All right, so let's go ahead and that probably are the colleagues who are running in a minute or so. Welcome to this Knowledge Dissemination Dialogue webinar. For us, we changed the schedule, so now we do it twice a month. And one of them is run in the afternoon, hours afternoon in Central Europe, from 3 to 4. And so we changed, we are still all thinking that the lunchtime used to be, but we changed it to accommodate different regions' time zones. And so thank you for joining. And it will keep being that this one morning, the next one will be in the morning, towards the end of the month, morning in Central Europe, any afternoon this one. So welcome. And thank you Francesca. Francesca will be our speaker today to address this interesting topic of corruption in the airman. So I'm very much looking forward to it. Francesca will be addressing the relationship between corruption and AMR. And Francesca is a public health professional. Just finish her Master's in Public Health in UK. So it will be interesting to share with us what she has learned. A couple of housekeeping rules. Please keep your microphone on mute. Rename yourself with your name and organization. And please note that the views presented in this case today by Francesca are her own opinions and not necessarily FAOs. If you post something on the chat referring from, this is your company and any commercial product or brand. And at the end, we always ask the speakers to make their presentations relatively short, about half an hour. And then to have a dialogue, that's why the name of the webinar series to have a dialogue at the end. And please post your questions in the chat and the speaker will try to address them. I'll read them out and then Francesca will address them. Also keep in mind that this meeting is being recorded and afterwards. We always share the link in our dissemination channels. So please keep that in mind. Don't worry about the presentations and the materials. All of that is shared afterwards. So just enjoy the knowledge that Francesca will share with us. So that's it from my side, Francesca. Thank you for making your time available for us. And then for to you. I'll stop sharing. Thank you. Hello everyone. Thank you, Georgie and Dr. Pinto for actually let me go to my PowerPoint and start that presentation. Yes. Okay. Can you guys confirm that you can see my screen. Perfect. Okay. So I'm as Dr. Pinto Farera said, I'm here to talk to you about my summer project for London School of hygiene and tropical medicine, which is about corruption and Amar. And this project, the idea for this project actually sparked from a conversation that I had with Dr. Pinto Farera, and that I thank very much for allowing me to be here and present my research findings. I call a professional and other than Dr. Pinto Farera credits for this project. Go to Dr. Meenakshi Gautham, which is a professor at the school that she's been an excellent supervisor for this year. So let's start. As everyone knows, Amar is a complex problem threatening worldwide public health. Currently around 1.27 million people are affected by resistant pathogens. The environmental management of antibiotics drives a positive selective pressure toward pathogens that are antibiotic resistant, which will make it harder to treat infectious disease as antibiotics are becoming less and less effective. But overuse of overconsumption of antibiotics is just one way of driving Amar for which there is actually an evidence of a dose dependent relationship, meaning that to give an increase in antibiotic consumption corresponds a proportional increase in antibiotic in antimicrobial resistance. However, antibiotic antibiotic resistant pathogens can also be acquired through two other pathways, the direct spread of resistant pathogens from humans to humans or to animal to humans or from animal to animals and environmental spread, which is basically through either hospital wastewater or large wastewater that could be used as fertilizers. The relationship between AMR and antibiotics is not a perfectly linear one, as it lacks backing from observation that reveal a high proportion of AMR in various low and middle income countries, despite lower per capita antibiotic consumption, compared to high income countries. This highlights the fundamental contribution of contagion and environmental spread in driving AMR. All these three pathways, so overconsumption of antibiotics, environmental spread and contagion are taken into account into the five pillars of antimicrobial stewardship, which address both the appropriate use of antibiotics and the intervention to prevent infections and environmental spread. Precisely, the five pillars of AMR are establish and develop national coordination mechanism for antimicrobial stewardship and develop guidelines, ensure access to and regulation of antimicrobials, improve awareness, education and training, strengthen water sanitation and infection prevention and control, and surveillance monitoring and evaluation. These pillars are essential to reduce antimicrobial resistance because they are their aim to prevent the spread of multi-resistant pathogens and maintain efficacy of existing antibiotics. Delving deeper into what causes AMR, determinants are next. To briefly explain what determinants are, I chose this image that shows men from a village that keep falling into the river. Villagers keep throwing lifeboats at them, but unless they remove the slippery stones upstream the river, they will not prevent the fall. Acting upstream, in this case, removing the stones instead of downstream, which are basically the lifeboats, enables the prevention of diseases and not just the cure. The determinants of health are often structural elements of society, like socioeconomic conditions or political situations. For my project, I conducted a quick preliminary review and I found that the upstream determinants of AMR are alkyr per capita expenditure, temperatures, health systems quality and corruption, which is the determinants that I went on to explore. Interestingly, one study from the quickly preliminary review reported a positive association between corruption and AMR, so the higher the corruption, the higher the AMR. I found more ecological studies reporting a link between these two. It is worth mentioning though that they were carried out, this kind of study, the ecological one, they were carried out in high income countries where population level data are abundant and available. So corruption hinders efforts to combat AMR, but we don't know exactly how, which is what I aim to do with my piece of research. But exactly what is corruption? Corruption is a critical concept that is related to adherence to legal principle and societal standards. For my study, I took on with the definition of corruption being the private gain at the public expense. It encompasses both illegal forms of corruption such as fraud, informal payments, theft of drugs, the ground corruption, bribery and embezzlement, and also not necessarily illegal forms just like conflict of interest. Corruption and health care practices exist in both low and high income countries and of course in all domain, but health care is particularly susceptible because of the nature of the patient provided relationship, which is characterized by the asymmetry of information. But going back to the mechanism of action, how does corruption influence AMR? My hypothesis was that corruption may impact AMR by disrupting the strategies of antimicrobial stewardship and undermining their efficacy. For instance, there is evidence that antibiotics are being sold in unlicensed drug shops or by untrained personnel in low and middle income countries, and that health care personnel receive informal payments in exchange for unnecessary drugs or treatment, which is likely to impact antibiotic use. In the same way, if personal protective equipment is stolen from hospitals, it could make it harder to control infections. So to summarize, the objective of my study was to identify corruption mechanism that hinders progress in tackling antimicrobial resistance, which have not yet been documented in literature. More specifically, I went on to explore which corruption manifestation acts on which pillar of AMS and which forces drive it and what are its possible solutions. So I only had three months to complete the summer project, so I had to find a methodology that allowed me to quickly review the literature without it being a full on systematic review because first of all, I only had three months again, and it was just me looking at the literature. I was not a quick word about inclusion criteria. I was not expecting many studies to be here to be there in in the in databases because of the topics. So I included most study types, excluding commentaries, conference papers, preprints and retracted publications. Always due to time constraints, I only focus on human subjects, leaving out animals, and I chose to exclude papers that were reporting manifestation of corruption that were perpetrated by people that weren't aware of cause and harm. The reason for this is that for corruption to fit the definition of corruption, there needs to be a transaction between private gain and public expense. And although one could argue that such transaction still happens, even though the people that perpetrated are unaware, I was still more interested in manifestations that were aware and deliberate. Once done with the systematic research, I ended up having two big clumps of studies, the quantitative, made of mostly ecological studies and the qualitative one. Quality appraisal and data synthesis were performed using different tools according to the study type, which has been challenging because it really doubled the process. Quantitative studies were praised using the CASP tool and analyzed using the rapid best fit framework analysis, which uses a deductive approach of mapping data from the included studies onto a framework. In this case, the five pillars of antimicrobial was my choice. For quantitative studies in that instead I use the access tool for quality appraisal and a narrative synthesis approach because outcome and measurements were comparable, even though there were still two heterogeneous for me to make a meta analysis. So now on to results. Here you can see a Prisma diagram which basically synthesize my systematic search. My systematic search lasted two weeks I explored five databases, and my, the final pool of the initial pool actually about articles with around was about 811. Then it was after the duplication so after removing the duplicates and it was reduced to 541. After the first screening, it was 71 and then the final number of articles was around 25. I performed quality, I performed quality appraisal, but I had to include all 25 papers, even though the quality was not so great, especially for reviews and and cross sectional studies. A bit of study characteristics, a bit of demographics. So, most studies, so the qualitative studies accounted for 40% of the total, followed by ecologic studies at 24%, cross sectional studies at 20% and reviews at 16%. Most articles centered on research conducted in Asia around 48% and Europe around 20%. Just 12% focus on African countries and the rest either did not specify origin or had a global scope. Most studies 60% focused on low and middle income countries and 24% focus on high income countries. Most studies investigated link between corruption and antibiotics access and regulation around 56%, followed by corruption and AMR in general. The studies were mostly conducted in the community and the qualitative finding paint a rich picture of the daily menage of community pharmacies informal drug shops and private practices. Okay, so now let's delve into the meaty part. These are the results from the ecological study they use population level data to study the relationship between AMR and corruption. I, most of the time, indexes were used