Can you hear me better now? Yes, so food, good food, has very calming effects sometimes. They can put us in this half-asleep state. But this is a really fascinating topic in this panel. And we have equally fascinating experts on this topic. And the topic is Russia's increasing activity in today's media sphere, and how its propaganda at the intersection of the domestic and the foreign policy level actually tries to shape the international political landscape to its advantage. There are some really, have been some key developments recently, and we've got two experts who are going to enlighten us on that. First up, we have Mr. Carl Wilson, who's an annual alumni who graduated from the annual first class on his degree in Russian language. Yes. And he's got an outstanding expert knowledge on all things Russian, including the language. He's had a distinguished career and DFAT and worked for ONA as a senior analyst, as well as served as the official Russian interpreter for Australian heads of state, including prime ministers and ministers. And having heard Carl speak before, we're in for a really exciting presentation with lots of audio-visual material. The last time, we had some very interesting shirtless shots of Putin that were bringing those more theoretical points home. So Carl, the floor. Thanks, Katja. If people can't hear me, could they please wave or shout? Knowing that I'll go over time, I'll try and just give you very briefly my main message right now. I want to leave a few points with you, which I hope are of interest to you. The first is that my assumption is that Russia is fighting an information war on two fronts, domestic and the foreign, but they are the same war. Those fighting this war are the legates and draw on a very rich tradition of the Russian state and its handmaiden, the church, using images and words and suppressing other images and words, especially those of foreign origin, to try and influence the attitudes and behavior of the peoples of Russia. This tradition goes back centuries. And it's closely entwined in Russian history with a tradition of trying to neutralize and negate the influence of ideas that come from what Russia has called and continues to call the West. Third point is that this tradition was refined during the Soviet period, and especially in the first decade or so following the Russian Revolution, the most successful and effective form that this effort took was, in fact, the cinema, Soviet cinema. During the late Soviet period, this information war was prosecuted by a very large infrastructure that included the Central Committee of the Communist Party, its Department of Culture, the Ministry of Culture, the Ministry of Foreign Affairs, something called the All Union Znanya Society, which was the All Union Knowledge Society, and, of course, the KGB. Soviet friendship societies abroad were important, as were political parties outside the Soviet Union, sympathetic to the Soviet Union. And the final point would be that, as in other forms of war, Russia's autocratic political system, with its capacity to concentrate resources on strategic goals and to sustain the flow of those resources, is one of the advantages that Russia has over its adversaries. Now, the quality of this information activity or propaganda, some of which I hope to show you today, is something I'm not going to judge. I thought Bill Maley's point about propaganda boomeranging was one very well made. And if you'll forgive me the personal anecdote, when I was a student in the Soviet Union, one was aware everywhere of what were called slogans. All through the streets and on buildings, you would see these large slogans sometimes in neon red letters. And these were part of the effort to inculcate certain ideas into the Soviet population. And one I remember I saw in St. Petersburg, which was then Leningrad, it was a large slogan in huge red letters, and it said, Our target is communism. But the propaganda planners had forgotten that they'd put this slogan on top of the Leningrad Artillery School. Let me see. OK. I wanted to give you this quote from the present Russian Minister for Culture, Mr. Medinsky, because it seems to me it encapsulates very well an attitude which, as I've said, has a long history in Russia, going back to the time when Russia first emerged as a state after it emerged from the Mongol Empire, under which it was a part for 230 years. And if you wouldn't mind just taking that in, this notion that if we don't influence the way people think, someone else will. And that will be very much to our disadvantage. Now I wanted to show you, let's jump straight into the trenches of the information war, and I'll show you a typical contemporary Russian product if I can. During the three months of armed clashes in the Donbas region, the key of authorities have not been able to quell the uprising of the People's Militia. Inept command, thousands of dead soldiers, and a critical shortage of funding does not give the Kiev regime any hope of winning. Kiev's appeals to NATO for military assistance were ignored. So far, the conflict in the east of Ukraine looks local, and the attempt to provoke Russia into a war with Ukraine did not work. The next attempt from