Project Sanitarium: playing tuberculosis to its end game

Tuberculosis remains a global threat with more than nine million new infections every year (TB Alliance 2016, World Health Organization 2015). It is now the leading infectious disease cause of death, but is preventable if we had the tools and the will to eradicate it (Dye 2009; World Health Organization 2014). The disease is on the rise in many developed countries, where it was all but eradicated (Nebehay 2014), yet it is still largely regarded as a disease of the developing world. It is in the developing countries that the major burden of disease falls on the most productive age group. Thus, it is a disease of the poor and a disease that makes people even poorer. There is a stigma associated with the disease in some communities, which can result in some delay in attendance at health facilities. Many are unaware of the importance of tuberculosis and the threat to health that it poses to them, which may prevent individuals seeking care at a stage when their disease is more amenable to treatment. Where there is no facility for sick leave, paid or unpaid, many people delay consulting the health care system. Thus, the importance of seeking help for chronic cough or unintended weight loss is essential and attending a health facility rather than a traditional healer is important.

Conventional tuberculosis treatment remains difficult and there has been no significant change in the duration of the standard regimen since the early 1980s (Spigelman and Gillespie 2006). Moreover, many patients are unable to tolerate this treatment and discontinue therapy, increasing the risk of resistance (O’Neill 2014). Importantly, patients feel better long before it is safe for them to stop treatment, which can result in relapse of the disease and further damage to the lungs, or the risk of drug resistance developing. There is a growing tide of multiple drug resistance and few effective antibiotics to tackle the problem. Since the turn of the millennium there has been a surge in interest in developing new therapies for tuberculosis and a number of new drugs have been developed. Yet, these are insufficient and more research is required to ensure that we have enough new treatments and can understand how to deploy them, as clinical trials are expensive to perform (Gillespie et al. 2014; Merle et al. 2014).

There is a pressing need to explain the challenges of tuberculosis to a diverse group of audiences. Clinical research is essential, but expensive. Therefore, it is vital to communicate the importance to funding organizations, and the public that support them, to justify why it is necessary to make an increase in the funding to tuberculosis drug development. The market for anti-TB drugs is small, so there is little incentive for pharmaceutical companies to develop the required treatment (although many do through their corporate responsibility). This market failure means that tuberculosis research must be funded by the public purse and research on tuberculosis must compete with other worthy causes. Whether we like it or not, research into a disease competes for funding with other diseases: tuberculosis versus cancer versus malaria. If we are to increase the funding envelope for tuberculosis, the importance of the task must be made clear and that there is a route to a solution.

As tuberculosis is largely a disease of poverty and relatively uncommon in Europe in comparison with resource poor environments, there is a need to explain that research funding must be spent on a problem that is rare in Europe, but important globally. Even though we may argue that, in a global village, we all share infection problems, in reality diseases like tuberculosis are perceived to be distant and irrelevant. To address this challenge, we need to communicate to the wider population in an engaging way.

To be of value, tuberculosis research must be placed in the communities most in need of the solutions that the research may offer. Thus, before tuberculosis clinical research can start it is necessary to engage with local communities, explain the disease and the need for diagnosis and treatment, and the role that they may play in solving an important global problem. An important side effect would be to promote better health seeking behavior for tuberculosis and other diseases. Clinical research cannot and should never exist in an experimental vacuum; it must be placed in the context of a community. Thus, innovative educational tools could have an important role to play in achieving a permissive environment where research is possible because the community understands its significance and are empowered to test the assertions of researchers robustly.

Subjects of medical research often are required to participate in activities additional to their normal health care (Gillespie et al. 2014; Merle et al. 2012). It is more likely that patients will agree to this if they understand what they are giving to the wider community. We know from research that patients in trials have better outcomes than those not on trials irrespective of the disease in question. Thus, the better-informed patients are about their disease, the better their choice will be about whether they wish to participate.

