Speaker is Dr. Ken Isersen, Professor Emeritus of Emergency Medicine at the University of Arizona. Ken completed his fellowship at the McLean Center in 1991. Ken is Medical Director Emeritus of the Southern Arizona Rescue Association and a supervisory physician with Arizona's Disaster Medical Assistance Team. As you're about to hear, Ken has worked on medical missions on all seven continents. He recently returned from a six-month winter stint as lead physician of the U.S. Antarctic Program at McMurdo Station. Ken has published more than 10 books and hundreds of articles on emergency medicine, end of life care, clinical ethics, and on how to get into a medical residency. Is that the eighth or ninth edition? Ninth. Okay. Which is in the ninth edition. Today, what's your topic? Oh, I don't know. Okay, thanks, Mark. I'd like to start by thanking Mark for letting me into the fellowship low those many decades ago and allowing me to traverse the ethics community around the world. This topic was chosen by Mark. I want to let you know, I had a real bioethics topic, and he said, no, no, no, no, we want to hear about this. So this is bioethical issues in Antarctica, or actually what Mark wanted to hear is, what did I do in all of 2016? And I actually was in Antarctica as the lead physician twice, the first time for six months in 2009-10. That was the summer season. And then for nine months last year, and it started in the summer season, went to the next summer season. Yes, I was there during the entire Antarctic winter. Oh, all of my acid. Okay. This is basically a talk about the ethical issues involved in a resource poor environment. And it would have gone better probably in the global health talks, because that's really what it is. This is about resource poor environments. It's a complex and confusing topic, but it really comes down to two issues. What can we do with the resources at hand? And of all the things we can do, which ones should we do? And Antarctica is just one of those examples. But because I have talked to lots of people about Antarctica, there are so many misconceptions about what really goes on there. It is the seventh continent. Someone asked me today, are there really seven continents? Yes, yes, and Antarctica is the seventh. First half, more or less, I'm going to tell you about the environment, because that is what makes the ethical issues. And the second, a little bit about some of the specific ethical issues we faced. Antarctica overall is stunning, dangerous, resource poor, and it has a unique type of population there. It is a stunning environment. Those are emperor penguins. I did have an opportunity to get up close and personal, which most people actually don't get to do. And those are the southern lights. Those of you who've seen the northern lights, very few of you will ever have seen the southern lights. And they're just as beautiful. They're exactly the same. I'm colorblind, so I can't tell you if the colors are the same, but I assume they are. These are not permanent residents of Antarctica. The largest permanent resident, largest permanent resident in Antarctica is about a half an inch long and it's a worm, and it's in a few places around Antarctica. No penguins are not permanent residents. We have no polar bears there. That's the other end of the world. It's a dangerous environment. There I am in wearing what's called Big Red. Big Red is issued to everybody in the U.S. Antarctic Program. It is about this thick, and you wear it all the time if you want to live. That's our severe weather chart, and it's showing all red. That means you don't go outside unless there's an extreme emergency, and if there is, then you have to be with a rescue member, a special rescue team, and on a fixed rope, which we set up. That's a typical day. We're getting off the plane initially, and that's a typical day. Here are a couple of problems we saw. Some frostbite, and we did see frostbite. It's not frostbite, it's frostnip. I don't know how many times I saw it. Yeah, but your hand's turning black. The other one, and for the physicians, you'll be interested, it's high altitude pulmonary edema in one of our young people. We are resource poor. That's our medical facility, that's our hospital clinic, our pharmacy, trauma area. One month a year, we can bring in two ships, plus an icebreaker. It follows the icebreaker, and it's a supply ship and a fuel ship. Then we have fairly good communications, and that's some of the communication stuff that was sitting on my desk. The population, we have two, well three distinct populations. In the summer, and at McMurdo, McMurdo is the largest population center by far in Antarctica, and certainly the largest US station. We'll have more than a thousand people either working on the station or out of the station. Out of the station is very important because they're scientists who are also on the continent, and I'm responsible for their medical care. Even if they're working on the side of the volcano, I have done a rescue up on the volcano, or in the crevices or other places. In the winter, it drops down to about 100 people, 150 people, which includes personnel at the Kiwi base, the New Zealand base, about two kilometers away because we're their medical facility year-round. The three populations, one are the scientists, and all the scientists are under grants from the National Science Foundation. That's a requirement to be there as a scientist. The second population is the support personnel, and there's lots of support personnel year-round to keep the place going because people should not be in Antarctica. I mean, that's crazy. But we do science, almost every type of science imaginable is done there, and it's really important. It's not just global warming, it's everything. The third group are the Air National Guard, and the Air National Guard are the people who fly us in and out of the continent, in different places in the continent. No, they do not have weapons. That's one of the rules of the International Antarctic Treaty. I've worked at Scott Base in McMurdo and the South Pole. South Pole is about 600 miles away, and we have to go by air. You can only do that in the summer. Once you're at the South Pole in the winter, you're at the South Pole, except for something I'm going to show you shortly, kind of drama. We have to have a little drama in this conference. We did have most of the necessary equipment and medications. We had a lot of medications, a lot of equipment. What about during the winter? You can't get anything in? Well, you get at the beginning of the winter, you're stuck with, and that's it. Our personnel were generally screened medically before they came in. They had medical screening in labs and dental screening. People lie. Did you know that? That caused a lot of problems. In the summer, when people were still coming in and out, because we have about three flights in an on-continent and off-continent a week for various reasons, they gave leeway to key positions, which could be a problem. We had one guy. He probably should not have been out of the intensive care unit, but they led him come to Antarctica. That was for two days. That was because he was one of the three people in the world who could fix this one critical component on the station, and so they brought him in and out. Sometimes our VIPs, and I can't name who they were, but they were very important people, very important people, and they came in and they said, I don't need a medical screening. One guy got on the continent. He walked into the reception when it was being held for him, went to ground. For those who were not medical, that means he collapsed completely. He was in VTAC, and he knew that he went into VTAC frequently. He was on this special medicine that almost nobody could prescribe, and we didn't have it, so of course, we needed to get him out of there. This is in the summer. I should have been able to do that. I called up our chief of air operations. He said, you bet. We'll get him out of there with a medical team right away. Well, not right away. It'll be a week. We have the plane. We have the medical team, but the mother of all storms is coming in and you're stuck, so that's one of our problems. We tried to keep people with major disabilities off station. We had an application from a woman who was blind. I said, okay, you know, we have a few obstacles here, like everything is ice. You're walking around on ice all the time. We have stairs that are icy. We have all kind of, anyway, she didn't come. This is our medical building, and it was built around 1955 by the Navy who used to run McMurdo as a Navy station, but that's a whole, it's just a science station now. And that's inside our emergency department area. We have six beds for inpatients, and we, there's a picture of some of them, and we did use them. This is some of the medical equipment we have. So we did have medical equipment. We had a slant machine. We had oxygen, mostly oxygen concentrators because the big bottles were a little heavy to carry. Monitor at the defibrillators, ultrasound. Problem was we had different kinds of machines bought in different eras, and we had to know how to use all of them. It was kind of tough. A lot of ortho equipment, because a lot of ortho injuries, that was the number one problem we saw was orthopedic. We had a full dental clinic because two months a year there's a dentist there. The other time, I was a dentist. Yes, did I pull teeth? You bet. Was I using the dentist's power equipment to adjust bites? Yes, I did. Did I replace caps? Yes, I did. I was a dentist, and you want to know, did the patients know that I wasn't a real dentist? I lived with these people. I ate with these people. I played with these people. They knew what I was. But I was also the pharmacist, and any of you who are pharmacists, more power to you. That is the worst job in the world. So not only prescribed it, but I had to know where everything was and keep track and get rid of the old stuff. And what about the old stuff? If we had it, we used it. Radiology, yes, I was the X-ray tech, and I read the films, and I developed them. And we had a hyperbaric chamber, and it was a real hyperbaric chamber, a multi-placed chamber, because during the summer we do intensive scientific diving, dry-suit diving, obviously, but intensive diving. It has been used. I never had to have it used. We did do simulations, but that's one of my physician assistants inside the hyperbaric chamber, just for fun. She thought that would be cute. We had physical therapy, and no, I'm not a physical therapist, and that was the first consult that we had to have, was we had to call up and get physical therapy instructions, because that's tough. So now the ethical issues. Yesterday Paul Farmer talked about in a desert, clinical desert, what you're looking for is you're looking for stuff, staff, space, and systems. Okay, well, we had problems with systems, as I'll explain, and staff. We had the stuff, more or less, and we had the space. Okay, so of all the things, what could we do, and what should we do? Our interventions, these are some of the ones we were supposed to do, disease and injury prevention, and that was tough. Imagine I lived with all of you guys, you know, we all live together in dorms, we live in dorms or barracks, and I've got to convince you to have influenza shot. Okay, but I had one you say, well, this is new. This is the one, because we were in the southern hemisphere, so that comes early. So I have to convince you, and then I have to give it to you. And is it going to hurt?  Is it going to hurt? Okay, so it can be hard.  