Kiev was the shooting down by the Ukrainian military of a civilian aircraft. The responsibility for this terrible tragedy, even without having started an investigation, was put upon Russia, which supports the People's Militia. Such a crime was necessary for the Kiev regime to make this conflict international and to show the whole world that the People's Militia are the international terrorists. The exposure of this fabrication by the SBU fake militia's negotiation, as well as the hard facts provided by the Russian general staff, proved the involvement of the Ukrainian army in the plane crash. This provocative murder was carried out under the orders of Kiev and the American special services in order to draw NATO into a war with Russia. Why do Americans need this war? For improving their economic position. Just as they did in the First and the Second World Wars, the accusation of Russian aggression allowed countries to impose sanctions on it, freeze assets of the Russian structures, causing the write-off of hundreds of billions of dollars and ease the heavy debt burden of the United States. Broken economic relations with Russia are going to aggravate the condition of the European economy and weaken its position in competition with America. The destabilization of the banking system will encourage the capital outflows into the United States to maintain the dollar pyramid. The retraction of the European countries into a war with Russia is going to strengthen their political dependence on America, which will lead to decisions favorable to the United States rather than the EU. Thanks to this war, the American military-industrial complex will get many orders. The US economy will flourish. Meanwhile, weakened by the war, Russia will be easier to control as it used to be in the dashing 90s. Thus, after destroying the main competitors on the world's arena, America will get a strategic advantage in the fight for global leadership with China. In contrast to the EU and Russia's collapsed economy and piles of corpses, Americans will stay as winners. The war on foreign grounds is what has saved the economy of the United States more than once. It's safe to say that Ukraine will not stop the genocide of the Russian population, and their provocations will become even more horrifying. Sooner or later, Russian troops will enter the territory of Ukraine. But to avoid millions of Russian, Ukrainian, and European victims, the EU leaders must turn away from their overseas owners and admit that Russia does not only protect its national interests, but seeks to prevent the outbreak of World War III. Otherwise, the survivors of World War III are going to witness the new American economic miracle. Thank you. What you've just seen exemplifies the line that the Russian state-controlled media were taking in the 18 months or so preceding the presidential election in the United States in November last year. This line was essentially that if Hillary Clinton was elected, the planet would be plunged into World War III. The line was supported by quite a number of non-Russian academics in the Americas, in the EU and elsewhere, and by some US publications like The Nation and The National Interest, and it was supported in Australia by some academics and media commentators. I now just wanted to very, very briefly set the context. I was a translator interpreter and they'll tell you that context matters. And two points about the context. First of all, for the first time in its history, for the last 17 years, Russia has been ruled by, the best term I can use is a secret policeman, but it doesn't really get the Russian word. A secret policeman and his colleagues. This is unprecedented in Russian history. There was Andropov, but Andropov was essentially a party functionary. He was the head of the KGB, but he wasn't a career functionary of the KGB. So you have this group of men there, sometimes called the Securocrats or the Siloviki, they share an outlook, they are cohesive. I think it's not unfair, we should avoid emotive language, but I don't think it's unfair to call them a cabal in some contexts because they are shadowy, they are professionals, they are very good at secrecy because secrecy is their business. And they're very good at information warfare because that was their business too. They were taught information warfare. How good, I'm not gonna judge, the second point I want to make is that the context is that Russia has always had a strong martial culture. It's not alone in this of course, but I would submit to you that if you look at Russian history in the last four to 500 years as expanded out from Moskvy, essentially to the same borders as had been occupied by Chinggis Khan's empire with the exception of China, then for obvious reasons, Russia has always required and has had a very strong military. It has that strong military today. I think that tradition, I think it's fair to say that Putin and his colleagues have seen it in their interests to emphasize that tradition. That's context. The third thing I wanted to say to you was that, as I've said, Russia has a very rich tradition of using imagery and using words. Recently, a reputable Russian opinion polling firm asked 1600 Russians in