Clinical research ethics require patients to give fully informed consent. Although there is considerable literature about the danger of potential conflicts of interest and unconscious inducements to participate, there is very little research that describes what background information potential subjects need to have before their decision is deemed informed. In some studies, potential subjects are given information and can only consent if they pass a test at the end that proves they understand the implications of their decision. Gaming may provide education without pain and it might be possible to embed in the game rules testing of essential principles that could confirm that potential subjects understood the nature of the trial, the benefits and the risks.

In a world where the mobile phone is everywhere, computer games provide a platform for communicating complex ideas and details in a digestible way. Much more can be communicated when the information is delivered in a “fun” environment (Singh 2014). Games that incorporate the facts of a disease and its treatment could have an important role to play. This has already been proven through games such as Foldit (2008) and Plague Inc. (Ndemic Creations 2012) Created by various departments and labs from the University of Washington, Foldit demonstrated that a game about folding protein strings could help crowdsource scientific solutions through gaming. In 2014 NDemic Creations galvanized their Plague Inc. community to help fundraise for charities that were working to fight the Ebola outbreak. Over 800,000 players visited the webpage and approximately $76,000 was raised for charities such as the Red Cross, Disaster Emergency Committee and Médecins Sans Frontières. Other serious games that utilize crowdsourcing were a significant influence on the design of Sanitarium. Fraxinus (2013) is a game made to combat a specific species of fungus that was causing Ash Die Back in ash trees across Europe. The player uses real genetic data to try and find why some trees are immune to this fungus. Fraxinus demonstrated that it was possible to make a fun, entertaining game based on real scientific data. In particular, the gene matching puzzle showed that complex data could be presented in simple form and gameplay. Similarly, Play to Cure: Genes in Space (Guerrilla Tea 2014) funded by Cancer Research UK uses the collective force of players to analyze real genetic data. Ostensibly the game sees the player piloting a spaceship in order to collect Element Alpha. Underneath the surface the game finds the optimal route to pick up the most Element Alpha, and in doing so plots a course through genuine ‘DNA microarray’ data. Crunching the data helps scientists identify the DNA faults that could lead to cancer. Other more specific TB games were, unbeknownst to the team, being developed at the same time and have subsequently been released. On World Tuberculosis Day, 24 March 2015, Tuberspot (2015) a serious game developed by researchers at the Polytechnic University of Madrid was released. In Tuberspot, players help analyze real digitized sputum samples and the overall aim is to develop a microscopy system on a mobile phone to allow telediagnosis. In 2016 a new version of the Eterna game from Stanford University was released. The initial version of Eterna was developed as a way to let citizen scientists design potentially useful biomolecules that are stable enough to function inside a living cell. Over the years, the players have become more and more expert in designing complex RNA molecules. The new version was developed with the aim of encouraging players to design a molecule that could help spur the development of a new tuberculosis test (Dushek 2016).

The collaboration for Project Sanitarium developed from the desire of the clinical team from the University of St Andrews to create a simple visual tool to present data from recent clinical trials (Gillespie et al. 2002, 2014; Honeyborne et al. 2011). At Abertay University, the School Arts, Media and Computer Games has established an interdisciplinary workplace-simulation model for students (Wenger 1998). The model groups students from across six degree programs (covering the disciplines of art, audio, code, design and production) into small teams. Each team is then assigned to a client brief and provided academic and industry mentors. The semester structure means that although the module is core for all the undergraduate programs it only accounts for a part of each student’s academic workload. When looked at in contrast to professional development, the amount of time dedicated to all aspects of the project is approximately six weeks. Given the time constraints and the additional complications of working in a University environment (no dedicated workspaces, a completely flat team hierarchy, difficulty in bringing in additional resources and the restrictiveness of the academic calendar) the main goal for the students is to deliver a working prototype. The value of the model has been endorsed through various industry accreditation and academic reviews. From the academic perspective, industry-based interdisciplinary team projects help characterize the students learning experience and the situated practice ethos provide students with a portfolio of achievement. For industry, interdisciplinary workplace-simulation delivers a strong parallel with games industry practice and the requisite skills sought in prospective employees.