Disease prevention, let me think. Okay, all right. We did therapy, including rehab therapy. The first person in the winter that I had to treat was a shoulder dislocation, alcohol, ice, okay, and he was a little older, and I had, I don't want to move my arm. This is afterwards. As he was repaired, he was, okay, you know, I don't want to do that therapy. Said, if you don't do the therapy, I'm going to have you restricted the quarters for the rest of the winter. This was, he finally did it. But rehab is tough. And then patient support. Yeah, a lot of counseling. Here we have a psychotherapist. Boy, I could have used you. Really, really, not as much situational depression because of the dark. Everybody thinks it's because of the night. It's not. The alcohol takes care of that. But also the activities. They have scheduled activities and they're pretty good about that. So it's a community and we get over that. We had satellites. Okay. But this woman who is actually fairly experienced almost backed her truck over a cliff. I mean, it was halfway over the cliff when they got in there, got her out and attached the truck to a tow line. And I mean, she was you can imagine. I mean, she saw that she was going to die, which she was if she went over the cliff. So we had a lot of counseling. It's not really alternative therapy, but I do use hypnosis and I have for a long time in my practice, emergency medicine practice. And I used it with her and counseling and but a lot of other counseling, a guy got off the plane, got to the bottom of the steps. He looked around. No, I'm not staying here. All right. So we tried a little counseling, but we got him out. Okay. Okay. So I said one of our ethical issues related to staff and the staff was that we oftentimes didn't have the not the breadth of knowledge we needed to do all the things we really had to do dental boy. I was on the edge. I did have a consultant dentist that I could talk to at literally 24 seven. And I knew him and he's very good and very responsive. I took dental x-rays for those of you who haven't done it. That is please give me chest x-rays any day. Dental x-rays are terrible. So those ladies in the dental office who do that. That's tough. That really is anyway. So we did that dental was at the edge of what we were doing pharmacy managing the pharmacy. We knew how to prescribe radiology and imaging laboratory. We were also doing blood banking, blood banking. My wife in her first career was a medical technologist. She says that's hard. Tell me about it because we had stuff that from 15 years ago that we were having to use for blood banking and nursing procedures. Anybody who's a nurse in here more power to you. Boy, I wish we had had a nurse. We had to actually borrow a nurse during the winter. I had a PA and myself and we had to do this whole thing. But a friend of mine happened to be an RN, experienced RN. She was doing something else on station. She didn't want to do the RN stuff. But I said in a crisis will you come over and help. She said okay because it's you I'll come over and help. That's management in Antarctica. Please help me. Okay. So she came over occasionally and helped us especially with drips and things like that. Now what we could do is limited by the systems, the consultants. Occasionally we had consultants and they said we'll just bring them down to my office. Do you understand I am eight hours away by Air Force Jet from Christchurch, New Zealand, which is where we go in and out of. Do you have any clue who you're talking to or where we know? Okay, never mind. Sometimes they wouldn't come to the phone. Sometimes the quality was just terrible. So consultants is a problem in these kind of resource poor environments. I've worked in other resource poor environments. As Mark said, I've worked all over the world. Sometimes I relied on my own friends who in various specialties, the University of Arizona, and I could just call them up or email them and they said sure, this is what you do. That was fine. Sometimes we had to use other people. Supplies, medications, equipment, like I said, multiple different kinds. We had to know all of it instantaneously and sometimes it was outdated. Managerial decisions, we won't go into. Weather conditions, I told you about the case, but weather conditions all the time. And weather conditions also, we were part of the emergency response team I was as the lead physician, which meant middle of the night to get called up. Oh, this science team hasn't reported and you have to go to the command center and you have to figure out where they are and because the weather had just come up and they were going to get zapped. Okay, bureaucracy. Here's some of the patients it costs about for an emergency evacuation it can cost into the millions. And I'll show you why in just a second. And okay, this is about three minutes, but it's worth it. Tude of going to South Pole or anywhere in Antarctica in the middle of winter is fairly serious. We hadn't been involved with Antarctica in June before. So this is the unknowns and the first times were a lot of us. It's the worst time to be down there flying, that's for sure. The Antarctic poses bearing risk with extreme cold weather conditions high altitude during the winter season. The middle of winter is fairly serious. We hadn't been involved with Antarctica in June before. So this is the unknowns and the first times were a lot of us. It's the worst time to be down there flying, that's for sure. The Antarctic poses bearing risk with extreme cold weather conditions high altitude during the winter season. It's dark for the entire period. That makes this mission more challenging than what we routinely do. Prior to leaving I tried to visualize all the problems that we would have along the way to try and not be caught off guard by it. Things like an engine failure. If I had to land, where was it going to be? And you can plan for everything, you can plan for winds, you can plan for enroute weather, but you just can't plan for the breakdowns or the unknowns that come out. The limited resources and facilities on route compound the danger.  Just watching our fuel it took up a lot of your mind for most of the trip. We don't have a lot of reserve, any kind of head winds and changes of two or three knots on that distance at our slow speed was going to make a difference and you know could we actually make it all the way. The weather extremes were quite large. The silt pole was minus 59.8 degrees exactly when we landed. Parting out a silt pole to tell you the truth we weren't entirely confident we had enough room of cleared the skiway. Just to get the airplane moving took pretty much all the power of the engines. They lit a fire and a couple of drums and that's what we had for lighting there. I believe we had maybe about 7000 feet down the skiway. Even at that point we weren't sure if that wasn't enough for us to get airborne. I got to recall just getting the nose off at around the five to six thousand foot marker and at a weight that is way over the maximum normal operating weight for that aircraft and we slowly got airborne. Okay that was the rescue first time ever during midwinter during actual midwinter from the south pole station. I was involved in the decision and also alternative preparations at our station in case they had to come back our way. You were seeing one of the pilots the guy who went to the south pole. He was asked are you the best pilot Ken Borek has. Ken Borek is the only company in the world that does that kind of flying. They fly in the Arctic and they fly in Antarctica and that's it and they have the only planes that'll land in that and can take off again in that weather because your oil freezes usually but that's a specially built plane. Anyway he was asked was he the best pilot because he was going to the south pole. No I'm the second best pilot. The best pilot is back in the British station on the peninsula the two planes because he's got to come get me if something happens. So what we should do is limited by costs. That was a more than a million dollar decision. They took out two patients. Okay and I can tell you one of them had an acute MI and potential danger always an incomplete knowledge. What we should do was limited by all the various constraints and I can tell you about one constraint which was public health is I instituted for the first time a quarantine system for people coming in who had any signs of upper respiratory disease and I quarantined them for three days. I got enormous pushback from the companies and then all of a sudden people realized hey we don't have diffuse coals throughout the station so it worked. Okay we had more medical resources on hand than most of the places in the world that I work resource poor same or better communications but we had less ability to get people to higher levels of care and usually none and I'll just end with a question that a number of people has asked what if I needed to do surgery on any of these people in midwinter. The setup we had was we were going to change our trauma area into an operating room. We had a telecommunications system there was going to be a camera over my shoulder. I was going to operate and surgeon was going to be talking to me because we did and we had plenty of anesthesia that was not a problem we had propofol but you just have to live on the edge and the people there knew it and that was kind of tough so while this is going on this is a I think we need the bottom one it's just going to play if you guys have any questions this is this is a combination of a actual drone going over and some fancy stuff they did but in any case thank you very much are there any questions any volunteers for next season okay okay


Oh my gosh I mean I tweeted a while ago that hey We're doing a bunch of stuff and I tweeted these pictures of all those like video equipment We had set up and you know we do radio free equestria and we do these like geek nights minis and all this other stuff but a lot of people have asked us to watch Utenna again and do a final thoughts episode we haven't done nearly as Many of those as we should have but Utenna is sort of an infamous show, right? It's been around for a long time. We've watched it. I've watched it twice I've seen Utenna all the way through four times. Yeah a lot of times It's like rooms favorite show ever and it's an a anime. Oh, yeah, like a But it's infamous because this show in particular compared to other animes, right? Is that it has a lot of this really kind of weird imagery. It's low budget But there's all this stuff going on like, you know, why is Mickey always stopping his stopwatch? And why is there's cats in the background and what's up with those shadow girls? It also starts kind of like a stereotypical show Joe like oh, there's a bunch of people at a school fighting over a ring and a Rose broad and all this stuff. It's like the actual stuff that goes on is pretty straightforward until the second season when it goes crazy dark But you know burning coffins. There's just lots of just you know Imagery all over the place that it makes people really have a hard time with the show It's like what is that symbolize and what does that mean and what's going on here and yada yada So we thought hey, let's watch it's got Yeah, it's like I mean we're talking this episodes later on well They'll be a cat and they'll be a finger blinking on the screen pointing at the cat And then those cut away and cut back to the cats on the windowsill while someone's talking There'll be two cats and the finger will blink again I'll cut away and come back. There'll be no cat Then it cuts to the like the glass the guy's drinking from and there's lipstick from the girl who was just there It's pointing at the lipstick right and a lot of this is dual purpose on the one hand They can have someone talking without having to have a mouth moving and they can save a lot in animation It's really easy to animate a hand being there and then not being there. It's harder to animate a mouth going Along with some words or it's more work, especially this is all hand-drawn They weren't using computers except for the really bad CG castle But anyway it One many people we know watch the show all the way through mostly on our recommendation and then they come to us and say But Roman Scott, what was that show about and the answer is actually really complicated. I Mean, you know a lot of its Symbolisms and weird imagery is just weird and isn't really important But it's deep enough the allegory is strong and the show is such that it is consistent on multiple levels You can look at it from a few different perspectives and it's completely consistent in all of them Yeah, and the show does mean something right? It's not Just some nonsense situation. Yeah, it makes sub points along the way It makes it has a few like tangential ideas, but the key is it's a complex show.  Oh, yeah Thing is it's we not do this. It's been it's been time. I just watched cowboy bebop again You know what goddamn is that a good show? Oh, yeah, I just watch I want to watch Gundam seed again And I realize not as good, but it's a good. Yeah, Modica magic. I can watch that again Watch that ten times. So I you know, you're right when you watch and I'm gonna you know I've seen Utena four times. We just watched the first episode of shojo Kakame Utena again Just now for the first I haven't seen it in years and I have this burning desire to watch more of it Oh, yeah, so if you have not seen Utena at all, we're only gonna spoil the episode We just talked about so you should probably watch it and then you know go along with us And it maybe we will be able to enhance your viewing experience because commentary from Ikohara ain't gonna do it He really likes that sort of thing Oh, he does now if you never watched Utena because you thought it was some shojo crap And you don't believe us and you're not just willing to watch the entire show on faith alone I will you should do something that I have had many other people do who are reluctant to watch the show Watch there's an episode from a the second season I'll send a link to the actual details or whatever, but it's a two-part episode that spoils a ton of stuff But simultaneously shows you what the show is really about the one with Wakaba and the onion king and all that stuff That was mentioned in episode one if you watch those episodes That is what Utena is really about and I don't think you need to watch those No, that is that is if you are stupid and aren't listening to us right now when we tell you to watch the show I put the show right up there with cowboy bebop and Evangelion as a great anime for all time Yep, and it is to the test of time it has indeed