to estimate AMR and corruption. Overall, all the studies pointed in the same direction that there is a strong association between antimicrobial resistance and corruption. And specifically, there is an inverse correlation between the indexes of control of corruption, governance indexes and corruption perception indexes and the various antimicrobial resistance indexes, meaning that for every improvement of the former, there would be a decrease in the latter. The strength of this inverse correlation seems also coherent. In almost all studies, an improvement of the corruption index of one unit will cause a reduction in the antibiotic resistance index of around 0.4. The most interesting part of the study for me was the qualitative analysis which provided descriptive accounts of various forms of corruption, each affecting one or more pillar of AMS. So overall, the manifestation of corruption that I have identified are over-the-counter sale of antibiotics, the influence of pharmaceutical industry education and training, concept of interest, counterfeit drugs, payment of cash to state official and regulatory capture. Unfortunately, the systematic search found only papers asquavable to the first three pillars of AMS, which are establishment of national guidelines, antibiotic access and increased education and awareness, and I could not find any manifestation of corruption linked to pillar four and five. So here I will present the findings for each pillars of AMS involved, starting with the first one, which is to establish and develop coordination mechanism. Only two qualitative papers reported on how corruption impacts the first pillar. Both studies were recent and reported data from low and middle-income countries, and both mentioned corruption-related barriers to implement WHO-led AMR National Action Plan or not. The first study was carried out in Pakistan and discovered that policymakers were actually reluctant to endorse restriction on powerful professional groups such as doctors or pharmaceutical companies, whereas they had no problem in casting them on informal drug sellers. The authors pinned on powerful healthcare lobbies the lenient regulation on antibiotic prescription, which then impaired the implementation of AMR NAB. The second study was instead conducted in Myanmar, and the authors uncovered complex connection between regulatory agency, state officials and informal drug providers. These letters provide easy access to antibiotics to the population. State officials are aware of this. Nevertheless, some of them require bribes to turn a blind eye. The reason for this seems to be ascribable to their insufficient government salaries, and the government, in turn, tolerates the bribes because it avoids them raising the pay of their officials. Both studies suggest that global policymakers should increase the involvement in the local national context before implementing policies to avoid promoting an over-prescriptive, almost one-size-fits-all policy. Going on with the second pillar, which is to ensure access and regulation to antimicrobials, this one rubbed the majority of the studies retrieved, and a manifestation of corruption identified where the over-the-counter sale of antibiotics counterfeit drugs and conflict of interest, which will explore one by one in more details. We'll start with over-the-counter sale of antibiotics, which is defined as the sale of antibiotics without a prescription. Most of the studies reporting it were predominantly, again, LMIC-based, and authors identified two main drivers. One ascribable to the demand, so on part of patients, and the other one on the offer, on part of drug providers. These two pull-and-push forces are synergic. The push is the growing demand for antibiotics from patients who do not want to consult a physician because of how resource-intensive it is. They need to accommodate time and money, travel long distances, miss one or more days of work, pay for the doctor consultation, and also for the full course of antibiotics. So they will rather go straight to the pharmacist slash informal drug provider and ask for antibiotics. The pull is the fear of losing clients if the antibiotic is denied from doctors or drug providers. Losing clients means decreased revenues for drug shops and pharmacies, a condition worsened by the high market competition. Several authors believe that this is fueled by the meager salaries earned by former and informal drug sellers. In between these push-and-pull forces, there should be the regulatory hand of the government that protect the citizen from exploitation using laws and regulation. However, these laws are reported to be lacking or not even enforced, or even sometimes they seem to fuel the market competition. Counterfeit drugs, which is the next manifestation of corruption associated to this pillar, are drugs that are deliberately and fraudulently mislabeled with respect to identity and source. Two studies, I found two studies that were linked to these manifestations, and in both the studies that were carried in Benin and Laos, almost 60% of the essay drugs were not compliant with quality requirements. Even though, in both cases, the author could not determine if the low quality of the drug was attributable to faulty substandards or decay, or actually was attributable to falsification and counterfeiting. Counterfeit drugs being sold in drug shops and pharmacies is actually an important concern for medical professionals and health workers, as reported in many studies. However, the professionals also report to be aware that even registered drugs could be faulty and substandards, because they think that the quality checks are not actually in place. As a matter of fact, some drug sellers reported that they did not believe they were harming patients by selling them unregistered drugs, but rather they were providing an equal level of service for just a smaller price. A key driver identified by several papers were the high tariffs and taxes that were put on registered drugs in lower middle income countries, which led to increased drug costs, driving down and sending for supply, causing a subsequent scarcity of antibiotics, which is a condition exploitable by counterfeiters that can fill the gap in the market. Other structural drivers are the excessive reliance on international supply chain, which often evades the stringent regulatory supervision of the national supply chain and the lack of quality assurance programs. One of the solutions that were identified to combat this problem was criminalization of falsified medical products, which is a very downstream solution, and the strengthening of the structural flaws in both the supply chain and improve the quality checks. Moving on to the last manifestation of corruption for this pillar, we find a concept of interest, which occurs when personal interest interacts with professional obligations. Hospitals and pharmaceutical industries often exert pressure on providers by incentivizing the sale of antibiotics, jeopardizing the capacity of a provider to make an unbiased decision, and this happens all over the world. Medical representatives are rewarded. This is an example that came from the papers from this review. Medical representatives are rewarded based on number of antibiotics that they are able to sell. And to increase their sales, they share their rewards with drug providers. These relationships gave them access to other networks, which in turn helped them expand their business opportunities. Similarly, they also tried to incentivize prescription of antibiotics by providing doctors with sponsorship to Congress or gifts. Of course, there is no obligation for them to sell the given drug, but it is a very important, not subtle, not so subtle way to influence a prescription. Regarding the drivers, the studies have identified again poor salaries of doctors and drug providers as main driver together with a lack of protective regulation and high market competition, especially in low and middle income countries that see that there is an insignificant out-of-pocket market for their expense and private hospitals. The natural proposed solutions was to decode the couple, the incentives from sale targets to increase ethical practice and to increase also quality controls. Now we are a third pillar of AMS and the corruption manifestation that I found to be associated with that. And this pillar is to improve awareness and education on AMR. So in this topic, I only found two studies, again both conducted in low and middle income countries that dealt with the topic. Both studies identified corruption as the undue influence by the pharmaceutical industry on drug provider education, informal and informal healthcare. Controlling education on antibiotics can lead to biased prescription favoring overuse and ensues. The examples that were given from these two papers was that pharmaceutical company representatives were often the single source of new knowledge, especially for informal health providers, as they often organized meetings, conferences to promote their products among local drug providers, especially in remote areas. From both papers transpires that one of the major drivers is the lack of widespread institutionally provided training, which is independent from pharmaceutical interests. And of course, one of the solutions that were suggested was to actually provide such training. So this is coming to an end. And here I tied all of the knowledge coming from a systematic review in this logic model. If you see on the left column under the inputs, these are all the drivers that are color coded depending on the frequency of retrieval, with insufficient protection law or enforcement being the most common driver that I found throughout the papers. And they are categorized into three groups, so socioeconomic conditions, government and healthcare structural flaws and emerging private interests. Each of them is then linked into the activities, which are the manifestation of corruption that I was able to fetch, and that are linked to the AMS, to the five pillars of AMS, which are then directed toward one or more mechanism of acquiring a resistant pathogen or genes, which then leads to antimicrobial resistance. What this logic model shows is how the structural feature of a country create a fertile soil in which manifestations of corruption persists. For example, poverty is a significant factor that often forces people to prioritize their basic needs over seeking medical attention. Patients in these studies only sought medical help when their conditions were severe, viewing a doctor's visit as a luxury they could rarely afford. Spending money on medicine or food was more critical for them than visiting a healthcare provider. They believed antibiotics are the only cure that could help them recover and return to work in order to supply their family. Antibiotic consumption seems deeply entangled in the daily life of people living in lower middle income countries, and most of all in rural areas and informal settlements, because it is connected to the ability to work and survive in an equitable place. People actually broker their emancipation from an unjust environment through antibiotic use. Before concluding, I'd like to point out a couple of limitations that I had during my research. First of all, there is this big data gap of data that could be retrieved from lower and middle income countries, which were mostly qualitative in high income countries. Because high income countries studies were mostly ecologic and focused on the relationship between corruption and AMR because they had population data that are routinely retrieved because they have high capacity for research, why we don't have the same in lower middle income country. That actually impairs both the research capacity and the data that we're able to get from lower middle income countries and also impacts my external validity, the external validity of this