 mil­lion law­suit against Rock­star Games and the com­pa­nies as­so­ci­ated with dis­tribut­ing the game. US sen­a­tors be­gan ref­er­enc­ing stud­ies on vi­o­lent games and ag­gres­sion. (There re­mains no def­i­nite link be­tween the two. Some stud­ies ar­gue that videogames have a neg­a­tive im­pact on the be­hav­iour of young adults, how­ever, in some cases, these con­clu­sions were drawn from iso­lated in­ci­dents in­volv­ing ran­domly cho­sen par­tic­i­pants show­ing mild signs of ag­gres­sion and anti-so­cial be­hav­iour im­me­di­ately af­ter play­ing a vi­o­lent videogame – things like cut­ting off the per­son in front of them while walk­ing out of the study, or not say­ing “please” or “thank you”.)

Ac­cord­ing to Cole, these stud­ies were of­ten cor­rect about the po­ten­tial of in­ter­ac­tiv­ity to in­flu­ence be­hav­iour – but in­cor­rect about how that po­ten­tial is re­alised. “Most videogames are not very im­pact­ful, ei­ther pos­i­tively or neg­a­tively. You re­ally have to work hard to make a videogame im­pact on some­one’s be­hav­iour – it’s not ac­tu­ally an easy thing to do, in our ex­pe­ri­ence. So I think the gen­er­al­i­sa­tion that games rou­tinely do this stuff is wrong.”

Omid­yar used the de­bate about vi­o­lent games to her ad­van­tage: if some peo­ple wor­ried that games had the power to mo­ti­vate bad be­hav­iour, the best thing she could do was use the same ar­gu­ment to show games could mo­ti­vate good be­hav­iour. In 2001, she set up her own com­pany, HopeLab. She reached out to physi­cians, pa­tients and their fam­i­lies to get in­sight and data into the strug­gles faced by young cancer pa­tients. Then, she turned to the ques­tion of de­vel­op­ment and distri­bu­tion. Should the stu­dio work with out­side de­vel­op­ers, or hire a team in-house to de­sign the game?

Af­ter test­ing out sev­eral game con­cepts on young cancer pa­tients at Lu­cile Packard Chil­dren’s Hospi­tal, HopeLab fi­nally set­tled on a fi­nal de­sign from an LA-based game de­sign stu­dio called Real Time As­so­ciates. The first ver­sion of Re-Mis­sion was com­pleted in 2005, but Omid­yar wanted one more as­sur­ance that she was on the right track be­fore re­leas­ing the game. Specif­i­cally, she wanted the sup­port, and re­spect, of the med­i­cal com­mu­nity. So, in mid-2005, she as­sem­bled a large, ran­domised con­trolled trial of Re-Mis­sion. This is a trial in which par­tic­i­pants are al­lo­cated at ran­dom to re­ceive one of three

“You re­ally have to work hard to make a video game im­pacts on some­one’s be­hav­ior – it’s not ac­tu­ally an easy thing to do, in our ex­pe­ri­ence”

things: the clin­i­cal in­ter­ven­tion (a drug or in this case, a videogame) be­ing tested; a placebo; and no in­ter­ven­tion at all. “A ran­domised con­trolled trial was, and still is, the gold stan­dard for test­ing,” Cole said.

Cole be­gan the “gar­gan­tuan strug­gle” of wran­gling a team of 34 dif­fer­ent med­i­cal cen­tres across the US, Canada and Aus­tralia, each re­cruit­ing teenage cancer pa­tients. The pop­u­la­tion of ado­les­cent and young adults with cancer is rel­a­tively small, mean­ing in or­der to get the sam­ple size needed for a ran­domised clin­i­cal trial, HopeLab needed to re­cruit from a large sam­ple size. The fi­nal number of pa­tients – 374 – seems small, yet it made the study one of the first and largest to fo­cus on ado­les­cent cancer pa­tients. HopeLab man­aged to se­cure fund­ing for the trial from The Na­tional Cancer In­sti­tute, who told Omid­yar she was crazy for try­ing to do the whole thing in a year. It would take at least five, they said.