Hi everyone. We are going to go ahead and get started. I wanted to say a quick thank you again everybody for coming out. I think Sophie's birthday party analogy several hours ago was particularly appropriate. It's just really great to see that people care so much and want to talk about the issues that we find so interesting here at Mittler. And it's also particularly appropriate given that this is our journal's 25th anniversary. So thank you all for coming out to celebrate our journal's birthday with us. I have the task of introducing our keynote speaker tonight. She has the difficult but enviable task of balancing considerations of brand loyalty and consumer experience and trust for one of the world's largest payment providers with trying to move fast and innovate and remain competitive in what's becoming an increasingly competitive and cutthroat market for financial services firms. All the way out from San Francisco to our frozen corner of the world out here. So please help me and join me in delivering a warm welcome to our keynote speaker Vice President and Chief Privacy Officer Paypal Christi Chan. Thank you. It's so exciting to be here with you and thank you for the warm welcome. Being able to actually talk about, learn and just have a good conversation about the topics that I care so much about. It's incredible. It's awesome. And I geek out at this. So thank you for indulging me and setting aside a day to be able to do this with you. So as I was getting ready to come here and just like any of my other work trips or business trips, I was preparing dinner with my family and as part of normal routine, I think on Thursday night we made salmon or something like that. And I usually sort of start my cooking sessions whenever I put something in the oven with a command to Alexa. Like, Alexa, 15 minutes on the clock please. Or sometimes I say, actually my five year old corrected me the other day and saying, Mom, you have to say please. So 15 minutes on the clock. As the time ticks, my five year old daughter Leila continues to engage with Alexa. Saying things like, Alexa, count from one to ten. Alexa, sing me the Sesame Street song. Alexa, what is the temperature in Chicago where Nana lives? Going on and on and on, engaging. And this is very fascinating because even a year ago, one, Alexa didn't really understand what Leila was saying. So she would sort of come back with answers that were irrelevant. But the way that my five year old learned how to engage with our digital assistant has just improved dramatically. And with that Alexa's response also improved dramatically. She knows to firmly state Alexa before she begins to wake up Alexa if she's not already awake. She knows exactly how to enunciate each command and string together search terms. And she also knows to slightly over enunciate because sometimes if she doesn't then Alexa comes back with a wrong answer. And this is incredible because like I said a year ago Alexa didn't respond appropriately and Leila didn't know how to engage with Alexa. So just in the course of a year the progress that how a five year old can teach artificial intelligence, digital assistant to be able to adapt and learn the owner's style of speaking, the type of commands that is executed is just amazing. And in order to adapt to the owner's voices and commands and styles Alexa listens and stores our voices, our commands in Amazon database, servers. And this is to enhance the quality of the response to be able to train the assistant and to train the model to be able to be more effective and to be more accurate, right? So this is all happening in the four corners of our home. Normal day, we're going about, and I have, and I don't think about, I actually have not thought about until a while ago, that this information was going to be shared with somebody else. It almost feels like there would be somebody standing outside of my house, a stranger, or even somebody you know, but somebody who's going to stand outside and listen to our conversation and that's a little bit creepy, right? So I don't think about the fact that this potentially could be shared outside of the four corners of our home. Well, and it doesn't, at least I don't think, but a couple in Portland having a private conversation in their home thought the same. So it turns out that a woman in Portland, Oregon, found out that her Alexa had recorded a conversation between her and her husband without permission or awareness and sent the audio recording to a random person on her contact list. Yeah. It was a major glitch. And you know, Alexa doesn't record everything in the house, right? Alexa has to be woken up, Alexa has to be, the command has to start.  It was a send the message request. At which point Alexa as Alexa does checks to whom and background noise again was interpreted as John, I don't know if it was John, but somebody on their contact list. Alexa then said, John, right? And the background noise again was interpreted as right. And the message was sent. So this is very, very unlikely, but it happened. And we don't sometimes think about the way that we engage with a lot of these technologies, the way that information is gathered and how it is then utilized and transmitted. And enhanced data technology including trained AI which brings significant benefits and convenience to any view and the society. But the protection of this data from misuse and unauthorized disclosure are increasingly becoming challenged by the massive amounts of data. And the technology that's always enhancing smart, getting smarter to become, to combine and analyze the data. And even more than ever trust in how data is processed is top of mind. So let's talk about the massive amounts of data and the footprint that we're leaving around. Who here has a Facebook account? Not anymore. A lot. Instagram account? LinkedIn? Thermo? Yeah. The vast amount of personal information and social media information that we post on social media sites combined with the ability of social media companies to link our online behavior to physical locations and other information is creating a shift in the way that companies are able to utilize the data and of course including marketing. For example, micro-targeting is actually a form of marketing strategy that uses consumer data and demographics to identify interests of individuals or very small group of like-minded individuals and potentially could influence their thoughts or actions through advertising. And to achieve this personalization on such a massive scale, there needs to be massive quantities of data and continuous updating of that data about individuals to create predictive analytics about the sentiment of the group of population. If we apply this to the voting population scenario which is not unfamiliar to us, understanding the population on an individual level can enable potentially campaign leaders and directors to go beyond standard political party-oriented messages and communicate to the voters about specific topics and potentially influence the voters' decision. Online advertising, I think we heard from the panelists a little bit about online advertising where your behavior on websites, what you click, what you visit, what you visit before and after is tracked and that through cookies and it informs sort of what types of products that we are potentially looking for. I consider that sort of back in the days right? Now that online behavior is merged with other data, offline data about persons whereabouts, persons what they did, what they purchased, and is able to create this holistic omni-channel experience. For example, I'm actually in the middle of renovating my house and the other day, last weekend, I was with my daughter and we're at a park and I needed, I was looking for a rug on my phone and as I was looking for the rug I got distracted and chasing after the five-year-old and so I decided to stop looking at it and a few days later, as I was on a different device, I think I was on my work computer, the topic of rugs came and presented flashed from various different companies, not from the company that I looked at the rug from, but also I started to get coupons of 20% off of rugs from all these places. Not only that, I started to also get information and advertising about toilets. Somehow they figured out that I was renovating and I was, but toilets and bath tubs and random house renovation types of advertisements that, you know, to be fair, I actually didn't look for toilets and I actually didn't plan on buying toilets, but when shiny new toilets sort of color came about, I said oh, maybe with my bathroom renovation I could maybe should or maybe use one, right? So it's starting to, you know, influence the way that I could potentially think about. It's just a lot of data that is generated about our activities and we fuel that one way or the other. We may consciously do it in instances of personal finance management sites, right? I don't know if you have memberships or a part of min.com or other financial aggregation sites where it helps you see a holistic picture about your finances. How information gets aggregated there is by your choice. You decide to provide that information, right? Because it is nice and it is convenient to be able to see all of this in one place.  