study. The results from this research may only applicable to lower middle income countries. Also, the quality of studies was not always great. Ecologic studies and qualitative studies fared better and had higher scores than reviews or cross-sectional studies. And also, I'd like to point out that since I am a researcher coming from Western countries, I might have actually read the accounts coming from lower middle income countries. Through a Eurocentric and Western lens. So to wrap it all up, I have some take-home messages from my research, which I think are fitting. Corruptic practices in the use of antibiotics in lower middle income countries seems to be filling the gaps left by the government and institutions. Fighting corruption will need to account for country-specific dynamics rather than one-size-fits-all plan. Because the use of antibiotics is deeply rooted in the socioeconomic fabric. Also, there are important gaps in research and I think I advocate for qualitative studies to be done in high-income countries to retrieve the same kind of breach accounts from those countries. And also, a review with similar objectives to this one should be carried out in the food and environmental sector to uncover further mechanisms on corruption that are in their AMR and have the full picture. That's it for me. Thank you so much for your attention and I am open to answer all questions that you shall have. Thank you. Right. Thank you, Francesca. Great presentation. Very clear and very interesting. Many of us do not work in these topics. We don't necessarily think about these connections. So it's great that you made that good pieces together that we usually don't put and think in systems and you went from the salaries of officials to counterfeit drugs. So I found it very, very interesting and it's not surprising that you get many questions in the chat. And I have a couple of myself, but let's first address the ones that came in the chat and then we go to the others. The first one was on the sample size. And I guess in this case it will refer mostly how many papers we looked at because the basis of your study was the liquid review. So the question was how much is the sample in total you addressed in your survey. I guess in this case it would be about the papers that you included. You explained that if you could cover that better. Yeah. So the papers that I included overall were 25. If I can go back to share my screen, I can go back to Prisma Diagram if you want. Let me go just back here. Can you see my screen? Not yet, but maybe. Okay. Yes. Okay. I'm going to go back to the slide in which I had my Prisma. Yes, there it was. Yeah. So the included studies, the overall included studies were 25, but overall the one that I could include because they would be includeable after the first screening, they were 71. But then I had to, I went into the full, I screened them using the full text and then they were not fitting. So it was around 25. Then I had to exclude, I think the inclusion criteria that was more strict was the one regarding the intention of people perpetrating manifestation of corruption because I excluded those papers in which people perpetrating corruption was not aware. So for example, they were selling antibiotics, but they didn't know they were harming patients because of AMR, they didn't know they were fuelling antimicrobial resistance. So I think that if you include them, you might have a higher number of studies, but still there was not much literature on the topic at all. Thank you, 25. Now great. And being biased, I fully agree with your next suggestion of next step, look at one's food and animal protection, being fully biased, being a veterinarian that will be interested in looking at that side. Let's move on into the questions that came up in the chat. One question, are the quantitative studies solely based on correlation? So a question on correlation of your studies. Yes. Yeah, so the quantitative studies that I was able to gather, first of all, they were all the gathered data from Europe and the gather routinely collected data, so population level data, both from AMR and for corruption. Corruption and both AMR and corruption were not like, of course, directly measured, they were estimate from indexes, and they were not, especially from AMR for corruption, they were they were indexes coming from the literature, so it was not, because it's not really measurable as for now, corruption. I had, I found transactional studies, but they were survey based and they were more qualitative than quantitative. So yeah, so the strong quantitative part was mostly based on correlation and they were mostly ecological, which we all know that kind of study have a lot of studies have a lot of fallacies. Great. Thank you for the next question is also on the correlation. So asking if the study you only integrated correlation between the corruption index and AMR, or you use some more refined metrics is like the antimicrobial use per kilogram of biomass, or the amount of counterfeit drug sales. So if you look at the correlation between corruption and AMR or other metrics is like AMU per kilogram of biomass or the amount of counterfeit drug sales. No, I only found the core, I only found papers talking about corruption indexes and AMR indexes, not even just AMR in general just, or like for example, I don't know the burden of the burden of AMR not just AMR indexes and corruption indexes. Regarding counterfeit drug sales, it's really hard to find papers that give you a number because I found these two papers that literally took samples of drugs and put them under, put them into the essay machines and to look for the quality of the drug. But that's it. I couldn't find like many papers talking about counterfeit sales, which I think it's really interesting because I read that there are lots of emergencies, especially with one happening in Nigeria with kids dying from counterfeit drugs. So I think it's an emerging problem in this country and has been for a lot of time in lower million countries. Thank you very much. One interesting about the interviews I guess you addressed because I mean it really triggered a lot of interesting questions and follow ups. One way you had this in mind, a colleague is asking if the study includes interviews on the manufacturers about counterfeit drugs. So I'm assuming that it was basically the literature review. But if you thought about that, including interviews with the manufacturers about the counterfeit drugs. No, it didn't. So the literature review did not. So basically I found some interviews of drug sellers providing counterfeit drugs, but that was as far as the researcher or that primary study went. She did not or she or he did not find any other, she did not find any other manufacturer of counterfeit drugs or any other person involved with the counterfeiting. I think it would be very interesting to ask them about about to ask the manufacturer about counterfeit drugs also to understand to understand like to have more insights on how they try to. They actually escape the quality checks and and how to how they they're able to insert their lots in the in the markets because it is I think one era which has been not discovered yet so many people many authors were saying that they are not really able to understand like how this big lots of counterfeit drugs enter the markets without being without being checked at all. Yeah, we have been doing some work on that thing we did a pilot in each and one of the reasons why it says and been much study comes with many, many challenges to put together the the parts of those drugs and the testing of those drugs. It comes with significant challenges that we were somehow aware when we started, but it became even more when we tried to do it but we will keep moving, but it's it's one of the reasons it the endless challenges to actually analyze those drugs. But very good point on. Next, if your work, if review has already been published, or if it on the way or how are you in the public with it will take some time between the work and the actual publication till you actually have the PDF, and you have it usually go out for dinner to celebrate so tell us how you are in terms of the Yeah, I'm still, I'm still, I'm working toward it, but I've been busy the last few months but now I will work toward the publication of this manuscript as soon as I can. I'm really here to publish it yeah it's been a lot of I think there were many people interested in in reading it and further working on it which is great and then that's one of the purpose of these dialogues is always to trigger collaboration collaboration between the speaker and FAO and colleagues in the chat and that's that's the goal of this to trigger further collaboration of interesting work like like yours. Next question in the case of counterfeit the two week postmark of surveillance. Should we slowly blame it on corruption as you highlighted or just low budget allocation by government. So I guess the question is, why do we have counterfeit time. That's the, the question that we post market of surveillance or corruption or low budget allocation by governments to fight this. Yeah, I think the, I think what it's interesting of this whole work is that corruption is not something to blame at the end of the day, but it's a way that people find to actually broker their emancipation and how it's a way for them to go on with their life and survive, because they're already embedded in a in a fabric which is really unfair. So corruption corruption is just one way that they can use to survive in the case of counterfeit drugs. I think. So counterfeit drugs are a part like our manifestation of corruption right, and I like the studies that were that that I found in my research and my research piece, we're actually blaming. We're actually blaming the high market, the high taxes on drugs so that were not that they did not drive the incentives of government to actually have to actually to actually stock on antibiotics so there was a scarcity of antibiotics in that particular country. And because they weren't enough antibiotics and the one that were in the farm in the pharmacies were actually costing a lot of money. They did a gap. So, a counterfeiters filled the gap by inserting unregistered drugs being sold mostly by unlicensed drug shops. So I think that counterfeit drugs are surely a manifestation of when a government of a government being falling short on something. Very good. About government, the next question relates to the natural action plans, natural action plan on a market. And so the question is, how do you see the impact of your of your leadership review related to the implementation or open open and the civilization. The big work of national action plans so many countries are now, most of them do have a plan that not most of them have a plan. And I'll say most of them are already implementing them. The summer struggling with the funding which is a common problem that they might develop on but they struggle to find the funding to implement it. But how did you ever think about that the connection between your result. And for countries are implementing or even revising the national action plans on the MR. Yeah. So, the, the, the, the WHO led any MR now had several, several recommendations for for countries and one of them, for example, to create a technical group, right. You can see this as being a technical group and actually try to find some leverage in the government to actually strengthen the governance. And I think that is quite tricky for lower middle income countries because this, as long as we stick to the results of my, of my research, the problems is really sometimes lying in the government is itself, which are not improving the salaries of public officials like doctors and pharmacies, which is itself, given incentives for these professionals to promote over the So, so yeah, I think this could be a big problem if you