Dur­ing the study, pa­tients were asked to play Re-Mis­sion as much as they wanted to, with the stip­u­la­tion that they play at least once a day. At Stan­ford, Dahl ap­proached Lore to help him re­cruit pa­tients. “It took a while for some of the younger pa­tients to get it, but a lot of the older kids re­sponded to it,” Lore said. “The point was to teach them about their treat­ment – so, for ex­am­ple, yes, the chemo makes you feel bad, but at the same time, this is why we need to do it. This is why you lose your hair.”

In the end, the study was com­pleted in un­der a year, like Omid­yar wanted. What’s more, it proved her as­ser­tions about the game were cor­rect. The con­trol group re­ceived PCs pre­loaded with a pop­u­lar videogame; the rest of the par­tic­i­pants re­ceived PCs with the same pop­u­lar videogame, plus a copy of Re-Mis­sion. It was Kato’s be­lief that the kids who played Re-Mis­sion would be less hes­i­tant about their cancer treat­ment, and over­all show more will­ing­ness to get bet­ter. Af­ter three months, the re­search team found the pa­tients who had played Re-Mis­sion had taken their an­tibi­otics more con­sis­tently and with less re­sis­tance or com­plaint and, sur­pris­ingly, main­tained higher lev­els of chemo­ther­apy in their blood com­pared to those in the con­trol group. The Re-Mis­sion kids also seemed to know a lot more about their cancer than the con­trol group af­ter the study was fin­ished – things like the names of par­tic­u­lar cells and the bi­o­log­i­cal pro­cesses in­volved in each of their treat­ments. (The re­sults of the study were pub­lished in the peer-re­viewed med­i­cal jour­nal Pe­di­atrics.)

But, while the game seemed to be work­ing, in the sense that pa­tients who played it were pay­ing more at­ten­tion to their treat­ment and seemed to be more mo­ti­vated to take their med­i­ca­tion, it was hard to tell where the self-ad­vo­cacy was com­ing from: the tex­tual in­for­ma­tion in the game, or the act of play­ing the game? (The game was pre­loaded with all kinds of in­for­ma­tion, in­clud­ing some pos­si­bly over­long cutscenes about all the bad things that would hap­pen to Roxxi if she didn’t take her medicine, and so on.) Was it pos­si­ble to sep­a­rate the in­for­ma­tion from the mo­ti­va­tion and see which was hav­ing a stronger ef­fect?

Around this time, Cole of­fi­cially joined HopeLab as the vice pres­i­dent of re­search and de­vel­op­ment. Af­ter study­ing the re­sults of the study closely, Cole rea­soned it wasn’t the in­for­ma­tion in the game that was hav­ing the most im­pact, but the mo­ti­va­tion. To test this, HopeLab part­nered with Stan­ford to con­duct a func­tional mag­netic res­o­nance imag­ing (fMRI) study in which the brain ac­tiv­ity of pa­tients play­ing Re-Mis­sion was mon­i­tored and com­pared to that of pa­tients who were only watch­ing the game. The re­sults, pub­lished in the jour­nal PLoS One in March 2012, showed that neu­ral cir­cuits in the brain re­lated to re­ward and mo­ti­va­tion lit up only in par­tic­i­pants who played

Re-Mis­sion, and not in those who sim­ply watched, ex­plain­ing why ac­tive play­ers were more likely to change their be­hav­iour and at­ti­tude in re­la­tion to their treat­ment.

Cole paid care­ful at­ten­tion to see whether it was the in­for­ma­tion pro­cess­ing re­gion of the brain that was light­ing up when pa­tients played Re-Mis­sion, or whether it was re­gions to do with sus­tained pos­i­tive mo­ti­va­tion and goal-seek­ing. “By the time we had done all of these fol­low-up stud­ies, we were pretty con­vinced that it was re­ally about that act of play­ing it­self – the chas­ing cancer cells and learn­ing more about them and get­ting fur­ther in the game – which was turbo charg­ing the good be­hav­iour in the pa­tients.”