Although the workplace-simulation model fosters academic–industry collaborations, the development is not funded in any way and as a result success largely depends upon student commitment and engagement with the client and the project idea. The concept brought by the Infection Group demonstrated a clear opportunity and a suitable challenge to develop a game based around disease, but there was an inherent risk in persuading students to create a “fun” game about a deadly disease. In order to improve upon the project credentials, an initial concept was worked up to a more developed brief that settled on three core elements. These were to create a game that mimicked how the disease developed in a person, how treatments might be utilized to cure the disease and lastly to explore how new treatments might potentially work in the future.

The aims were still broad and there remained a clear need to further define the audiences for the game and to consider how a game could remain “fun” but still engage with the serious subject matter. The project team embraced the challenge with a series of meetings to further define and develop the concept. It was through these sessions that new requirements and audiences were defined. It was established that the game needed to visually simplify multiple complex parameters for people developing new treatments for the disease. Features had to be developed to allow for exploring different patient symptoms, and how the virulence of the disease could be affected by different drug regimens or by designing and testing better treatments. There was additional discussion on the look and feel of the game. Whether the game should reflect the combat between the bug and the host and provide a quasi-realistic feel with images of the lungs, bacteria and human immune cells, or to take a more abstract consideration of the game aesthetics, mechanics and delivery. These meetings were essential to allow all parties the creative space to pitch ideas and respond to feedback. They also proved to set the tone for development through iterative ‘sprints’ rather than relying on designing everything upfront (Boehm and Turner 2003). The iterative nature of the development was largely feasible because the project was unfunded (there was no external or internal pressure to succeed) and success only required delivery of a prototype. Early mock-ups and rough code prototypes were presented through regular meetings and presentations, and through the frequent feedback each iteration on the core game became gradually stronger. One of the challenges of iterative development is that it can often be difficult to see progress. The team compensated for this by targeting several milestones each based around the delivery of a core feature. The result was the delivery of a prototype that delivered the project aims through focusing the core game on a mathematical model.

The game prototype of Project Sanitarium was made available through download via the web in summer 2015. Since then the project team have attended events, presented at various games shows and delivered talks about the project with the aim of slowly growing the user base and making incremental gameplay improvements based on the analytics gathered. The prototype phase moved into an evaluation phase. The prototype demonstrated that the initial objectives set out in the brief could be achieved. Namely that a game could simulate the experience of clinical trials in a fun and informative way, and more fundamentally that the mathematical model could be modified and adapted based upon the data collected.

Using the data collection regarding player engagement and retention from April 2015 to end of December and correlating the data with events and social media campaigns demonstrated that the game had some success in achieving the original aims (see Fig. 7.). Analyzing the number of installs and tracking the number of active users demonstrated that attending events and talking about the project was necessary in generating interest in downloading the game, and that there was considerable drop off of active players as time progressed. This was entirely expected as the game prototype was significantly limited in scope and without new content and additional development players would naturally drop off. In each of the player engagement measurements the team witnessed spikes that directly correlated with the game and public engagement. Competition success, demo events and associated press coverage proved to be the most effective means of encouraging new players. Without any marketing budget this was also the most cost-effective. Overall the game attracted over 500 players and using the analytics it was possible to track their largely similar user journeys. The data demonstrated that players initially engaged in longer play sessions and, by tracking in-game events, showed that players would generally play through the patient lifecycle. Players understandably wanted to see not only how the disease developed in a person, but how treatments might be utilized to cure the disease. The aim of educating players about the threat of tuberculosis was enhanced by the fact that player sessions were representative of the patient lifecycle. However, it was also clear that player retention (players returning to play the game) was always going to be limited. Indeed, the percentage of players still playing was measured after one, seven, fourteen and thirty days and the retention is calculated by looking at players that played on a specific date and then returning. Once internal testing was removed from the analysis it was apparent that the prototype did not deliver player retention, but this was largely expected due to the lack of a fully featured product and limited game content. The team was initially buoyed by the stickiness measurement of the game.