talk about strengthening governance and actually involving government representatives and then actually having them not to talk like you have to have them not to talk about the MR, but first of all, you have to talk to them about giving incentives to people, they're actually working in a frontline of healthcare to be able to, for them to engage in ethical practices, because then what's the purpose of having them talk about a MR if you don't address the structural flaws that you have in the government. And also, for example, there was another suggestion from the NAP that is, again, the funding if you don't allocate, like you need to allocate funding for a MR, you need to allocate funding for for people to be able to do it to promote education awareness but then, then again, like, what can we do if, if they're not allocating funding then to the, to the subsidization of antibiotics so that they don't have antibiotics that are that are sold in a good amount in in pharmacies. So I think it's a problem of structural like, or at least for the lower middle income countries, they should revise their, not that they should revise because I'm no one to say what they should be, but defining my research, they're aiming at saying that probably global policymakers and in should engage more in the local environment before writing up a policy that it's global. All right, very good. The next one, you might want to tear again your screen, because you have a good slide addressing it. If you could please repeat, are you defined corruption? Is it that deliberate behavior to deceive or defraud? And if you looked at the relationship between trust and corruption, so either you can just address it or you might want to Yeah, we can see. Okay. So this is the slide. Let me share it. Yeah. This is light and I defined I use the definition of the private gain at public expense so basically I use this transaction between something that it's private so my own private interest and something that is paid by the public so I'm prioritizing my interest over the common, the common good, basically. And what was the question again other than this one definition. What was your definition of corruption and if you look at the relationship between trust and corruption. No, I didn't. I didn't look into the trust and corrections, I think it would be very interesting because most of the accounts coming from positive papers were actually saying that they did not trust the government, especially when it comes when it came to counterfeit drugs. The same health professionals that were condemning contrafeit drugs were not putting trust in registered drugs because they did not believe the government was able to provide quality checks on registered on registered drugs so I think that would be that is an interesting an interesting questions and that's why I think that it would be interesting also to have accounts, qualitative accounts of corruption coming from high income countries because it's also it's always a taboo topic to talk about corruption in high income countries, while I think that I think that you will see in the future that in countries where the government is trusted, the less there will be a higher levels of corruption, because we don't we just don't trust each other we just we just don't trust the government so we will find our own ways to survive, which is probably legal. The next question, if you may be in this literature review, if you I mean your focus of corruption and EMR and the question from the colleague if you have, how do you think results that you found would align with similar studies on corruption and other health issues to come across some studies on that corruption and other health issues not amr other diseases or any other link between health issues and corruption for no way, but other corruption and other health issues if you if you came across some papers on other not amr I think that I saw a couple of papers focusing not on on amr because in the preliminary review and in there is this general association with corruption and worse health outcomes, but in general, and that's also coming from ecological studies which have the fallacy of being ecological so you just see the bigger the bigger picture you just see the bigger association but if you if you delve deeper than you might see different things. But I did not explore specific like a specific health issues, just the overall outcomes and I think that that's the trend more corruption worse health outcomes. Okay, thank you for the question about and the graphic, the different graphical areas and the different graphic results. And it was very interesting that you highlighted the limitation of your studies, we see it, both of us, for example, European so we would see three the papers with that angle, which is my default bias as much as we tried to control it. And so there was a question of that, did you see any differences between geographical areas for example Asia versus Europe. I wish I could compare them, but unfortunately I don't have data I don't have in my review studies ecological studies coming from Asia, nor I have qualitative studies coming from Europe so I can't really compare the two. I only have qualitative papers for Asia and only have ecological study from Europe. And that's a big gap in knowledge because we shall start collecting, we shall start like collecting, making doing interviews on corruption in Europe so that we have the same amount, the same kind of knowledge and we can we can actually compare them and actually trying to understand which are the underlying the determinants and mechanism that fuel corruption and, of course, and determines the worst health outcomes and worse, in the areas. Thank you. There is also a question on. And I think this is a broader present how do you would improve the health systems so that people do not have to turn into informal markets the issue about counterfeit drugs, or even expired drugs. So I think you touched about a bit about that on the incentives for example, but the question is that how do you think from your literature review, we could improve the health systems, so that people do not turn into the informal markets where they might find the expired or counterfeit drugs. And that's one million dollar question. 30 seconds to answer that. Thank you for the trust but I think that, I don't know, it really comes down to poverty to fighting poverty in some case so I think before trying to strengthen health systems, I think we should, we should focus on combating poverty and trying to tackle the fabric of the country in which corruption lies, because once you fight poverty and once you make sure that people are living in a dignified way, you actually start seeing the health outcomes improve. And, and also yeah incentivizing people that are working in the frontline health care because they're the first defender of the health systems and they don't believe in what they're doing. If they don't engage in ethical practices then that it's going to be less trust on them less trust in the government. They're not going to believe the drugs that we will be giving them. And, and it's going to be just a cascade. So I think fighting poverty and then surely incentivizing the work of first line health care workers. The next one is, if you have a, I think you addressed some of these but maybe you want to emphasize some points or maybe address it both potential recommendations for medical regulatory authorities. In this case in low and medium income countries, and their impact on a mark so it would be the question on recommendations to medical regulatory authorities. I think you address some of these by speaking in general about governments know not just medical regulatory authorities but if you want to address it. And you can address the question. Yes, so one of the solution that were proposed by because I think it's about counterfeit drugs. The one of the things proposed was a very downstream solution which was the criminalization of of counterfeit drugs which I think it's not in place in many countries and that was one of the main issues that others were stating. But I think it's very downstream. I think, again, we should try to strengthen health systems by improving quality checks and by trying to subsidize drugs that are so important as antibiotics and by subsidizing them we allow pharmacies to be able to sell them properly on their prescription but for a price that is actually affordable by many people so that you don't just have to go and go buy it from a provider that is not registered. Thank you for checking. So I'll take the last one before we wrap up and out of and I know that you focus you very clearly said and explained very well that you focus on human papers human related literature. Just to see maybe colleagues that are listening to us would like to follow the other side or one of the other sides on the animal. You recall when you did the first lead to research where there's some other studies on on animals, the environment, use of antimicrobial implants, there was there some literature that you intentionally exclude because it makes elections yet make justice. Did that come across some results or not much was really just humans that you came across. I think they were fairly a good amount that's why I had to exclude them. I would I would have loved to include them, but there was a fairly good amount of correction practices with animals. And because this project only have only happens around across three months I could not include them because alone alone they wouldn't they wouldn't have made a whole systematic review but without but with them, it would have been too long. And I came across them especially for sludge sludge wastewater is used as fertilizers sold for environmental sectors and for for animals, the use of antibiotics and I think the one that that were inserted in in the food for animals I think was one of the big deals. And yeah, it would have been so interesting to complete the picture and have these two other piece of the puzzle so that we can understand how, how everything goes and I could, for me, I could complete the logic model and have have it all on one piece of paper. It would be great. So who knows, you might have the chance to follow up or other colleagues listening to us might be might be willing to reach out to you and I'm sure you'll be knowing you and know that you'll be willing to to getting that feed other colleagues and provide some guidance I think you learned a lot from your research to the matters that you used. And if colleagues are interested in our following up on the annual side. I'm sure we will need to collaborate and support and get. So that's it. Thank you very much. It was excellent Francesca very well done very thankful for you to take time to present to us your results. And we have shared in the chat, the feedback, the question and feedback for the, the question and to let us know what we can do for example, the idea to change the schedule came from the feedback questionnaire. So it's very much and we hope that right now our colleagues in the Americas this schedule is a bit better. And as I said, the next one will be on February 27. And it will be 930 am. So in that case, the colleagues in Asia might be a more decent time to corner to connect in working hours. So please do fill in that and you can for example suggest different topics and different speakers. The goal is that to colleagues, mostly working. We call it data in a broad sense, can be a little bit like Francesca so well presented today, but colleagues that are out there in the regions in the fields in the countries, making complete two different works and we have addressed a broad range of topics. So we are very thankful if you can complete that form and let us know how we can improve. So that's it. Thank you all for joining and thank you Francesca. I wish you all very good rest of the day. Thank you. Thank you. Bye.