face-to-face interviews, not over the phone, face-to-face, to rank the greatest people of all time. And in the top 20 were two poets, both Russian poets. In fact, Pushkin came in number two with the same number of votes as Vladimir Putin. Number one was Stalin. Number nine or number 10 was another Russian poet, Lermontov. My point is this, that in Russia for hundreds of years, to pick up a pen and write a sentence or to pick up a brush and draw a stroke on paper has been a political act. Pushkin has some very famous lines I wanted to quote to you, one of his most famous poems, the second greatest figure in history, there in the desert I lay dead until the voice from heaven said, arise, O prophet, work my will. Thou that hast perceived and heard on land and sea thy charge fulfill and burn men's hearts with my word. Well, burning men's hearts with the word was really, I suppose, what the German missionaries did in Northern South Australia when they translated the Gospels into Aboriginal languages. But the point is this, that in Russian, as Leonid Petrov could tell you, the old word for word was glagol. Today the word is slova, but it used to be glagol. And that's the word that Pushkin uses in his famous poem, The Prophet. Today glagol means verb. As Les Patterson would say, you can see my drift. Words are actions. Words have potent consequences, as Paul Keating knew very well. And now images. Images to our actions. And this is probably one of the most celebrated propaganda images in Russian history known to every Russian school child. This is Ilya Edipin's The Barge Hallers 1873, 74. This picture changed Russian history. This image was, I think, one of the factors, very hard to say how important it was, in bringing down the Roman of Dynasty. Can I point out to you here the young man in the very middle of the image taken by Russians at the time as an image of a protest against the Roman of Dynasty? And it seems to me probably no coincidences, Stalin would say, that today the Russian rulers are very, very concerned about the young people of Russia. And they're concerned about the young people of Russia because most Russians get their news from television. And television is controlled by the state. 70% of Russians say they trust television. 95% of television controlled by the state. But people under 30 are not watching television. They're watching their devices. And that is probably why Mr. Putin, who enjoys a genuinely high approval rating. I don't know if it's 80%, but it's genuinely high. And it's been much higher since the annexation of Crimea. Why would a man who enjoys an 80% popularity rating be worried about a single figure called Navalny, who's 41 years old and whom only one in every two Russians say they recognize? They're worried because they're worried about the youth vote. Let me go on a little further. I just wanted to point out to you, this is Sige Verkhovs, who in the 1920s produced a film called The Man with the Movie Camera. To this day, that film is considered one of the 10 greatest films ever made. And if the British Film Institute every 10 years has about 350 critics and 350 directors and 830 critics vote on the 50 greatest films of all time, there are at least six or seven Russian films in that list. And Eisenstein's Battleship Potemkin for many years was the number two film after Citizen Kane. Verkhovs' film, Man with the Movie Camera, is still in the top 10. The Bolsheviks understood the power of the image, they understood the power of the camera. Here's the, probably no greater, no more famous scene in the whole history of cinema than the Odessa step sequence of Eisenstein's Battleship Potemkin. So, I'm leaving ahead, I just wanted to show you this because this is the Russian institute, this is the Museum of Technology. It's actually on Lubyanka Square and it happens to be diagonally opposite the Lubyanka or the headquarters of the FSB. This was the headquarters for many years from 1947 of the All-Union Znanya Society. Until television came along, the Soviet state devoted a vast amount of resources to trying to get people to think in the right way. And it was the job of this organization, the Znanya Society, to get people to think in the right way. I know how they worked because in 1974, when I was struggling to learn Russian, I was asked to interpret for a Znanya Society professor who came to the ANU to enlighten us about the real, the realities of Russian, of Soviet foreign policy and I had to interpret for him, for a group of students. And it was, there was a rather ironical denouement because he was halfway through, he was a very nice man by the way, he was halfway through his spiel when a gaggle of Maoist students erupted into the room in the Hayden-Allen building and shouted him down. He could not complete his lecture. I just wanted to show you a couple of examples of the image in Russia today. So this is from a calendar which was on sale last year, really part of the personality cult for Putin and this is Mr. Navalny whom I mentioned, who is really the only genuine opposition politician to Putin and you see him, this is, if you look very closely, this is Moscow, so the foreigners have taken over Moscow, there is Mr. Navalny with