Did you recently buy a house? How much was your mortgage? What is your credit score? All of those information are aggregated and added and it becomes bigger and bigger and bigger. Apps, right? Before it used to be computer and then offline shopping. Now with the explosion of the use of mobile devices we have put and share so much information, very intimate information about ourselves and we record it on these apps. Because again, it helps us track, it is convenient and it is incredibly beneficial to some extent. We are busy, everybody is busy and so it helps us track exactly what we want to do. So there is a lot of data and then there is the ever-changing data technology and the capabilities to crunch, combine, analyze massive amounts of data that we have not been able to before. The evolving technology is constantly increasing in the capabilities on what it could do and how much data it could consume. So let's talk about your face. We talked about I think biometrics earlier but facial recognition software is a technology that is capable of identifying or verifying a person from a digital image. It generally works by comparing selected facial features from given images with faces in a database. I know that mobile device users are familiar with this because one way to use this technology is through for security authentication. We have face IDs on iPhones. I'm sure there is something similar in Android but I don't use it. So I'm not familiar but something similar to be able to authenticate and to really validate that the person who is trying to access the device is who it's supposed to be. There are also you may be familiar with this technology when you are trying to tag your friends on Facebook photos or Instagram it sort of automatically suggests who the person is in the picture. Or you might be familiar with this Snapchat's animated filters. It's super fun like the dog face or the filters. It is really fun. But other cases use cases include uses for use for law enforcement and law enforcement related activities including there are real-time face recognitions that allow surveillance camera to scan sort of the faces and the pedestrians on the street and stores it in databases along with other images and visuals from driver's license visa applications, passports, etc. And many of these use cases raised concerns about privacy. And while facial technology, facial recognition technology is improving, there's also been studies demonstrating that these technologies may be imperfect, inaccurate, and sometimes ineffective. In fact, facial recognition technology has been proven to work less accurately on people of color. There has been a study done by Joy Bolamani from MIT Media Lab that found that the error rate for gender recognition for women of color within three facial recognition software technologies range from 23% to 36% whereas for lighter skinned men it was between 0% and 1.6%. I mean that is a dramatic difference. Data technology, AI machine learning is only as smart as the data that is used to train. And some of these show that biases in the world can seep in to the technology. So we have massive amounts of data and there's cool and ever changing, ever improving technologies. Let's talk about our reliance on these technologies. Today, we're no longer trusting technology to just do something but decide what to do and when to do it. Simple artificial intelligence organizes and filters my emails as it's coming in. It organizes into three tabs primary, social, and promotion. And it does this by learning it does this by learning models and preferences based on my own behaviors because what may be spam to me may not be spam to you. And Alexa you now know that I love Alexa. Alexa knows which fish oil to oil or order when I say Alexa order me fish oil. It knows exactly the brand. It knows exactly when to send me. It knows exactly where to send it to me and all I have to say is Alexa order me fish oil and two days later the brand that I want is in my house. Seamless incredibly seamless. Smart cars. I live in northern California and I kid you not the other day as I was driving down to my office on 101 I saw a car next to me where a person literally had their laptop plopped up. I moved to California from the east coast and that totally scared me.  There was a driver but just not a person there right. But imagine your digital assistant being able to plug into the smart city to direct your smart car to the nearest free parking space or your smart refrigerator ordering use supplies when it recognizes that the food stock is getting low. The interconnected devices and the train data through the smart technology makes my experience so seamless and I become more and more reliant and even dependent on the technologies. So talked about the massive amounts of data and ever improving data technologies to combine and train the data and the fact that we rely on them a lot we train these technologies by the way. I think someone said technology is neutral well I don't know we train these technologies so what if we're inadvertently training biases technologies do precisely what they're taught to do and are only as good as the construction and the data that they're trained on algorithms that are biased will end up doing things that reflect their bias and the data used to train the model if it doesn't accurately reflect the environment that the model is going to work on then it's not going to accurately reflect the result and potentially flawed algorithms can amplify and nudge bias practices and behaviors. So the boundaries differentiating organizations in different sectors and also in different types of consumers, different verticals are all blurring as data and technology becomes an enabler of almost everything and it's really converging privacy, security and technology. Organizationally I see this changing a lot as well so just looking back on my career history I started out at a law firm advising clients usually the clients are inside in-house attorneys who would call and say hey this is we need to figure out this problem can you please write a memo for us trying to figure out what actions we need to take. Very seldom at that time did I deal directly with technologists, security folks or product developers privacy used to be part of within an organization privacy as a function used to be within either a legal organization sometimes within a risk organization sometimes within a compliance organization but almost always separate apart from the security organization and the technology organization. And now I see more and more companies organizing under the same leadership to ensure that these topics are thought of collectively that they are now coders and developers with privacy experience that we're thinking about coding privacy into the products and that security and secure life cycle development which is sort of a development life cycle considers and has input of these topics and we need translators right. Largely these versions and these verticals sort of stayed separate because and people didn't really understand. Very seldom did privacy professionals or lawyers go knee deep into technology development if that was happening I think that's tremendous way way way ahead right but you're seeing this a lot more often wearing the technology hat. How do we consider and build policy implications into the technology that we develop and me now wearing the technology hat. Our developers sometimes I think Melissa you said earlier but sometimes developers come up with even actually more creative solutions than what a policy maker or legal team could go and say can you please do this. Instead it is we have this problem that we want to solve. How can we do this right. And so as the converged group thinks about this because it can't be one function how do we think about using data responsibly and ethically. We need to not only think about the principles of data ethics but we need to think about how we can operationalize the data principles and make and really instill it into the culture of the organization. How do we make this into almost like muscle memory and habit right. In other words we need to think about how we incorporate the ethical safeguards and the ethical considerations into the design and architecture to build it right from the beginning as we're thinking about the concept of the product of the tool of the technology so that it's not an afterthought. Sound familiar? I know many of us have talked about GDPR and especially in the last panel had a really rich discussion right. So this concept of privacy by design is not new and in the last couple of years many companies including mine in preparation for GDPR really thought about this and have tried to build this concept out. But you can think about this layered approach of on top of the privacy principles on top of the privacy by design. Think about this as one layer above which is like data by design. Because we now have to think about it holistically with the technology considerations, security considerations and privacy considerations and really this is like data by design right. So let's walk through some of the principles and as a practitioner, someone who thinks about this every day, how do we start to make this and build muscle memory maintain data hygiene. Remember there's a lot of data and AI and machine learning enhanced technology thrives on data and learns to make better decisions using vast amounts of historical data. So keeping data hygiene is critical. It includes things like what do you have, where does it come from, how old is it, is it current, is it relevant, is it correct. You know I think Rita you mentioned how hard it is for companies to do this and before if you really just stop at the compliance layer there were a lot of companies that sort of did this bring in lots of people, consultants, lawyers to be able to map the data that you have in the systems. Map it, put it in an Excel spreadsheet figure out what data you have, when it was collected, if you know how it's used and file it away. It can't be a one-time exercise in order for this to work. It won't work. It won't work. And with the vast amount of data that gets generated every day, you have to be able to think about how do we maintain data hygiene. You have to establish it first, which is already hard. It's really hard. And you think about large companies, kind of grows by acquisition sometimes, or kind of grows by other means, but largely at least based on my experience, companies don't have a unified way to store data in a single beautiful place with the catalog of everything you have. It's lots of systems, lots of different IT infrastructures. Sometimes doesn't even talk to each other, right? So how do we think about maintaining data hygiene, building data hygiene and maintaining data hygiene? I see a lot of startup technologies that are coming out in this space touting to say, hey, I can understand your data. I can go in, I can scan it, and I can tell you exactly what you have and how it moves and, you know, all that jazz. But personal data is unique to each company. Because I think as we learned in the first panel, it is any data that is about an individual. So however that gets formed in a company, of course there's the basics of name, email address, that are spelled out, but largely this is kind of proprietary, right? It takes time to figure out, okay, what data do we have that is linked back to the individual, and how do we keep tabs on that, right? How do we keep tabs on that? How do we ensure that we have a record of something that comes in through a system, track its movement, understand who that information is shared with, understand how stale it is, how old it is, and understand how you, you know, the processing activities that are associated with it. We have to maintain data hygiene and make it part of the company culture. And I will be the first one to say that it is very, very, very hard. And it is not a sort of a, you know, once and done and for all. It is constantly reinventing the way that you do it, the way that you keep up, and the way that you can improve. And when I have conversations with regulators actually on this topic, I'm very, very open and honest about, hey, this is how we're thinking about it. And we're not there. And we won't be there for a few years at least, even to get the baseline. Just understanding your data landscape and being able to refresh it real time to be able to get alerts if something changes, to be able to understand whether the product that you build is potentially oversharing or undersharing to get that built out, it is incredibly hard. But the way to build it into the culture and to maintain it is to bring in our technologists, the developers, the security engineers to say, how are we going to solve this? Right? How do we maintain? How do we build data hygiene and how do we maintain that? Be transparent. And we talked a lot in the morning about transparent notice to the customers about the data that is collected about them through the privacy notices or through our terms. And I do think we have to get better across the industry about providing more relevant and meaningful, you know, providing that transparency, right? But the transparency here goes beyond the customer. I think we need to have transparent functionalities. So whatever we build, the AI technology, how is what is it meant to do? What does a successful result look like? Was the algorithm built for one use but then has started to be used for other purposes? What does the result look like there? And how do models and analytics and algorithms arrive to specific decisions? How can we quantify the accuracy of the models? And how can we communicate this to the customers? And in some ways, you may not be able to, right? We talked about how information flow could come