I've got a new camera. Let's check it out. My name is David Patton. When I started photography, I wanted to make art. But with bills to pay and a family to feed, I decided it would be better to be a working photographer than a starving artist. So I took a job as a photojournalist. 25 years and thousands of assignments later, it was time to go back to my first love. Come along as I follow my passion trying to create art that shows the essence of nature in a photograph. I'll be sharing my successes and my failures in hopes to inspire and educate. This is my journey. This is Riding the Edge. Today I'm trying out a new to me camera. This is the Sony A7R II. Now this camera came to me as a donation, as a gift. It was gifted to me by a generous woman named Louise. And I'm going to take this out. It's got a 28-70mm variable aperture lens. Very small, compact. And over a period of a few days, maybe even more, I'm going to exclusively use just this camera and lens. I really see this as a handy walk-around setup. Kind of a general-purpose lens. It's super small. From what I can tell from what I've heard and what I've read, it sounds to be a very capable camera. So I'm going to have to figure out how to use it. And I'm taking you along. Well, the light's not that great today. So I'm not expecting a whole lot. I know that sounds negative. That's why I'm going to need more than one day to get an idea what this camera can do. But you've got to start somewhere. And I'm just itching to take this camera out. So I really don't care that the light is really harsh right now. We're going to try to make some photos. I'd rather test out a camera with these kind of conditions anyway if things are really cool and kicking off. I wouldn't want to... Someone's using a saw over there. I wouldn't want to take out a new camera. Especially when I've never actually used. If you're familiar with my channel, my photography, you know that I use Nikon or Nikon. Everyone wants to see it. Cameras. And I have pretty much my whole professional career. Never really felt the need to try other brands. The big part of that time, my gear was provided. So, you know, why buy something different than you're using at work. Never considered using a Sony camera. Although what I'm shooting this video with in most of my videos is on a Sony action camera. So it's not that I haven't had to experience with Sony. Just not in a camera like this. Another first for me is I've never... I know it's going to sound kind of weird, but I've never used a mirrorless camera. What I'm most interested in is how well the sensor does. How well does it convert to black and white? Am I going to be able to get the images I want taking this camera out? I feel like I'm playing with the light. It's kind of filtering through the trees. And because it's kind of on an angle, I'm getting some beautiful texture in these leaves. The veins are really brought out by the light kind of scraping across the top of me. Something that's made this combination so appealing to me is I've been thinking about trying to use my bike as a way to get out on days that I don't have a car or just want to get some exercise. I need the fitness. And since I've lived where I am here, I've not really ridden my bikes. I've got a couple of them. I used to ride quite a bit. So I've been thinking I should probably try to incorporate bikes back into my life, if not just for the fitness. I thought, well, while I'm at it, maybe I should take along a camera. And Louise was so generous to donate this camera. I thought, well, that's perfect. I've worked perfectly for that kind of activity. And even just walking around like this, I see this as being quite a valuable tool, no matter what brand it is. I just need to learn how to use it. It's a different language. Every brand has a different menu system, different ways to get the most out of the camera. Whereas on my OVF cameras, I'm almost always manual focus. I'm finding that on this, I think I'll probably use it mostly in autofocus. And it works pretty well. So that's not really a big deal. It's just an adjustment that I have to make. No matter what you do when you switch cameras or even brands, there is going to be an adjustment, a learning curve. I have a feeling that learning curve is going to be pretty steep for me. Because I'm switching brands, and it's also mirrorless. But it's also exciting. It's a lot of fun. I still have on my Nikon gear, so it's, you know, we're not here to see if this is going to replace my Nikon gear. It possibly could in the future, but what we're here to do is just see how I can incorporate this lens and camera into my photography now. And I'm also not reviewing this camera. I mean, this camera's been out for a while and there's plenty of people that do that. This is just me trying to learn something new. And why not make a video while you're doing it, you know? I'm really surprised by how close this lens focuses. Quite a bonus, actually. It's not a macro lens, but I'm getting some pretty close-up shots with this lens. Now how I've got this camera set up is I've turned off all noise production. I've turned off steady shot. It's just the barret bones. I don't want to be influenced by any of that. I actually don't have any that turned on on my other cameras. I want to see what this lens is capable of. I want to see what this camera's capable of without any of these aids. Plus there's a bit of a breeze, so having steady shot, turned on really isn't that beneficial. The subject you can most likely be moving if I'm doing close-ups. Spring is in full swing here in the Pacific Northwest. Finally, got lots of new growth. I'm enjoying it. Gives me a lot of new subjects to make images of along my pathway that I like to walk on. Oh, I like the looks of this new growth right here. Maybe I'll make a photo. It's kind of dark in here, so I'm shooting this at 3,200, and I even went up to 6,400. I figured out, well, I need to see what it can do at higher ISOs. Probably... the aperture's probably around f8, f8, f10, f11, something that range. I'm trying to separate it from the background, but f11, when you're close, there's a background quite a bit, surprisingly. I'm just looking for separation. The background's pretty dark, and it's quite a distance away. You can see it moving around, so I'm at a shutter speed around 2.50 of a second. Well, I've made a few compositions. What I think I'm going to do is take these home, get them on the computer, and kind of study them. See if there's anything I should be changing or doing different. I think I've been doing something a little different. I think I've got enough to kind of study so I can have a better idea what I should be doing next time I go out. We've got a lot more work to do with this. This is just step one. So I've had a chance to look at a few of the shots I made the other day on the computer, and you've seen them as well. YouTube's not going to show all that much information. I'm just going to get a general idea of what I got. But by looking at these images on the computer, I have to say I'm pretty impressed with the quality of the files. They edit really really well on my editing program. I use Affinity Photo, but these files looked really good. Something else I was impressed with was I didn't expect this lens to form as well as it has so far.  I'm so impressed with the size of this camera. It's being a full-frame camera. It's the same size as my crop sensor cameras on my Nikon. Right now I'm photographing this dogwood bloom. It's really at the end of its life, I guess. It's not going to be here much longer. There's a lot of discoloration and stuff. But in black and white that might actually add something a little more toothy image. It doesn't really matter. I'm just trying to get a few shots this morning to kind of support the ideas I'm developing in my head about this camera. Nora and I are at the lake. We're in the middle of a heat wave. It was 90-something yesterday. So that probably is going to make springtime blooms like this. That looks so good. I was trying to get over far enough that as you can see, I'm shooting this looks like an old stump that was growing in the top of this rock. And I was trying to get some kind of contrast. Where the light is, it's just shining flat on it. Front light is pretty boring. But when I get further over this way, this cracks show some let me see it. These cracks begin to show some detail, some contrast because of the shadows in the cracks.  I don't know if that's a good photograph, but maybe a different light. I'll have to come back here. Maybe if the light was at a different angle, either earlier in the morning or maybe from this direction. Because from this angle the light's pretty flat. But I do like the way that rock and stump come together. It's pretty cool. Every time I walk by this bunch of grasses, I think there's got to be a photograph here. I've tried to like isolate just a section of it and just kind of get this chaos, this mass of lines going different directions. Something abstract. I know this is probably not that exciting of a video series topic. I don't talk good that much, but this is my journey. This is my photography journey. So introducing something new into my way of making photos that's part of my journey. And taking something out of my equipment is also part of my journey. I've got decisions to make now. What Louise has done is and I don't think she's I know she wasn't her purpose. She's given me a pathway into another system. Already having a camera body in a lens. I could add another lens to this or a couple lenses. And I could cover quite a few focal lengths in just another zoom lens. And I could use just this camera. It does everything that my other stuff does. Now if I was going to go mirrorless with my Nikon gear, I don't have anything to sell.  If I went with Sony I have equipment I can sell to go into Sony's mirrorless. It's actually the most straightforward pathway from now for me to go to a mirrorless system if I want to go that way. So I think I'm going to head back to the car. I'm going to get these last couple compositions. There's just a couple on here from this morning. I'll get those on the computer and see what I got. And as I've said earlier, I've got a lot of thinking to do on how I'm going to use this camera. Is it what roles are going to fit with my photography. I've already decided it's very good camera. It's images I think are, if I don't get a good image it's not because I was using this camera. It changes hard for someone like me. I was telling my wife if I was going to sell my Nikon gear and go 100% Sony it'll be the last time I change camera gear at my age. So I want to make sure that that's what I want to do. If you like coming along on my photography journey and would like to help keep me out making photos and videos consider picking up one of my zines. Or visit my PayPal donation page at my website Most of all don't forget to like and subscribe. And why not leave a comment introducing yourself. I'm always interested in who stopped by my channel to say hello. So until next time thanks for coming along for the ride.