all his luxury yachts and he's looking on. So in other words, what this is saying is that Mr. Navalny is an agent of foreign influences. He cannot be other than an agent of foreign influences because he opposes Mr. Putin. And Mr. Putin is Russia. As Mr. Putin's chief of administration said, Putin is Russia and Russia is Putin. So if you oppose Putin, ergo, you're an agent of foreign influence. I wanted to show you this one too. This is from the same collect, the same calendar. So here you see Putin hooking over the shoulder of Edward Snowden. This is the Putin he's dressed in black. Of course, the Russian KGB and the FSB has its origins actually in the Mongol Empire. The first man to establish a kind of secret police of a thousand people around him, they were called the Kashuk and they were black. The first Russian secret service, Yvonne the Terrible's Puritina, were black. So Mr. Putin is quite properly in black. And this brings to the black, wind and white snow. A very good book by a man called Charles Clover. And I think it's useful because Clover has summed up very, very well. One of the main, it seems to me, one of the main messages of the information war on the domestic front. Russia is unique, Russia is different, Russia is superior, Russia is under attack, Russia must defend itself. And I think if you asked Mr. Putin and his colleagues why the information war, he would simply say, well, it's what you're doing to us. What do you expect? I think that's what he would probably say. I thought it was important that Peter Grestor pointed out that this, another key idea, the idea that there's no truth, only lies.  This has been taken up with enthusiasm by Mr. Trump and his Caravanserai. I won't do that. Oh, by the way, that's the line of call on the greatest people in history. And so there they are. And that's the second power I mentioned you failed. I mean, it really says something about the culture where I think very positive that people decide that two of the greatest people in history are poets. Hard to imagine Australians deciding that Banjo-Patterson would. Well, there's Murray. I'll just whip through these rather quickly. Bob Agander, of course, has built many pointed out from work against those who actually created it. And this is a Russian cartoonist of genius called Yolking. And this, of course, is some wing of the two and Pika, Pika is Mr. Putin. And this is Syria. I like this one, too. This is Mr. Putin's press, folks, and that's the church. And there he is. I wanted to mention these two gentlemen to you because they're important in the Russian information campaign. This is Mr. Slavin, even though he's the grandson of Morgoth, he's the head of something called the Russian World Society, Ruskin Mir. This is a society which attempts to outreach, information outreach throughout the world. And on his left is a man well-known to me, well-known to the NE, Mr. Toleray, who was the consul general in Sydney for a while. I just showed him here because two years ago, Mr. Toleray was invited by an Australian, I think you could say, rather extreme right-wing group. The council for, what is it, the council for economic, for electoral... CEC. CEC. The... Citizens Electro... Citizens Electro Council of Australia. They're a rather odd group funded by the LaRouche organisation in the United States, and they're certainly not full of the love of their fellow men, as they say. But anyway, they invited Mr. Toleray to come and talk to them at the International Conference in Melbourne, and his theme was that Australia should become an observer, and ultimately a participant in the BRICS organisation. And Salve Nikolov is the grandson of Wallachov? He's on the third volume of a biography of his grandfather. Now, I wanted to get to this... I'll get that tablet to help me with this. I wanted to show you a recent documentary shown on Russian television about Australia. And it's on a program which is made by Anna Chapman. As you may remember, Anna Chapman, the time was... She's hot. She was one of the 11 people who expelled from the United States because they were sick, I think. Hello. I'm a Russian occupant. This is my profession. So it happened historically. So I'll give you a little bit of Anna, and then I'll just give you a few of the points that she made. The Cognito forest is a mysterious southern land. This country has been called for several centuries. It's still the biggest part of what we know. It's made up of solid myths for the eyes. What really is happening in Australia? A country that some politicians are pretty much based on is another US state. Australia. Summer 2017. It's always quiet and almost unnoticeable. In general, the country's information field goes to the first place in the most diverse ratings. It becomes the undisputed leader among the state in which Russian tourists stay for more than two weeks. Russians choose to rest on the green continent despite the expensive 20-hour flight. The flight back and forth is at least 70,000 rubles. Thanks for that. Give us two points on this. Um... ...the country has been burned from day to day, which that explains that Australia is a major source of ISIS terrorists. According to official information, 200 