from one place somehow migrated onto the other. Yesterday, I don't know if you read the article from the Wall Street Journal, but I would imagine some of you did. There was an article for those of you who have not seen it yet, article about apps that are sharing very, very intimate information with Facebook even though there is no integration whatsoever. You know how there are some apps where it says, hey, you can sign up for this by logging into Facebook. And it's super easy. So easy. So I know that a lot of people do it. A lot of my friends do it because you don't have to put in the email address, your address and other things that apps ask about you. So it's super easy. But yesterday's article in the journal said even if you didn't go through that route, which gives you that expectation and kind of in the back of your mind thinking, okay, since I'm signing up with Facebook, I guess some data is going there. No, these were situations where you weren't doing that. And the apps were sending nonetheless data about very sensitive information that you thought you were putting in your own device on the app about things even as sensitive as whether you were considering to get pregnant when your cycles are. Body weight where you want to get to, body percentage, bad exercise schedules. I mean, these are incredibly sensitive information that I would imagine the users of those apps did not have an expectation that this information was going to be sent to Facebook, which then combines with the information that they have to be able to use it for whatever purposes. So how can we be transparent and transparent, more real time and transparent where it's really relevant? Because we all know, as noted before that people don't necessarily read the privacy statements. And in the case of yesterday's article, it seems that in the privacy statements don't really mention that either. So how do we really elevate that? So that people can take ownership of their data. I'm sure those people, had they known that the type of information was going to be shared with Facebook may have decided that, you know what, I don't want to use this. I don't feel comfortable sharing this type of information. So I'm not going to use this. I think it gets very, very blurred. Whereas before who we told our sensitive information to among our closed circles of friends, it was very deliberate. And with these apps and not having a good understanding nor on the flip side where it is not transparent what you share and with whom is very blurred. You don't know sometimes. So we need to be accountable, right? As we build these types of models and algorithms assign responsibility for all parts of the process. So here, again, I think in the traditional days, and I've been there, trust me, in many companies where you say okay, we've got to do the PIA fill out this Excel spreadsheet form, you know, what data is it collecting, how is it going, what is it doing, and then file it away. No, this is about what is the product that we're designing? What is the capability? What are we doing? And who is working on what? Is there somebody who's looking at it from the beginning and wearing that data ethics hat and saying just like we have a legal colleague on a lot of the projects, right, there almost needs to be another sort of level of review, right, and engagement so that the products are built in a way and sets clear boundaries for the development. It could of course include monitoring and testing algorithms regularly to know that bias is not creeping in and the models are still operating as designed. In I think yesterday's article, there was one company where they said no, no, no, no, we only share de-identified information, so it's not about you. But when testing was done, that their information was linked to a unique advertising identification number, which then Facebook couldn't understand that that unique identification number actually belongs to Christie Chon. So guess what? I know Christie's body fat or whatever it may be, you know what I mean? But the true de-identification has to be tested for, right? Test for potential biases. As we know and as we heard, unwanted bias and training data can result in unfair results and we need to think about fairness. And I think that fairness is going to be different, right, depending on what you are building. And we have to think about building tests and establishing tests for identifying curating and minimizing bias and training data sets. So this could, you know, I noted one type of bias before, but this could be, if you're trying to build something that's supposed to operate 24 hours in a day, let's say you're building a smart car, that's supposed to operate obviously, you know, 24 hours a day. You don't know when people are going to drive. But if you only put in the data sets for results after it being driven during the day when the sun is out, the functionalities at night is probably not going to work, right? And so how do we ensure that there is a wide enough data set? And this goes sometimes against the principles of minimization, right? So when these topics converge, we have to work through these complexities and think about, okay, what is the end goal here? Because it is not going, it is not simple. It is not black and white. That's the fun of it. But it is very, you have to think about here testing for biases and making sure that the data set is broad enough, bigger and more diverse data sets will help reduce the bias and risk, bias risk, right? But it has to be balanced with proximity and security, the other principles that we really, really care about, right? If you wear the sort of customer centric hat, I think a lot of the times what I tell my team is put on your customer hat. What is your experience going to look like if this happened to you or if you were using this, is this consistent with your expectations on what it's doing and how it's performing? Is it seamless? I mean, we briefly mentioned the whole scraping concept, right? If I go to sign up for a personal finance management website and I want my financial information ported into the single place, if it doesn't happen, then my experience is broken. I would wonder, okay, why did four of these financial institutions port my data but this one didn't? It may be that because that institution thought that the PFM tool didn't have the right level of security but how do we bridge the customer expectation, the customer desire, customer consent with all of these other competing and very important considerations of security, of meeting legal obligations, right? Which is also very, very important to companies. So we have to think about it holistically and we have to make sure we apply the various different filters of the lenses. Maintain and test for anonymity. I mentioned this briefly before but we have to ensure that if, let's say, there are training models that are being performed and that are being developed, let's say for example, about KYC Know Your Customer, fraud protection. These are incredibly hard to do but these are also very, very important to protect the customer. Imagine a world where you can sign up for a mortgage. I think the process of buying a home is so, so painful or selling in fact, you have to provide so much information that I am like, oh my goodness, what else do you want from me? It's like I have to tell you not only what else you need to know. But imagine if we could build as algorithms or smart ways to be able to better understand the seamless experience for the customer in going through these types of experiences. I think it's going to be really important but utilizing that data is one thing but you don't want that data to come back to the particular person. I call it the creepy factor, avoid the creepy factor. And make sure that you test for reverence to engineering, de-anonymization and otherwise the potential for exposing confidential information. Because if let's say a string of data sets would reveal something about somebody and without my name on it, it's a whole different story than if that data set had information and then it said it's about Christie. Or it is so specific enough that somebody so easily can identify that that's Christie. And underlying all these principles, there is protection. We need to think about appropriate protections and security measures. And this is a topic that I think you've heard several times today. But I think with the evolution of the data and the technologies, the concept of safeguarding is evolving as well. It has changed, right? Before we were worried about intruders and hackers stealing our identity, our credentials, financial data to create fake accounts. And if you look at our state breach notification requirements, it is usually, in majority of the cases, it's like name plus, like a financial instrument. Or name plus something sensitive. But think about what we all spoke about today. Think about the large scandals of this year. It's less about the name plus the financial instrument, but it's really a tangible concern around our digital identity as a whole because it's not just piecemeal. There is so much the ability to combine all this information. Whereas before security almost presented a more tangible concerns over privacy. I think we thought about those separate, largely separate. It's privacy, it's a data breach, cyber security breach. But the concerns are broader now. And it brings in concepts of privacy and security together to think more about digital identity as a whole. And requires for responsible use and protection of our data. And these principles, by the way, are not new. You've all heard of these before. But it's evolving with increased data, with enhanced technologies bigger and more reliance and dependency on these technologies that can influence us. We have to create a culture of responsible data use. And it continues with these conversations. And not just companies alone, not just regulators alone not just policy makers alone. These conversations not just students and academics alone. This has to happen collectively. We have to be in the same room. We have to talk about it together as technologists, as customers, as regulators and people who care about not only our data, but the impact that it can have on our society. And we need to continue to innovate. But we also have to have ethical and responsible data practices and continue to figure out what that means and how we do it. I think we've spoken a lot about the challenges, but it's hard to think about the solutions. But we need to continue to have these conversations in order to think about the how aspect of ethical and responsible data practices. Thank you. I think we have time for questions, correct? Hi, I'm Sharon O'Hellern from Columbia University. Sure, Sharon O'Hellern from Columbia University. One of the ways in which there's been tracking of very large quantities of complex, almost realistic data from multiple disparate sources that has been done over decades has been through SIC codes and through customs. And using same types of technologies is actually where it gives you unique identifiers that can be traceable throughout global supply chains, which is absolutely necessary, is very similar to the types of flow data that you have here. So it's not a cultural problem, it's actually a logistical processing problem that you need to have a common source identifier. And once you had the SIC code custom, right, unique identifier that was the regulation that was standardized, customs and tracking and global supply chains and all those other types of things that flow became quite simple. Not simple, but it was tractable. So using the same types of identifiers within a stamp, if you will, on the types of data, you can classify data into two digits, right, you know, something very large, somebody's financial data, somebody's personal data into those, and then it can go all the way down to 20 digits in describing the types of data, right, and then a combination of that could provide the unique identifiers. So that's how customs and goods and services from unique places at times and products are classified. And because that's important, because they're giving a different type of tariff, right, so they're treated in a different way. And that's why you need to have that. So this is a standard problem that can be solved in a similar way. I