Okay, we're back. We're live. Community Matters. I'm Jay Fidel. This is Think Tech, and the fellow next to me is Tung Boy. He's a luminary at the Shiloh College of Business, and he's a Madsen professor there. And, wow, I know him a long time. We are good friends. Welcome to the show, Tung Boy. Thank you, Jay, and thank you for having me back. That's great. So we had a very big event coming up next week, March 20th, and this is a major event, in my opinion, because it's a major issue. Let's talk about the issue. You know, we live in a time like it or not when we are dependent on the internet. We're dependent on technology, information technology. Fact is that there are those people in the world who would like to hack us and bring us down, and we have to protect ourselves. And there was an article in the newspaper, just concomitant with, you know, the development of your event next week about cyberterrorism, cyberwar, cyberattacks, and the like, indicating that according to the FBI, we were the number one vulnerable place the state of Hawaii to cyberterrorism, cyberattacks, and the like.  And there was a lawyer there who managed to get his phone charged in the course of the blackout. He managed to be able to call National Public Radio. He managed to be able to, you know, have an articulate experience describing what it's like for an extended blackout, just for example. And it was really horrendous what happens to people, what happens to society, and we're at risk for that. That's only one of the various things we're at risk for. So your show, your event comes at exactly the right time. Can you describe the risk? Can you tell us more about what the newspaper article, you know, advised us? Well, that is actually unfortunate to know that we are ranked number one on that area, being exposed to the Internet.  Yeah. And, you know, for the point of view of the Schuyler College of Business, I mean, this is a particularly important issue because like it or not, if business becomes the victim of cyberterrorism, cyberwar, cyberattack, cyberhacking, whatever it is, that affects us all. If the business community cannot function because of an attack like that, then we can't function. I mean, you know, in fact, the leverage that the attacker gets by attacking the business communities is much more profound than if it attacks us individually. That is very correct. As from the perspective of the business school, what we would like to convey to the business community out there is that cybersecurity, cyberattack, all of those hackers out there, it could be from our own country. It could be from overseas. We heard a lot about the Russians. We heard a lot about the Chinese. The matter of the fact is that for the business layman, the most important issue is not to worry about how do I set up an IT expertise in order to do that. You can expect a medical doctor to do that. You cannot expect a dentist to do that. You cannot expect a restaurant owner to do it. But the textbook recommendation that any business school would want to convey to the business community is that whatever the threats are out there, the most important thing is to keep your business going. And then this is what we should care about. And this is what we would like to do on the March 20th workshop. We would like to tell people four things. Number one, do just a checkup about the risk, the potential risk that your company might have. For example, do your secretary or your friendless people handle credit cards of your clients properly? Have you managed the password properly? Have you changed more often or not? And then so those are the issues that we need to do. How do you set up your router to have access to the internet? Have you changed password often? And these things are important to do. So this is one thing. Another thing that we would like to get people to be aware of the workshop is that for God's sake, if by any chance or mischance, I would say that we got hacked or we got attacked. Our employee left the company and took away all of the social security numbers of our clients. What should we do? Should we call the FBI or should we call the CIA? Or should we call NSA, the National Security Agency or should we call the HPD? So they are actually in the government sector a proper chain of command on how to report a situation like crisis in terms of cyber attack. A major problem that we have seen in our research in terms of how business community should be handled cyber security is basically three phenomena that is actually quite interesting. Number one is that it's like the elephant in the room. The problem is so overwhelming, so complicated, so difficult, so fearful. No one wants even to talk about it. Right. So if you talk to an dentist, worry about your computer server, watch out this one guy who kept looking at your computer screen. They don't want to hear these things. They just want to focus on what they do best. So people tend to give up or some kind of denying what the real problem out there. Denial. Denial. The second problem is that the problem is so convoluted and then the community out there trying to help us out. Each of them only look at one aspect of the problem. You remember the metaphor of blind people touching a big elephant? Yeah. So computer science people only look at the hardware and the operating system. HR people only look at watching the personnel. And then so there are different people looking at different aspects of cyber security, computer networking, people only worry about the routing, the telecommunications aspect of it. But no one has a complete view of the whole aspect of the problem. This reminds me.  Right. And you have to have both in your mind. And this reminds me of an incident, an attack on MERSC, the Scandinavian shipping company, which is huge and global.  A worldwide system. Somebody attacked them, brought them down. All the systems were brought down. Right. What do you do for recovery? They brought in people from all over the world. They brought in their best managers from far away places instantly, immediately, and had, you know, these 24 hour meetings in their headquarters. I think they met in the UK.  They didn't have a solution ready. And they didn't have, you know, a resilient system in the first place. And that's why they were vulnerable. And I suspect that's the case for a lot of companies, even big companies. No prevention and no plan for recovery. Luckily, MERSC was able to recover in a matter of a few days because they did what you were suggesting. They brought everyone in. So everyone knew the whole story and everyone addressed the problem. But the fact, the matter of the truth is that not every company, especially in a small state like we are in the state of Hawaii, to have that many resources as a company. So especially we are targeting in our workshop. What can we help for the small mob and pop, small and small and medium sized enterprises? What can they do? Another issue to make the picture a little bit even darker is that even if we are in due diligence, try to do the best we can. Technology in cyber hacking gets better and better over time. Yes. So it's like a cat and mouse issue. Yes, we do the best we can. We have put together a plan in order to protect the business that we are in. And then surely enough, and sooner and too soon enough, that the hackers have something even better, that we don't have the tools to defend the new stuff. Let me ask you, though, you know, I mean, that you have bad, bad actors who are nation states who do this, not for sport, and not for financial gain, but for geopolitical reasons. And they could do hacking that would be devastating. They could attack a city, state, a country, and you know, with with the kind of process in Venezuela, they could bring it down, bring down the grid. And you know, everything else comes down to it's horrendous. And the longer it lasts, the more devastation there is. So they have the capability. They have that they have some of these nation states have every resource you can imagine. Look what happened with North Korea and Sony a few years ago. Why don't they just do that? Why do we see this only at random? Why do we see this only ad hoc? Why don't they just act? What are they waiting for? And can we figure out when, you know, they would apply their resources to bring, you know, jurisdictions, large jurisdictions down? And this is actually a billion dollar question. I think the problem is so complicated. There are so many moving parts in the whole issue. So again, going back to the perspective of a small business, I think the best thing we can do is to make sure that we do our own part to protect the best we can. So basically to me, there are a couple of basic principles that we could do. I'm not getting I don't think we can be 100% safe. But if we follow a certain best practices that we would be saying and recommending at the workshop, people might be able to I would I would say reduce the risk by a huge percentage. For example, principle number one, whatever you think truly sensitive that you do not want people to poke your nose in. Just don't put it on the internet. Save it on a safe box and then put it offline. Then you don't have to worry about it. A recommendation we have normally is not try not to store social security numbers anymore, or try not to store credit card numbers of the clients. Anytime we charge a client, just ask again, and tell the client that this is to protect your privacy, your security, and they would love to hear that. It takes two more minutes of your time, but then it puts you in the peace of mind. Because one more time, everything that is connected to the internet is open to is exposed to possible intrusion. And the second, the second thing is unfortunately, most of the problems in small businesses in terms of information leak came out from the people working for the company more than some guy from North Korea. No, that's absolutely true. Because I mean, these those big bad guys, they are looking for big companies. You heard about these things, but not as small dentists as a small restaurant owner. So I think that is that is the second principle that we do. And principle number three that I would argue is the timeliness of the whole thing. You don't wait until things got even worse before you report to the police.  We have in theory a concept of what we call the escalation of conflict. We have a secretary, for example, she just discovered that her colleague steal all the credit card and go away and run away. So instead of reporting to the boss right away, she's afraid of getting yelled at or being fired. She just tried to hide it or probably call people in order to get help with reporting. And things could get even worse. Oh, yeah. So those are just the law. And it's against the law is fired by statute, right with penalties and all that. Yeah, to report any any invasion in your system. Right. So again, going back to the workshop, we are so blessed, literally to have about 30 best minds in the state, including the people from the FBI, Homeland Security, NSA, and the C, the CEOs and information security of corporate information security officer to come to the panel, sharing their problems, sharing what they can do in their companies, and even sharing what what they did as a victim of a former cyber attack. So I think this is actually quite exciting to listen to them. And there's two sides to this, it seems to me, one is the government itself. Because, you know, whether it's justified or not, we all walk around thinking the government will somehow protect us. That may not be true. But that's what we think. And to some extent, the government can and should protect us. And we ought to know what they are doing. Because then we can figure out what we need to do. It's got to have, as you said before, comprehensive look at this. And we have to, you know, compare notes. Otherwise, there'll be redundancy and there be gaps in our in our planning, our protection in our recovery.  