It seemed un­likely that the pa­tients were for­get­ting how to take their main­te­nance chemo­ther­apy, or for­get­ting the ba­sic prin­ci­ple that main­te­nance chemo­ther­apy is im­por­tant for fight­ing cancer. They all knew all this. More in­for­ma­tion would not be help­ful. But, mak­ing kids feel like main­te­nance chemo­ther­apy was a kind of am­mu­ni­tion for a gun or rocket launcher that they could use to fight this epic foe threat­en­ing their well­be­ing was a dif­fer­ent story. There was also the ac­tive ver­sus pas­sive el­e­ment: why weren’t the kids who were watch­ing the game ex­pe­ri­enc­ing the same pos­i­tive be­havioural changes as those who were play­ing it? “The em­pir­i­cal an­swer is if you watch some­thing pas­sively, your vis­ual cor­tex lights up – you know the in­for­ma­tion is com­ing in,” said Cole. “What’s dif­fer­ent is where that in­for­ma­tion goes.” In other words, how does the brain utilise that in­for­ma­tion? The area of the brain par­tic­u­larly re­spon­sive in par­tic­i­pants play­ing Re-Mis­sion was the area that drives goal-seek­ing be­hav­iour.

Once peo­ple know they are in charge of an out­come, they will fight hard to win, even if they don’t par­tic­u­larly care about what they are win­ning. “I mean, you can give them a dead fish at the end of the day, they don’t care – they just want to win the game.” Game-play­ing par­tic­i­pants also ap­peared more aroused – their brain was mov­ing around in­for­ma­tion much quicker, and to more places, than the brains of non-game­play­ing par­tic­i­pants. Fi­nally, Cole no­ticed the hip­pocam­pus – the cen­ter of emo­tion and mem­ory in the brain – of game­play­ing par­tic­i­pants was light­ing up pretty reg­u­larly com­pared to non-game-play­ing par­tic­i­pants, mean­ing that those play­ing the game were much more likely to form long term mem­o­ries of their ex­pe­ri­ence than those sim­ply watch­ing. “So if you

wanted to take a piece of in­for­ma­tion, get it into a per­son, and then have them do some­thing that is go­ing to stick with them over time, these are the three things you’d re­ally like most to see. One, a lot of pos­i­tive mo­ti­va­tion to do some­thing with the in­for­ma­tion; two, ev­i­dence that their brain was mov­ing the in­for­ma­tion around and pro­cess­ing it; and three, some proof that their brain was steer­ing this in­for­ma­tion into long term mem­ory.”

Jo Len­nan, 31, was di­ag­nosed with cancer two years ago. She un­der­went eight months of chemo­ther­apy start­ing Novem­ber 2014. Af­ter one surgery, her doc­tors gave her a choice: con­tinue tak­ing ke­tamine, a mild painkiller that can cause hal­lu­ci­na­tions and night­mares, or switch to a stronger drug. Len­nan chose to stick with ke­tamine, even af­ter ex­pe­ri­enc­ing a par­tic­u­larly bad night­mare. The ex­pe­ri­ence was rare, she said. “It doesn’t come nat­u­rally to some doc­tors to em­power their pa­tients’ choices. More of­ten, they would pre­fer to weigh things up them­selves and then let you know what you’ll be do­ing. As hu­man be­ings, though, we usu­ally want rea­sons to do things, and ‘be­cause I say so’ isn’t as il­lu­mi­nat­ing or mo­ti­vat­ing as knowl­edge can be. That’s as true for kids as it is for adults.”

Re-Mis­sion was re­leased in 2006 to near unan­i­mous com­men­da­tion from the in­ter­na­tional med­i­cal com­mu­nity. The en­cour­ag­ing re­sults of both stud­ies led HopeLab to in­vest in

Re-Mis­sion 2, a col­lec­tion of free on­line games playable both in browsers and on mo­bile plat­forms that ad­here to the same prin­ci­ples as the orig­i­nal, only with more game­play and less in­for­ma­tional cutscenes. Game lev­els start out shorter and eas­ier, game ob­jec­tives are clearer, and tar­gets more ob­vi­ous. The game­play is op­ti­mised to help play­ers feel a sense of quick ini­tial ac­com­plish­ment and pro­gres­sive growth in skills. The in­ten­tion was to make Re-Mis­sion 2 eas­ier to play, and thus ap­peal to a wide range of ages and both gen­ders.

By switch­ing to a se­ries of smaller minigames, HopeLab was also able to de­velop Re-Mis­sion 2 at much less cost (Cole es­ti­mates Re-Mis­sion 2 cost one-tenth of Re-Mis­sion’s bud­get to de­velop), and use mul­ti­ple game de­sign­ers to ul­ti­mately cre­ate a va­ri­ety of dif­fer­ent game­play styles. It also al­lowed HopeLab to do user test­ing pro­gres­sively through­out the game de­vel­op­ment process, rather than wait­ing un­til the game was com­plete and hop­ing that it worked.