just wonder why we can't apply these types of standardized applications here. It's known. Throwing that one out. Yeah, no, thank you for that. And I think, you know, in terms of solutions, right, what we are finding is that in different situations it is truly unique, and so there isn't, there doesn't seem, and I would love to hear from other experts here, but it doesn't seem to be a one size fits all type of solution in data management, right, and it's really one solution for one purpose may work, and that may not work in other situations. And so contextual understanding is, I think, and contextual information, I think it's what makes this problem even more complex to solve. A lot of the times, you know, when I talk to the developers, they're like, this is not personal data. And then you say, okay, but what about this and then this right next to it? It's right next to it. It's in the cell that's next to this information. If we combine that, like, do you know who that is? Oh, yeah, of course. But, you know, so it's really hard to be able to I think organize and make me utilize a single sort of shop one size fitting the solution. So what you just said was that each line would be treated in a different way by a regulation, and that who has access to that data would be treated in a different way. Once you have it in that format with the identifier, it could then be subject to a different type of intervention. That's a different question than this type of encoding. And whether that be textual, whether that be numeric, it can be done. So that, again, is a known problem. So those questions are independent of this. Maybe one more question. What do they say is people were adopting Venmo and using emojis? And what is it useful as a data source? How is it useful as a data source? That's a great question. And when we actually tie the way that emojis are captured and how people use those emojis, right? It's tied to the transaction. It's tied to the person. Exactly. So what does it say? It says that... Or is that personal data? It's personal data in that it can identify who said it. It could also be the utilization of analysis on what people are using with their money. It can identify that from the emoji usage could be, right? Proprietary information. But I can tell you that people love the emojis. I mean I think there's probably contest or purposely people not trying to use any words and just going through the emojis adoption. So very popular feature. For everyone in the world to view. So what's the responsibility of PayPal? So the emojis, that's a great point you raised. The emojis are available for people's view if you make it public. Right. So I understand that the default is always public. Which is a bit of a pain for me. I always try to... I'm not a very public person. I would try to make it private. But a lot of people they just don't care to share. They want to share. And you and me both, right? So I think when we start to talk about relevant notice, right? Transparency. I think this comes into play in that we need to make sure that when a person signs up it could be the default feature, let's say. But bring it up. When you first sign up for that product or when you first open the app you can say, hey, these are generally default public. Do you want it this way? Or do you want to keep it between the trans users? And those are types of sort of adoption in creating more transparency that we are adopting for. Because you're right. It is default by that. But we feel like we still need to tell you, right? And so that people may not know. And so how do we elevate that? And to say, hey, this is generally public. If you don't like it then you can change it. Thank you so much. Thank you. Thank you.


If other faculty were to approach me and ask me, should I use a simulation course? I think first and foremost, like any other course element, you have to ask yourself, well, why am I doing this? How is this fulfilling the goals of the course? I teach business, I teach marketing. It's very rooted in decision-making. It's very rooted in analysis. And so a simulation of this nature is extremely helpful. If there are good simulations for courses that stress other aspects of what we learn here at the university and it meshes well and it has value for the students and it is a good use of time, absolutely. It's different. It's not just the students sitting in their seats and the professor standing at the front, whether that is a lecture or a discussion or a case analysis or a role play or debate or anything like that. It takes them outside of that context. I'm a big believer in group work because that is what people will be largely doing when they leave university, regardless of the field they go in. I am a big believer in tying classroom outcomes and classroom activities to what people are gonna be doing when they're outside the classroom because there's a little sense in employing pedagogical tools or techniques that bear no resemblance to the so-called real world.


Good afternoon. Welcome to Asian Review. I'm your host, Lily Ong. It's nice to be back in the studio. Happy New Year. Today we're going to talk about the healthcare system of America and compare it with the healthcare systems overseas. There's no better person to talk about this with than Ms. Dr. Christopher Flanders. He's the Executive Director of the Hawaii Medical Association. Welcome to the show, Dr. Flanders. Well, thank you for having me and happy New Year. Thank you. Thanks for being here. Dr. Flanders, out of the 35 OECD countries, 32 of them have introduced universal healthcare, but United States is not one of them. Before we get your thoughts on what you think of universal healthcare for America, could you give us some background to the current state of the American healthcare system? So as everybody knows, we've been having this discussion for several years that everybody felt that the American system is in trouble, is broken, and that we can't continue to spend the amounts of money that we're spending on healthcare. About 16 percent of the GDP of the United States goes to healthcare, and that far exceeds what any other country is spending. So we really, it's obvious that we really need to do something to bring down those costs and to get spending under control. When this has been going on, there have been several attempts at doing this, as people probably have heard in the discussions, that going back to the days of Harry Truman in the 1940s, there was an attempt. And again, in the 70s with Richard Nixon, and again in the 90s with Bill Clinton, and then, of course, when Barack Obama came in in 2008, this was his top priority to reform the healthcare system in some form or fashion. Were they all trying to bring it closer to the universal healthcare system? That certainly is part of the discussion, or was part of the discussion, and continues to be. There was a lot of attention paid mostly to the European countries, and in Canada as well, because that's part of the culture that we're familiar with, and most people in the United States are familiar with Europe, and a lot emigrated from there, of course. Canada is a single payer system, is that right? Yeah. Canada is, yeah, it's a single payer system, although each province, each province, which is their equivalent of the states, sets up their own system. But it's all regulated and administered by the federal government in Canada, and a lot of states are that way.  Universal healthcare simply means that everybody has insurance, and that they've got coverage for illnesses. Single payer means that all comes from one source. You know, the other option is that... And when you say all comes from one source, it could be from the government or the individuals, right? Yeah, it could be from government, it could be from individuals, it could be from employers, but somehow then that has to be fixed at the price side, so there's not a lot of competition. The other option is just the mandate that all employers supply insurance similar to what we have here in Hawaii, or that all individuals purchase insurance like they've got in Massachusetts. Well, we do have a legal mandate right now that Americans are supposed to have health insurance, or they pay a penalty, but despite that, that's about 26 million that are uninsured, so is there no oversight in the mandate? Yeah, the oversight is supposed to come from the Internal Revenue Service, and they've been spinning their wheels trying to get that engaged. If you notice that on your tax forms, there's a spot in there that has the amount that's been paid on your health insurance, or whether or not you've participated in health insurance, so there is that mechanism, but the enforcement hasn't really been there yet. I'd say. So when I look at the Obamacare, I think that was the closest America ever came to having health care, and then when Trump came on board, he was trying to repeal Obamacare, but with Trump care, it would actually put 20 to 40 million more people out of insurance. What do you think about that? I know eventually it did not go through. What are your thoughts on that? So people having insurance and having access to health care is one of the priorities of physicians, and that we feel very strongly that everybody needs to have access to good quality health care, and if that's getting through insurance, we're all for that. The whole Trump thing about doing away with a mandate, I think it's more about political philosophy than it is about a working combination to have everybody get access. So we didn't really like that, and a lot of the reform propositions that were put forward in the United States Congress, the American Medical Association, of which I sit in their house of delegates, we oppose those just based on that, that we feel very strongly that everybody needs to have access to quality care. And when we look at the World Health Organization ranking, and even the ranking by the Commonwealth Fund, America was ranked last in the Commonwealth Fund ranking. They were looking at 11 developed countries, and even in the World Health Organization ranking where there's 195 countries being looked at, America was ranked number 37 overall. What are your thoughts on that? Yeah, and that is part of the concern, of course, right? Do you think much about those ranking today? Yeah, I think we have to pay attention to those. We're spending more money than anybody else. You would think we'd be at the top. And a lot of that is the access issues that we have pockets in the U.S. where we don't have good access to health care. And Hawaii is a good example. We've got, because of our island state nature, we've got a lot of people who live on Hawaii Island, myself included, that don't have convenient access to health care. Are you referring to geographical transportation issues? Yeah, geographic and just having an even distribution of physicians in the rural areas is one of the other concerns. So we need to work on a system that not only brings down costs, but increases access. Is the government providing any kind of incentive to get physicians to work in suburban or rural areas, just like they do with the teachers in America? Do they do that? Yeah, you think that would be part of the formula, right? But as long as I've been in medicine, it's been kind of a long time now, that's been part of the decision. Why don't we incentivize? Why don't we take Medicare dollars and Medicaid dollars and pay the rural physicians a higher rate than the urban physicians? But the truth is that it's usually the reverse, because the cost of doing business is higher in the cities than it is out in the countryside. So that incentive part of it isn't there. Now, it's common to have some state, primarily state-centered incentives. Like here in Hawaii, we've got a guaranteed student loan forgiveness program that if a physician graduates from medical school and goes and practices in an underserved area for a given period of time, say five years, then the state will forgive those loans. And those have shown some promise and some success. Was Hawaii the first state to do that? No, that's been fairly common. And actually, we had to work kind of hard to get that program put into place. Those programs have been around for quite a while. It used to be that there was the National Health Corps set up where, and you remember the show, Northern Exposure, where it was the young doctor who was put in this small town in rural Alaska. And that was part of that whole program to pay off the loans. And so it's those kind of things that we really need to implement, I think. And is the funding for those programs coming from the state side, Laura? It's kind of a mix here in Hawaii. There's a grant that we receive from the federal government that is a matching grant. So every dollar that the state puts into it, the U.S. government will match that. So it's kind of a partnership on that. Now, would you agree that not just not only do we need more doctors in rural areas, we need more doctors across the board? Do you think we need that? Yeah, I think we do. The studies here in Hawaii have shown that even Honolulu is short on positions in some specialties. And if you agree with that, may I ask, and correct me if I'm wronged, why would the American Medical Association advocate for a cap limit on the number of doctors? Oh, I don't know that they are advocating for it. Oh, medical students. I'm sorry, medical students. I think there's a cap limit on that. Now, you know, we've actually, the last few years, have been advocating for an increase. And not just in the number of students who are in medical school, but what's probably more important at this point is the number of postgraduate spots that are available. And those are the spots that train this, not just the specialties, but family practice, internal medicine are considered specialties, but their primary care specialties. But there aren't enough of those spots for every graduate from a U.S. medical school to be able to do that.  