I don't know how you establish this list. You must have been working on this for a while. Actually, I would like to give a lot of credit to all the partners of the Charlotte College of Business, like the University of Hawaii IT wide system. And then also the NSA station here. Oh, yeah, they are helping us quite a bit. Actually, the NSA even offered to UH Manoa every year a cybersecurity faculty in residence so that they could help us boost all the lectures we have on cybersecurity. And we also are blessed to have like people from like Joel from the senior vice president CIO at the Hawaii State Federal Credit Union. And she explained to us how her bank is dealing with cybersecurity. And then we have Robert Bonser, the NSA scientist residing in Hawaii, sharing with us a little bit about what is it they do and they have the plan for us. You know, what really appeals to me about this is that we have these experts in the room, they come from government, they come from industry, and we can hear what they have to say, not only in terms of the risk, you know, the risk seems clear from that newspaper article. But you know, what you have to do. There have been so many programs here in my observation in the past 10 years, where they tell you the risk, they tell you like climate change is a good example. They tell you all the awful things that can happen. And then the program is over. And nobody actually says, well, you should do this and you should do that. This program, it seems to me, it becomes extremely valuable because it's an action oriented program. That's right. It tells you what you can do, what you should do and what the other guy is doing. So everybody can get a hand on it. We can take a short break. Okay. When we come back, I want to get into the action points that people should be, you know, looking at and developing their own plan about. That is correct. That's where the rubber meets the road. Correct. I agree. Okay. We'll be right back with Troy Boy. Hello, I'm Dave Stevens, host of the Cyber Underground. This is where we discuss everything that relates to computers that's just kind of scare you out of your mind. So come join us every week here on thinktecawaii.com 1pm on Friday afternoons. And then you can go see all our episodes on YouTube. Just look up the Cyber Underground on YouTube. All our shows will show up. And please follow us. We're always giving you current relevant information to protect you. Keeping you safe. Aloha. Aloha. My name is Andrew Lening. I'm the host of Security Matters Hawaii airing every Wednesday here on thinktecawaii live from the studios. I'll bring you guests. I'll bring you information about the things in security that matter to keeping you safe, your co-workers safe, your family safe, to keep our community safe. We want to teach you about those things in our industry that, you know, may be a little outside of your experience. So please join me because security matters. Aloha. OK, we're back. We're live with Tung Boy. He's the Mattson Professor of Business at the Shiloh Business School. And we're talking today about a program that's going to take place on March 20th at the Hilton Hawaiian Village Coral Ballroom about cyber attack and cyber security. A very important thing for the business community, in fact, the entire community, all of us. Then we, you know, we need to get a handle on this together. We need to compare notes and with the speakers that he has organized, we have a pretty good chance of getting the comprehensive on this. So when you talk about the action points that the action issues and action, you know, points that are going to be discussed where, you know, you want to write them down, that sort of thing. Yeah. OK, so let me, in 30 seconds, to go through a little bit the concept that we put in the workshop together. As I mentioned very early in the talk today, a key problem dealing with this cyber security problem is the fear of it. And like a cancer disease, nobody wants to hear about it. So what we, what we, the way we start the workshop is to share with you respected companies in the state. They open the company and share with the audience that indeed some of them got hacked and how they solve the problem. Just to tell you that, Jay, I am much bigger than you are and I got hit. So don't be ashamed. So we want to build that trust and encourage people to have the courage to look into the situation as opposed to just deny it. That's really good. Tell all, tell all the honest.  So this is the first part of it. So the idea is that you are not alone, we are here and we are together in the thing. The second, the second part of it is that basically we do like a checkup, like we go to our internist on a annual health checkup. So the experts will tell you what you need to do. Have you have you checked, have you changed your password lately? How old has been your alter? What version of the operating system you have? How do you set up your browser so that you don't get cookies that you don't want, etc. etc. So have you done a screening of your personnel? And then so that is important. Antivirus or what do you do? Yeah. And number three is basically going through a case study provided by the FBI, FBI, running case study of a company of a small business being attacked, being stolen that data and then how would that company should do or did. So should they call the HPD or should they call the FBI and then what should they do? So we will go through the anti-case study so that people say that, oh, now I see what I should be doing if it happens to me. Yeah. And when you go to the FBI or the whatever agents or government agents it is, what can they do for you? You just to frame the question you should know what their what their range of tools are and what their jurisdiction is. That is precisely a question when you report it to them. But, you know, I wonder about a program like this, you know, there's a guy next to me in the audience, right? Right. And he looks a little suspicious. He looks like he might be a hacker. Is he there? Is he going to, you know, be able to get information from this program that will help him, you know, violate my cybersecurity or worse yet, to violate the cybersecurity of large companies? How do we protect ourselves from, you know, an invader right there in the room? You seem to have it dirty in mind, my friend. But you can't tell all. They can't. Well, basically to me, what is most important in the whole process is the process of doing things and not the outcome. We don't tell you what password you should put in. But we should tell you how do you what is the best way to set up a good passport, a good password. We don't tell you to hire employee A and not hire employee B. We don't say that. But we say that if you were to hire employee, how do you educate and train as a person so that it's so that your business is safer?  She got a call from somebody, a bad guy, saying that the business forgot to pay the electricity bill for the last two months. And then they are going to shut down the electricity within 30 minutes if we don't get paid right away. And then, oh, by the way, for your convenience, we are going to you can give us your credit card that we can settle the balance. And then you are back to your business. Social engineering. I know at the secretary. God bless her. She went into my wife and she said, may I have your credit card so that we that we can settle the balance so that we don't have to. And then my wife gave the credit card and then the secretary gave the number and only after that minute, she realized that no, she just signed a check to pay HECO just a few days ago. So this must be a phony scam. So then they need to call the bank in order to cancel the credit card. So those are those are kind of best practices, education and training to the personnel that we need to do. And screening is also a very important thing. True. You'd be so careful. I mean, really, this goes back 10 years.  And then they came back and, you know, they were community minded. They told us how and we disguised their names and everything. Right. They told us how they did it. More often than not, it was social engineering.  And then from that person information about the third person, now you have enough information to sound like you are in the company. And then you call the fourth person and you say, this is Joe. I'm on the fourth floor.  Can you can you just let me have that password again. And it sounds like you work for the company. It sounds legit, but you're actually, you know, way outside the company. More often than not, they would get enough information to crack the company. And this is not a tech technological, you know, attack. It's a social, it's a social engineering attack. We heard story after story like that.  And the problem is, according to our research, the problem is that the bad guys out there, they come from all walks of life. You could have a unhappy employee, maybe he or she got yelled at or not happy about the pay. And they just do it in order just to revenge the boss. Yeah. Or you can have a very smart IT guy who just look up sneaking into your computer as a challenge. Oh, I managed to do it. Cool. Right. So, so they're all kind of, then you can have espionage, people trying to steal your information. So they're all kind of possibility, all kind of bad people out there. So we need to be really vigilant about how to take care of them. And I think one of the interesting points is a, you know, it's an underlying, a fundamental understanding here is that it's very hard to prosecute people who do this. Right. Very hard to identify them, to find them within your jurisdiction to arrest them, to prosecute them. There are units in government, I'm sure there are units in the FBI and, you know, really every state and federal agency which is involved where they can go out and prosecute, but they have a hard time. So when you go into this, when you look at how you're going to protect yourself and recover from an attack, you cannot should not assume that the individuals who were responsible will be caught and prosecuted. You have to look at it another way that is protection only. Actually, that reminds me of the famous French wisdom. They say in French, Chacune-Pouxsois-Dier-Poutous, but it means is that every one of us have got to take care of our own only God, take care of everything else. So, so I mean, I understand that all the governments in the world are trying to do the best they can in order to secure the national information infrastructure. But then there are certain precautions that we need to do. Think about this. I mean, as a driver, the code for driving is actually pretty perfect nowadays in terms of speeding and traffic lights and everything. But then if we are careless, then we would want to do a car accident anyway. So any business should be doing their own duty and take responsibility of cyber security. So to me, this is a textbook recommendation that is actually very hard for business to understand, but my recommendation is that in the age of the internet economy, we need to embed security and privacy as a strategy of the company. Yeah. For example, even if if you have a bank, you don't just manage people's money. But you should be telling to your client that if you trust us in giving us the money to manage for you, we will we will protect your privacy and your internet. It's part of the trust relationship that you do. The same thing if you go to a doctor's office, not only you take care of the health of the patient, but you would say, if you come to me, we'll make sure that your health information is not going to be stolen by anybody else throughout our society. Right. So let's go back to the details of the program. It's March 20th. That's next Wednesday or Wednesday. And it's what 10 a.m. is it? Actually, it starts at nine o'clock. Nine o'clock. And it's in the Hilton Hawaiian Village Coral Ballroom. Right. And it's free. And there's the flyer on the on the screen here. Actually, it's not exactly free. It's receptive that spread a bit. The hotel charge for the lunch and the coffee lunch, of course. So basically, we asked for a little bit of contribution from the participant for their enough for the lunch. But actually we cover at least half the cost of the event. Okay. Yeah. All right.  You should have a huge crowd there of people who want to protect our society. There's no more, no more menacing threat than this threat. And this threat could bring us all down. So we all again be educated. I think this is a truly, as you mentioned a little bit earlier, we want the workshop to be hand hands on action oriented. So I guarantee that everybody who obtains the meeting will have some good take away to go home in order to do something about their about their business. So one step at a time, and the recommendations that you are providing are actually not very difficult to do. Example just cleaning your future employees a little bit better. Number two, requesting your employees to change your password more often and provide them some incentive to do that. And number four, making sure that you don't leave your USB or your password. You lay them around. Number five, like when you share your file on a iCloud or on Dropbox, make sure that you have password. So these things are or if you have the important document encrypted as supposed to get the password to open the file. So these things actually very doable. This doesn't require rocket science in order to implement them.  That is correct. We're out of time, but thank you so much for coming down. This is going to be a great and important program, not only for the business community, but for government and for individuals to protect us. And I would like just to take this opportunity to thank the 29 people speaking at the event. And they are very busy, but understand this is a very important problem for our businesses in Hawaii. So they are willing to do that time. It's great that you've got them together. Yeah. So yeah, I'm looking forward to welcoming everyone at the workshop. A very special program. Thank you so much. Yeah, most welcome. Thank you for having me. Aloha. Aloha.