Stickiness is defined as the ratio of daily or monthly active users returning and engaging with the game. If the stickiness is low then there are higher numbers of new players active in the game whereas if the stickiness is high then there are higher proportions of returning players currently active. However, it was quickly apparent that these numbers were unreliable. Stickiness proved too difficult to analyze and trust, due to internal testing and they were skewed further by using the same demo hardware at events (see Fig. 8).

The uptake of players and the fact that play sessions were generally covering the patient lifecycle also ensured that the analytics could track in-game events. The majority of the tracked parameters were used help improve the design of the overall game. Without the analytics we would have had to rely on less quantitative data through questioners on focus testing. The analytics enabled us to identify key issues, such as players not understanding game elements or where to go. The event parameters were also useful in providing information back to the Infection Group should they want to adapt the current mathematical model presented in the game. However, it was also clear that further iteration on the model would require a more complete game. What the analytics indicated was that the prototype had potential, but more importantly that analytics would prove to be vital in providing a large amount of useful player information: player numbers, returning players, stickiness, how long players spend on different parts of the game, how difficult players found specific mini-games. In a full game these would in turn affect further development, informing updates of the game and impacting on the future design iteration for both players and academics utilizing the data.

In order to determine the success of the project, the best indicator beyond the analytics was the plaudits the game secured through entering competitions and the press coverage. The completed prototype earned the team a place in the Games category for UK Finals of Microsoft’s the Imagine Cup. The game also placed third in the Microsoft Azure Gaming Innovation challenge, was selected as a finalist in the Game with a Purpose category at the TIGA Games Industry awards and won a Gold award at the 2015 International Serious Play Awards (2015). Press coverage was also favorable and started with an exclusive look on BBC Two’s Scotland 2015 program and the BBC News website (MacDonald 2015). The game was featured on both the Scotland and Technology pages. This was then followed by broadcasts on other local media channels such as STV, Radio Tay and Wave 102; game websites such as Destructoid (Parlock 2015) and Rock Paper Shotgun (Gera 2015); and international coverage in countries such as India where TB remains prevalent (Zee News 2015), Spain (Escandell 2015) and Turkey (Zaman 2015). Other sources that picked up the story include The Scotsman, Engineering and Technology Magazine (Gent 2015), University Business (Paddick 2015) and Yahoo! News. Certainly the coverage and limited success demonstrated that prototype had potential, but it was also clear that the game needed more development. The team had achieved considerable success, but could not continue development indefinitely. A hard decision was made to maintain the project and limit development to small incremental changes while investment was sought.

The Project Sanitarium prototype proved to be a successful academic–industry collaboration. The core educational aim of using a workplace simulation model to instruct students was enhanced by the success of a project that encouraged both personal growth through public engagement and collaboration with other institutions, industry partners and disciplines. The team proved that ambition could be a significant motivator, whilst the prototype has its limitations the foundations were laid for further research to establish the use of games to simulate a virtual clinical trial. If realized, such crowdsourcing could reduce the extensive costs of trials and enable researchers to focus on a limited set of potential solutions.

Project Sanitarium is furthermore an attempt to inspire new audiences to become more tuberculosis-aware, science-literate and to bridge the gap between learning abstract science ‘concepts’ and actually ‘playing’ with science through simulation. The project demonstrates the potential that serious games can have in delivering as both an educational experience and in raising awareness about complex topics. The game prototype, whilst enjoying some success in competitions and in generating media interest, also demonstrates what can be achieved with an undergraduate team and without project specific funding. For the undergraduate team to take on the challenges of developing and delivering a game that addresses the fundamental aspects of diagnosing and treating tuberculosis in the modern day, whilst remaining true to an underlying mathematical model, and still provide an experience entertaining enough to enjoy both industry and press recognition is a success for all of the team to be proud of. The project further demonstrates that serious games research and development provide unparalleled opportunities for raising awareness. However, for the project to progress to a fully-fledged product there is a need for further development and iteration. All the indications are that the potential could be realized but that success remains dependent on securing additional funding.