And as you mentioned, United States spent about 18%, 16 to 18% of the GDP on healthcare costs. Do you think the massive, I'm guessing it's massive, the massive insurance that comes from malpractice plays into that entire cost calculus? Because America is such a litigious society, how big of a chunk is that coming from malpractice insurance costs? Yeah, malpractice insurance does play, or not just the insurance part of it, but the response to the threat of litigation also plays a part. And most people have probably heard the term of defensive medicine, where tests that might not normally be ordered get ordered just so they can protect themselves in case they're sued. For example, somebody comes into the emergency room with a headache. They may get a CT scan, a CAT scan, or an MRI, just to rule out that there's not a bleed in the head that's causing the headache. So there's a lot of maybe unnecessary or preventable procedures that may not have happened? Well, yeah, it's all how you define necessary and unnecessary. And in the system that we have now, we spend a lot of time and effort arguing necessary versus unnecessary testing. What about giving the choice to the patients? Are they well informed enough to decide, you know, should I proceed with such a procedure or not? You know, it's an interesting thing that health care is probably one of the few areas where if you as a patient are going to make a substantial investment in money and something that you don't ask questions like that.  But if you go to a surgeon and the number one, the questions aren't ever really asked about, you know, experience and success rates and those kind of things. But because of the absence of deductibles or co-payment, they are less, I guess, prudent about spending. Yeah, I think that a lot of patients don't have skin in the game, if you will, that they do pay a little bit. But the co-pays that we pay in the United States are less than what a lot of countries pay in their co-pays in the countries with so-called socialized medicine systems. So they don't really have a big investment other than their personal health. They're financially not a big investment paid. So they don't feel like they're pushing to ask those questions. There's been talk about different ways that we can have some kind of patient investment in their own health care and, you know, either with positive reinforcement, with rewards for doing, you know, appropriate behaviors or stopping inappropriate behaviors, smoking and so forth, losing weight. Yeah. Well, thank you so much, Dr. Philandes. We're going to take a little break here. And when we come back, we're going to compare and contrast some of the health care system in the world with America's system. Thank you so much. Hello, everyone. I'm Desoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech Hawaii every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech Hawaii. Aloha and Richard Concepcion, the host of Hispanic Hawaii. You can watch my show every other Tuesday at 2 p.m. We will bring you entertainment, educational, and also we tell you what is happening right here within our community. Think Tech Hawaii. Aloha. Aloha, and welcome back to Asian Review. Today we have with us in the studio Dr. Christopher Philandes, who's the Executive Director of the Hawaii Medical Association. And he's here with us today to compare and contrast the American healthcare system with those overseas of similarly developed nations. So Dr. Philandes, this country is, to put it positively in a positive way, is equitably polarized. So when liberals look to, you know, look for examples to support their destiny for universal healthcare, they can look to Canada, which is a single-payer system. They look to France, which is a multi-payer system. They can look to the Scandinavian countries, and they can even look to Germany, which is a hybrid system. Could you share with us what are your thoughts on some of the, you know, European systems? There's a lot of attention paid for that. And I think that primarily that attention was geared at the European areas rather than some of the other areas. That's where kind of this whole socialized healthcare system started. Norway started there. They were the first country to try this, and they did that in, I believe it was 1912, sometime in there, about 100 years ago. A lot of the European countries, and I think almost all of them now have gone that route, they've done it different ways. In some nations, it's the federal government that administers and runs through payroll, tax, and those kind of mechanisms, the cost of paying for healthcare. In some countries, there's a mandate either to the employees or to the employers that they supply their own or their workers' healthcare. And how are they doing financial wise? I imagine that's a huge financial strain. I know Britain is a truly socialized, you know, has a truly socialized healthcare system, but they are sort of collapsing under the financial strength. Yeah, they are. You know, we're having trouble with trying to control the rising costs of healthcare, but every other country is having problems controlling their healthcare costs too. It's not something that's unique to the American system. The healthcare inflation is worldwide. And a lot of that is geared because of the increasing technology that we use in healthcare, the things like the sophisticated studies like the MRIs and the new PET scans that are kind of nuclear-based, those aren't cheap. And so those have all cost money. And unfortunately, when they do the ranking, they don't look too much into those innovations. They do take a take at it. And they compliment the U.S. on innovation and medical technology that really benefits citizens across the world. But there's other issues they look at like accessibility, qualitative care and outcomes and so on and so forth. Yeah, those kind of things are hard to quantitate. So I think that unless it leads directly to improvement in longevity or increased quality of life that's measurable, that it doesn't get a lot of attention. And but those are things that every country is trying to deal with, as to how we control the overall costs of healthcare. And like you mentioned, Britain is, my wife and I went to London last year and we met with a couple of families from Britain. And they all remark that Britain is billions of dollars in debt and paying for their healthcare system that it doesn't pay for itself, even with the taxes that are charged. And of course, nobody wants to pay more taxes. So they're trying to struggle with that. And Norway is highly socialized too. Do you think it's because they are supported by their massive oil reserves because they have money coming from other sources to support that kind of system? Yeah, it's absolutely oil in Norway. Yeah, the way they've got that set up is that, you know, this kind of off on a tangent, but the federal government owns the oil fields and they contract with the oil companies to pull out the oil, but the oil belongs to them. So all that money comes into the country and that's used to pay for healthcare and a lot of other things. It's really a very progressive and interesting nation. We know the French system was ranked number one among the OECD countries. Is there any good from the French system that you think we could take and implement it here? You know, there are a lot of the ideas about the access and the ease in getting into the healthcare system because as we all know, the healthcare system is difficult to navigate once you get in. When things happen, they tend to happen fast and they tend to progress very quickly and people end up just getting swept along with the flow of the healthcare system, whether it's in a clinic or in the hospital. France, I think maybe has a better grip on that. Their costs tend to be fairly low and I think that's because the prices get set a little bit tighter and that's where a lot of the countries have focused their attention now, is some central mechanism to fix prices. Japan, if we move over to Asia, for example, if I could interrupt you just when you said the intervention on the prices, are they trying to fix the prices on the insurance products or prices on the medical system itself? Yeah, it's kind of both. It's not so much on the premium side, although that probably comes along with it, but on the payment side, for example, I was going to get into Japan, it maintains very tight control over their fee schedule. So even though people might have different insurance companies that are paying the physicians in the hospitals, all physicians in all hospitals get paid the same for the same procedure. So there's no competition really. It's single payer even though there are multiple companies that are paying. And then what they can do, what the federal government in Japan can do, is that they can regulate the budget by adjusting that fee schedule up or down. If they've got a tighten up on the amount of money that's going out, they lower that fee schedule. So earlier we talked about some of the examples, you know, the liberals will look to, I like to measure examples that the conservatives frequently look to besides Japan and that's Singapore. Have you heard much about the healthcare system? No, I don't know that much about the healthcare system. I know that they've got a socialized program, more or less, in the universal system, but I'm not that familiar as to how that's set up. Yeah, well, I'm from there, so if you don't mind, I'll share with you. Yeah, no, absolutely. I'd love to hear it. So the conservatives sort of held that as the, as the gold standard. In fact, Fox News was advocating for America to copy Singapore, you know, healthcare miracle. So in Singapore, it's based on three ads. That's the MediSave, MediShield and the MediFun. So the MediSave is a mandatory health savings account. Every Singaporean workers have to contribute 7 to 9.5% of their wages into that account. And this is, this pays primarily for routine care. And it pushes the customers to look at routine care as a product, just like when you buy your shoes, when you buy your bag, you would think before you pay, versus you were giving a good example about how people in America, they don't ask those questions. They would just go with the procedures that's being recommended by the doctor. But in Singapore, because it's coming out of their own pocket, essentially, they would inquire, is this necessary? Why am I doing this? And then we have the MediShield so that when they hit the deductible, they can move on to the MediShield and that will cover, you know, the additional cost. So everybody has MediSave and MediShield is optional. We're automatically enrolled, but it's