It's chiptips, chiptips, I have no music and I can't sing! This is my junk room. I buy stuff, play with it, use it, whatever, and when I'm not using it, I put it up here in my junk room. I don't remember half the stuff that's in here. So that's what I'm going to talk about today. Memory. Really? Do I have to say that? Can't I just... Hello, chip friends. I'm going to be talking about memory, specifically static RAM. I have these chips that I actually want to use in my retro computer and there are essentially two types of RAM. There is static RAM and dynamic RAM. Dynamic RAM is memory that you constantly have to read or refresh in order to keep the bits around. That's why it's called dynamic memory because if you stop refreshing it, it goes away. It's very low power compared to SRAM. SRAM actively keeps each cell alive and active so it takes a little more memory but it's very easy to interface with and you don't need a whole lot of circuitry around it. Let's take a look at the timing for these chips. Okay, so here are the signals that go to the RAM. You've got 15 address lines, A0 through A14 because this is a 32K addressable chip and you've got eight data lines and these are bi-directional data lines so they're both inputs and outputs but only one at a time. You've got a chip-enable signal which is active low. You've also got an output-enable signal and a right-enable signal and those are also active low. The chip-enable signal basically puts the chip to sleep but it keeps its memory around so you can't actually read from it or write to it but it's useful to say power down and keep the memory around. The output-enable basically says to the chip, okay, output data according to the address lines. If you assert output-enable then whatever data comes out is whatever is stored at the address that you're putting in. In order to write to the chip, it's a little more difficult. Obviously, you can't assert output-enable or you wouldn't want to because you want to feed data in and if the chip is feeding data out while you're feeding data in, well your two output buffers are going to fight and one of them is probably going to burn out. That's no good. The way that right-enable works is that it's ordinarily high but then when you bring it low and then bring it back high again, whatever data you're presenting to the chip is going to be stored at whatever address you're giving to the chip. Let's take a look at the timing diagrams now. In the datasheet, this is called read cycle 1. What's happening here is that chip-enable is asserted, that is the negative chip-enable signal is low. Output-enable is also asserted and right-enable is not asserted because we're not writing. The chip is enabled, the outputs are enabled and we're not doing any writing. We present an address to the address lines of the RAM and sometime later the data will appear on the output. What is this time? In the datasheet, that's called T sub A and that is 70 nanoseconds and that makes sense because this is a 70 nanosecond memory. This cycle is called read cycle number two and it's a slightly different way of doing a read. In this case, it's called output-enable controlled because we're not going to simply keep the output enabled and then present the address and wait for the data. Like before, chip-enable is asserted and right-enable is not asserted. Here in this timing diagram, unlike in the datasheet, I'm showing output-enable as a positive signal, that just reduces confusion to me anyway. The idea is that you present the address to the chip before you do anything. Since output-enable is not asserted, you're not going to get any data out. First of all, how long is it between when you assert output-enable and the output buffers turn on? In the datasheet, this is called T sub ENG which I guess stands for time to enable based on, they actually call this the G signal but the G signal is also an output-enable. In the datasheet, this is a minimum of zero nanoseconds. So what does that mean? That means that there is at least zero nanoseconds between the output-enable going high and the data buffers being enabled, which means of course that slightly before you assert output-enable, you want to turn off any circuitry that's talking to the chip because otherwise the chip can turn on its output buffers and then again you're going to get outputs fighting or bus contention. So that's why they say minimum zero nanoseconds because they don't want you to assume that there is actually some sort of a delay over here. And then once that happens, how long is it until the data becomes valid? And in the datasheet, this is called T sub AG and that is a maximum of 35 nanoseconds. So in other words, between the output-enable being asserted and the data coming out according to the address is at most 35 nanoseconds. Now you might be asking, well this is a 70 nanosecond memory, how is it going as fast as 35 nanoseconds? Well the key is over here. You can see that the address has been set up long before you assert output-enable. And in fact, we have to look at read cycle number one to realize that from the address being valid to the data being valid is going to be 70 nanoseconds. So this is valid here for a minimum of 35 nanoseconds because if you add up all the times you will get 70 nanoseconds over here. So that's another way of reading when you don't want the output buffers to be enabled all the time. So let's take a little break here and look at the circuit where I've got a 32k by 8 SRAM hooked up. And I've got a switch connected to a debound circuit which is connected to just one of the address lines. All the other address lines are set to zero. So we're only going to be able to access two memory locations. And I've got an LED hooked up to one of the data lines. All the other signals are disabled so we're not going to write. However, chip-enable is asserted and output-enable is also asserted. So let me power it up and we don't see the light being lit. If I press the button to access a different memory address, I do see the light being lit. Honestly, I'm not sure why because on power-up the states of the memory cells should pretty much be random. However, in this particular case, every time I power up this chip, I find that one of the addresses has a zero written to this data bit and the other address has a one. Well, this is convenient because this is really what I want, and what I want to show is how long does it take between me pushing the button and the data changing so we can see how close it is to that 70 nanosecond value that we saw from the data sheet. Now I have this going at 100 mega-samples per second which means that I can only look at 10 nanosecond samples, so this may be plus or minus around 10 nanoseconds, but in this instance, when the address changed, the data changed 40 nanoseconds later. Let's take a look at one more instance. Here's another one. Well, actually, here's one. And as we zoom in, we can see one, two, three, again, 40 nanoseconds. Let's take a look at the next instance. One, two, three, this time 30 nanoseconds. And the next instance after that, one, two, three, 40 nanoseconds. So you can see that, you know, let's call it 35 nanoseconds, maybe 45 nanoseconds at most is when the data changes after the address. Now should we rely on that? The answer is, of course, no. The data sheet says that the most that this chip will delay is 70 nanoseconds. This is where you get into overclocking. And the idea behind overclocking memory is that, first of all, you're going to not pay attention to the data sheet, and you're going to see how fast the chip actually can go. Because remember, the 70 nanoseconds of the data chip is a guaranteed maximum. So if you really want to extract the most performance from your particular chip, then what you have to do is write data to the entire chip and then read it back as fast as you can and see how reliable the chip is over a long period of time. And you do this on your PC, and you can do this on a RAM chip as well. OK, so for this timing diagram, which is called write cycle number one, this cycle is write-enable controlled because we are going to control when we write using the write-enable signal, which means that the other signals, chip-enable and output-enable, chip-enable is asserted, and also output-enable is asserted. So we're constantly reading from the chip. The output buffers are sending out from the chip. But the problem, of course, is that we want to write to the chip. So here's how you do it. The first thing is you set up the address that you want to write to. Now of course, the moment you do that, because output in it is enabled, the chip is going to start trying to read its data and outputting it through the data port. So the next thing that you do is you enable write. So here's the data coming out. Now at some point in time, after you assert write, the output buffers are going to turn off, and when the chip turns its output buffers off, that gives you the opportunity to send it data. So what is that time? In the datasheet, this is called T sub dis w, which I guess means disable from write, and that is a maximum of 25 nanoseconds. So that's important to know, because if you simultaneously assert the write enable signal and send your data to the chip, well, you're probably going to burn something and release some magic smoke, because you were supposed to wait at least 25 nanoseconds before presenting data to the chip. So the question now becomes, how long do you have to present the data to the chip before you can disable write? In other words, how long does the chip take to write data? And the second question is, how long do you have to keep the data on the data lines after you've disabled write? In other words, how long until the chip notices that it should stop writing to its memory? And this is called the setup and hold times, and you'll see this a lot of time in datasheets, which depend on one signal relative to another. So this is the setup time, t sub s u, and this is the whole time, t sub h. So the setup time and hold times are minimum times. They are the inner bounds inside of which you cannot go. You have to remain outside the bounds. The setup time is how much time at least you have to keep the data around before write enable goes low, and the whole time is how much time at least you have to keep the data around on the data lines after the write enable goes low. And in the datasheet for this memory, the setup time is 30 nanoseconds and the whole time is 0 nanoseconds. And what they're basically saying is that you can simultaneously drop the write enable and the data, and the chip will already have written the data, because presumably the actual writing happens in this interval over here. And once that's over, you don't need the data anymore. So that's why the whole time is 0 nanoseconds. So you have to present the data for at least 30 nanoseconds before dropping the write enable line. And then you might ask, okay, well, after I drop the write enable line, how long is it gonna be before I see data on the output lines again? In other words, when do I have to turn my outputs off to the chip? And the answer, of course, is going to be 0 nanoseconds. But the manufacturers have put in their datasheet, what is the enable time from write? And that is a minimum of 0 nanoseconds. So basically what they're saying is you better turn off anything that's talking to the chip after you drop write enable because the chip can immediately turn on its output buffers at that point and start talking. So that's something very important to keep in mind. So that's the first way of writing to the chip. There is a second way of writing to the chip, predictably called write cycle number two. Okay, so for write cycle two, this is chip enable controlled. The idea is that we're gonna set up our address and data lines and also set write enable to asserted, except that chip enable is now low. So again, the chip is asleep, nothing's happening. So the question is, how long do you have to pulse chip enable in order for the chip to simply wake up, write, and go back to sleep? And this is called TCE write, and this is 65 nanoseconds minimum. So that's the second write cycle, and that's the second way that you can write to the RAM. Okay, so let's go ahead and try to write to this RAM. So I turn the power on and at one address, the data bit is low. And at the other address, the data bit is high. Now let's suppose I wanted to write a low onto this data bit at this address. So the first thing that I would have to do is, if I'm doing write cycle one, I would disable the output buffers. So you can see that nothing is coming out. Now the next thing that I'm gonna do is I'm going to set up the address and I'm going to set up the data by pulling this line low. And now I'm going to pulse write enable. So write enable goes low, write enable goes high. And then now I can release everything. So I'm just gonna release. And now if I enable the output, the data bit is low. I can put the bit back to one by doing the same thing by disabling the output, setting up my address, setting up my data to be high. And then pulsing write enable, done. Now I release the data so I don't burn anything. I can release the address and now I set up output enable and the data bit has been written. So that's really all there is to using a static RAM. It's actually very easy to use, so don't be afraid of it. Diggity-diggity-diggity-diggity-diggity. It's Wich-diggity-diggity-diggity-diggity. I have no music and I can't sing.