Both Re-Mis­sion and Re-Mis­sion 2 are cur­rently avail­able for free to young cancer pa­tients and in­sti­tu­tions in over 80 coun­tries and in part­ner­ship with or­ga­ni­za­tions in­clud­ing the Starlight Chil­dren’s Foun­da­tion and the En­ter­tain­ment Soft­ware As­so­ci­a­tion, the gam­ing in­dus­try lobby. At the time of writ­ing, more than 210,000 copies of the orig­i­nal Re-Mis­sion have been dis­trib­uted; Re-Mis­sion 2 game down­loads have also sur­passed the 200,000 mark and more than 400,000 game lev­els have been com­pleted by play­ers.

“This whole ven­ture of do­ing a se­ri­ous game was re­ally a shot in the dark,” Kato said re­cently. “We knew we wanted to fo­cus on ad­her­ence, and we knew you can’t get that out of show­ing some­one a video or telling them or writ­ing a brochure. If you’re a kid with cancer, it’s scary. You know you’re sup­posed to take your pills. You know if you do it you will live longer. But when you take your pill for chemo, the im­me­di­ate re­ward is that your hair falls out, your face blows up and you’re sick all the time. Re-Mis­sion made it em­pow­er­ing to have to go through all this. It made the kids feel like they were in con­trol, for once.”

HopeLab’s suc­cess with the Re-Mis­sion games in­spired the stu­dio to broaden its fo­cus to other ar­eas that might ben­e­fit from a videogame so­lu­tion. Look­ing at the land­scape of youth­cen­tric health is­sues, HopeLab set­tled on child­hood obe­sity, a grow­ing prob­lem in­creas­ingly cited by health ex­perts as a dan­ger to the health of Amer­i­cans to­day. Ac­cord­ing to the US Cen­ters for Dis­ease Con­trol and Pre­ven­tion, child­hood obe­sity has more than dou­bled in chil­dren in the last 30 years; in 2012, more than one third of chil­dren and ado­les­cents were over­weight or obese.

The Re-Mis­sion stud­ies had proven that it was pos­si­ble for a videogame to pos­i­tively in­flu­ence be­hav­iour in young peo­ple.

Fred Dil­lon, HopeLab’s direc­tor of prod­uct de­vel­op­ment, has helped steer the com­pany away from sick care and to­wards pre­ven­tion. “Rather than fo­cus­ing on help­ing young adults fight a dis­ease once it has al­ready taken hold, we re­al­ized we could ac­tu­ally cre­ate tools that sup­port health and well­be­ing early in life, and help keep them healthy,” Dil­lon said re­cently.

To bet­ter un­der­stand the tar­get de­mo­graphic, HopeLab in­ter­viewed 25 mid­dle-school­ers around the US about every­thing from their eat­ing and ex­er­cise habits to their pre­ferred leisure ac­tiv­i­ties. “It’s the age when kids start to fig­ure out whether they’re a sport kid or not,” Dil­lon said. The stu­dio then iden­ti­fied where a game would be likely to have the most im­pact: was it on the eat­ing and calo­ries part of things, or the ex­er­cise part?

Ul­ti­mately, it was de­cided it would be much eas­ier to mo­ti­vate kids to ex­er­cise than to get them in­ter­ested in nu­tri­tion, par­tic­u­larly as kids of­ten have lit­tle con­trol over what they eat in the first place. HopeLab also wanted to hear from the kids them­selves, so the stu­dio launched a com­pe­ti­tion ask­ing chil­dren to sub­mit ideas for prod­ucts that would in­crease phys­i­cal ac­tiv­ity. A lot of what came back was based on a sim­ple ac­tion-re­ward struc­ture: one kid sub­mit­ted an idea for a ver­sion of Dance Dance Revo­lu­tion, but with tex­ting – so kids would text with their feet.

The re­sult was a plat­form of games named Zamzee, whose aim is to mea­sure kids’ phys­i­cal ac­tiv­ity and re­ward them for it. Kids (and their fam­i­lies) can earn gift cards through the plat­form for com­plet­ing cer­tain phys­i­cal chal­lenges. The re­wards range from mon­e­tary (gift cards at a $5 value to places like Amazon or iTunes); pro-so­cial re­wards like con­tri­bu­tions to a se­lected char­ity (ASPCA, par­tic­i­pant’s school, Save The Chil­dren, and so on); and vir­tual re­wards, such as avatar items and graph­i­cal ‘badges’ that ap­pear on users’ home screens.