optional. You can opt out of it. And that's also a safety net, which is the MediFun. And that is funded by an investment income of a $3 billion endowment. So we don't touch the principle. And for 2018, we were just using the investment income from 2017 to pay for those who absolutely cannot pay. So it's sort of a payout of last resort. I know that America has sort of been looking at the Singapore system as well. Do you think such a system, based on just, you know, how I briefly described, do you think such a system will work in the United States as a mandatory health savings account? You know, yeah, I'm intrigued by that idea because prior to the Affordable Care Act, there were states that were developing the medical savings account systems. And I had one for several years. And it actually worked pretty well because it's a high deductible insurance company, meaning that you would have to pay the first amount of, you know, $3,000 or something of your health care. But you could also contribute a matching amount, so $3,000 into a savings account that you could use to pay that. Now, you know, that kind of puts skin in the game for patients. Because when they go in, you say, now all of a sudden, they've got to pull out the credit card that the bank gave them that has all the money that they've been able to save up. And they know how much that money is. And they want to know how much money is going to come out if they decide that they do want to go through with, you know, having this mole excise from my neck or whatever it might be. And so you start getting this give and take. And, you know, I think that's a good thing. I think that that more patient engagement, we get the better off that the system will be. I think you hit the nail on the head when you say gets the patient skin in the game. And Singapore system is truly the only universal health care system that gets the patients to pay for the chunk of the health care cost. The government actually pays just a quarter of the patient cost in the country. Yeah. So instead of having the insurance pay for most of the cost, which is evident in Western Europe and United States, their patients are one that pays the larger chunk of the cost. So they are forced to take responsibility for their own health. I want to talk a little bit about the pharmaceutical cost because I know that skyrocketed in United States too. Why does Medicaid prohibit? I mean, there's a lot that prohibits them from negotiating down the prices of the pharmaceutical products. Why is that? You know, I don't know what the history of that is because to me and to a lot of people, that just doesn't make any sense. We negotiate on the price of everything else. You know, why is there such a carve out? I don't really understand. And there's been a lot of attention paid to the cost of pharmaceuticals as a whole as to the last five, six years or so, especially the price of pharmaceuticals is just skyrocketed and even on drugs that have been around for years and years. And, you know, we asked the pharmaceutical companies, you know, what's going on here? Why is this happening? And, you know, I don't know that we've really been able to get a coherent answer as to what that costs. But that, I mean, if you have to point a finger at things, you know, that's probably one of the things that we need to take a look at. Do you think the doctors should bear some of that responsibility too? Because I know that pharmaceutical companies will sometimes woo doctors with incentives. They send them to resorts, expensive dinners, gifts like that. Is there any ethical oversight as far as, you know, where does the line stop? You know, that doesn't really happen. I mean, that may be used to happen, but now, for the most part, if you're going to go, it used to be that they did training for physicians and we'd be able to get our continuing medical education at programs that were paid for by pharmaceutical companies. And that's kind of disappeared. The, you know, the vacations and those things haven't been around in my time in medicine.  But, you know, pharmaceutical companies still can be an important source of information on new drug developments because there are questions that we need to ask about effectiveness and efficiency of drug regimens that only somebody associated with the pharmacology industry would know, particularly. So, you know, I think there's still a role in there. You know, there's never a kickback. There is never a, you know, we don't get paid for prescribing certain drug or whatever. And as I hear that periodically, and that's just not the case. I'm very glad to hear that. Well, Dr. Flanders, thank you so much for being with us today. I wish we have more time, but we'll come to the end of the show. Thank you for having me.


I'm Gunner Sergeant Timothy Erickson. I'm in 06-88 currently. That was the Cyber Security Technician MOS. So the new occupational field is the 1700 occupational field or 17xx. There will be two primary MOSs within that field, the 1711 and 1721. The 1711 will be the offensive cyber operations marines and the 1721 will be the defensive cyber operations. So on the defensive side, what we're mostly looking for is either the presence of or recovering from the effects of any type of cyber threat, whether it's a computer virus or degradation of service based on some sort of cyberspace threat. So we're looking for those types of threats or mitigating the effects of them or recovering systems that have been affected by one of those types of threats. On the offensive side, what we'll be working on is, you know, trying to find and exploit vulnerabilities and systems to our advantage in the cyberspace battle. As of the beginning of this month, all the marines in the 06-88 MOS were individually assigned a new MOS. So there was a cadre who were assigned to the 1711 I MOS. There was a number of marines who were assigned 1721. And then there were some who were assigned 0679, which is the cyber network operator or cyber network chief MOS just based on the needs of the Marine Corps and input from the Marine's chain of command. So there are already movements taking place. So going forward, the goal is going to be to get to those staffing levels that we need in each of those MOSes and make sure that we're not taking too many marines from the traditional communications side of the house and moving them over to the cyberspace operations or, you know, neglecting the needs we have on the cyberspace side based on, you know, a desire to make sure that we have the cream of the crop over there. So what we're trying to do is find a balance right now. And then going forward, we're going to look for highly qualified marines who have a desire. It really boils down to aptitude and initiative. We want marines to have the aptitude to figure things out for themselves within the cyber environment. And then marines with initiative to, you know, take it upon themselves to continuously learn and grow and build their knowledge in that.


Hello everyone. So this is just a quick, well a public service announcement let's say and I just wanted to point out something that might affect you if you're looking for jobs if you're looking to be hired by translation agencies and also because stuff like this occurs every now and then so I wanted to bring it up and just show you how I deal with it and basically what happened was I came across this article it says federal court tosses lawsuit over forced company sale and as far as then I could I can understand what happened is there's this company called Transperfect Global which is it was set up by this guy Philip Shaw and his former fiance Elizabeth Elting and what happened was they had a fight you can see it says former fiance which means that they are not together anymore and this probably you know they had personal problems which probably kind of came to be reflected in the business itself so I mean the article here is just saying they tried to appeal or I guess to dismiss the lawsuit or sorry they had a lawsuit challenging the judge's decision and that lawsuit was dismissed by the federal court in essence upholding the judge's decision before because their relationship had become dysfunctional again why why do you care right you know this is semi interesting because it's the translation world but why should we care in our day-to-day lives well because this might be a company that we might have to do within the future or might try to hire us you know it might still be in business this company and so we suggest kind of keep it on our radar what I like to do in this situation is go to the blue board of pros the blue board is where they keep track of the job outsourcers basically the translation agencies the people that hire translators this is where they keep track of them and so if we insert the name Transperfect there we go we get a couple examples I'm going to go with this one because it has 151 entries and seems to be the biggest one so you know if we click on here then we can see I had an average of 3.9 which isn't that bad remember it's out of five though so it's not all that good either and here we can just look at the entries they have now the top pinned entry remember it's pinned by the company so I mean you know don't put too much stock in that but here we see the other ones and we see four one two two three three you know we see one five otherwise two one another five three two five five five and and there are more fives but still lately they've been having quite a few issues it seems most of these things you know if they don't have a five they should have a reason for not having it and and if you compare it to any other company you'll see that most of them tend to have fives see even here with a four he says steady provider good pms only hitches very bureaucratic payment system simply not worth doing small jobs for them you know so already there's something wrong with that every now and then you'll get a one or two because someone's just mad look it's like yelp or anything like that right but usually it should center around you know on the high end what you know people if they're going to give a score they they usually like to give it on the high end and if they have a problem they'll tell them personally and that's how people usually deal with it so these are a bunch of red flags i don't know if this has anything to do with what's going on in the article but usually when i see an article about a company having problems i like to search for it and then you know see what's going on with the company itself on on the blue board and here let me give another example of a company i had problems with in the past and it's this one intertrado and you can see their average lwa is very low here very few entries i'm pretty sure they're out of business and i'm hoping that fact is reflected here yeah outsource has been banned from posting jobs and pros dot com because they've just been i mean completely crap and uh they in fact someone unfortunately relatively recently did something for them i wrote a bad review for them because i had problems with them and uh since then yeah she had someone write a very good review but i'm you know i don't know i don't know who that was anyway she was a crook and um and so a lot of these things will be reflected anytime you deal with any company actually it's a good idea to look them up on this blue board and it'll give you a good idea of what you're dealing with unfortunately this person right here if she or let's see this person sorry um if she had looked up the um this company ahead of time she would have seen all these negative ratings which you know hopefully should have helped her she carried out three translations and didn't get paid so you know that's not nothing anyway long story short whenever you come across the name of a company whether it's in the news or anywhere else just a reminder to look them up on the blue board and you know to get a better idea about that company and whether you should be working for them or not and what problems there might be so i hope you found this useful if you do please don't forget to click like because i really do appreciate that and um and don't forget to subscribe if you want more videos like this in the future dealing with freelance translation and freelancing in general otherwise i'll talk to you in the next video thanks bye