Early pi­lot tests con­ducted in part­ner­ship with lo­cal schools

and uni­ver­si­ties showed an in­crease in phys­i­cal ac­tiv­ity of up to 30 per cent. Usu­ally, pi­lot tests lasted from six to 12 weeks, with 60 to 100 kids. In a six-month, 448-per­son ran­domised, con­trolled study, HopeLab found that kids us­ing Zamzee were 59 per­cent more ac­tive than a con­trol group. (That’s the equiv­a­lent of do­ing an ex­tra 45 min­utes of non-stop pushups each week.)

It’s Dil­lon’s wish for HopeLab to broaden its fo­cus be­yond gam­ing. This means work­ing with ev­ery­one from for-profit or­gan­i­sa­tions to health­care providers to uni­ver­si­ties – any­one with a vi­sion on how to use tech­nol­ogy and games to im­prove ar­eas like health and psy­chol­ogy. Re­cently, the lab part­nered with the Yale Cen­ter for Emo­tional In­tel­li­gence to cre­ate an app which tracks users’ moods through­out the day. Called the Mood Me­ter, it was orig­i­nally based on a vis­ual aid in Yale class­rooms. The app en­ables users to plot their feel­ings, and se­lect strate­gies to man­age each feel­ing. They can also sched­ule re­minders to up­date the app through­out the day on mood changes. “We’ll work with any­body who wants to make the world a bet­ter place,” Cole, who is still with HopeLab, said re­cently.

Back at Lu­cile Packard Hospi­tal, Lore took us to visit An­drew, a 12-year-old whose leukemia had re­lapsed. An­drew eyed the iPad hun­grily as Lore ap­proached, con­ced­ing that while Re-Mis­sion 2 is hard, he likes it be­cause it gets his brain mov­ing. “It does make you think about [cancer]. It gives you a bet­ter idea of what’s go­ing on in­side your body.” Later, Lore vis­ited Mirella, a seven-year-old with leukemia in the room next door to An­drew’s. She was in the mid­dle of an ar­gu­ment with her mother about tak­ing her liq­uid Tylenol. She said it tasted bad. She lay curled in the fe­tal po­si­tion on the bed, her small, hair­less head the only thing vis­i­ble above the blan­kets. She eyed Lore ap­pre­hen­sively as he ap­proached. “Look, Mirella, I’ve got a game for you.” She saw the iPad in his hands and re­acted in­stinc­tively, throw­ing the cov­ers off and sit­ting up­right.

Lore handed her the iPad and asked if she’d be in­ter­ested in play­ing a new game that would help her feel bet­ter about her cancer. She nod­ded, and Lore clicked on the Re-Mis­sion 2 icon. She be­gan play­ing without wait­ing for Lore’s in­struc­tions, get­ting the hang of the game as she went along. Ev­ery time Lore would ex­plain some­thing, she would just nod, her eyes glued to the screen.

Mirella’s mother watched on. “What did you say this game was called?” she asked Lore. Lore ex­plained the con­cept. “We some­times use it to help kids un­der­stand what cancer is and why it’s im­por­tant for them to keep fight­ing,” he said, talk­ing to Mirella’s mother but keep­ing his eyes on his young pa­tient.

Af­ter ten min­utes, Lore told Mirella it was time to take the iPad to an­other pa­tient. “Did you like the game?” he asked her. She nod­ded, not un­en­thu­si­as­ti­cally. “Now,” Lore con­tin­ued, “how about that Tylenol? It won’t taste so bad, right?”

Mirella threw him a look, as if to say, I know ex­actly what you’re do­ing, and it won’t work. But when her mother picked up the sy­ringe of bright pink liq­uid, she didn’t protest.

“Rather than fo­cus­ing on help­ing young adults fight a dis­ease, we re­al­ized we could cre­ate tools that sup­port health and well­be­ing”

This is an ex­tract from Power Play: How Video Games Can Change The World. It’s avail­able now in hard­cover from bit.ly/pplay­book

Laura Parker is an au­thor and journalist for The New Yorker and The New York Times

Asi Burak, chair­man of Games For Change, which pro­motes games as a pos­i­tive so­cial force

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