Australians currently fight for ISIS. That may seem like a drop in the ocean, but the numbers may be even greater. The Australian government is supporting terrorist organizations, including ISIS financially, and the film purports to explain our role in Syria, because we are... Well, no, I won't go there. Here's a few quotes for you. Life in Australia has become intolerable for many ordinary people because the Australian education system is inculcating into the minds of five-year-olds that homosexuality is virtuous. And so whoever did that, that piece of propaganda for, um, the debate of immigration that, you know, come to Australia and you'll lose control of your children, well, they're right. Um... The Australian treatment of its Aboriginal peoples is worse than Hitler's treatment of the Jews. I like this one. The British nuclear tests in South Australia led to the extinction of the Tasmanian tiger. It's there. It's there. It's there. Australian policymakers are slow to respond to global threats because they always await guidance from the United States. Um, it seems to me that what you can say about... This is a 45-minute documentary. Um, what you can say about this is it illustrates to me the effectiveness of marrying crude and often ludicrous falsehoods with quite plausible assertions. You intermix reliable sources, like the economists or Australian academics, with bogus ones. It's devoid of logic. It's devoid of coherence, but it exhibits visual and dramatic flair drawing on the traditional strengths of Soviet and Russian propaganda. It was shown on a notionally private channel called Ren TV, which is in fact funded by an oligarch. It's been viewed on YouTube 350,000 times. Thanks very much for your attention. Thank you so much. Thank you for the opportunity. Very fascinating and engaging. It's now my great pleasure to introduce Professor Matt Sussex to you. Professor Sussex is the academic director at the National Security College here at ANU. And he's an expert on Russian foreign and security policy, but his interests and knowledge stretch across a wide range of topics, including counter-terrorism, Australian foreign policy. And in particular, the evolving role of propaganda as a tool and part of hybrid warfare. Thanks very much, Katya. That was both generous and the crowd was generous as well. How can I possibly match the visual stylings of my colleague, Mr. Kyle Wilson? Absolutely impossible. I'm not even going to bother, to be honest. I shall just give you some random observations about the future of information warfare, which I have attempted to put into some kind of structure that you may find believable. And if you do find it believable, then it's effectively the type of plausible deniability that Vladimir Putin seeks to engender every time he summons up a new information operation. My topic today is to sort of extend the Russian theme a little bit further, but to look more in terms of what the future might be for information warfare. What's it likely to resemble? What types of threats are we likely to going to have to respond to? And I think we make an error when we look at Russian info-ops and to say that these are part of a very carefully calibrated strategy. I think there is a real difference between strategy and opportunism, which I would argue is what Vladimir Putin has been doing, but that he is particularly adroit at making opportunism look like strategy. If you look at many of the scholarly writings on Russian info-ops, then they tend to start with the Garazimov doctrine, which effectively says Russia is involved in total war. And in an era of total war, it is necessary to use all mechanisms at one's disposal in order to achieve one's objectives. The problem with that is that Russian capabilities in the information space are actually more modest than they would like you to know. They are very good at slick propaganda. They are very good at cyber. They are very, very good at various aspects of targeting small groups of people. Effectively, however, I'd argue that information warfare is warfare by the weak rather than the strong. And I think that picks up a little bit on the types of concerns that Russian feel, sorry, Russian elites feel with respect to the next generation of Russians coming through, that they are concerned just as much internally as they are with shaping expectations externally. Second observation I'd make is about another error that we make. And that error is to assume that information presented to achieve particular political ends always has to be benign. Now, I mean this in reference to the debate about soft power. Soft power, customarily, we think of as something that projects the best aspects of a society.  I'd argue that the Russian use of information operations is soft power as well. However, it's the dark arts of soft power. The concept said soft power is all about getting others to want what you want. But that misses the point, I think, that in contemporary information warfare it's all about getting others to reject what they have rather than want what you want. It is in fact unnecessary if you're performing information operations in many respects to have your target population echoing something that is synonymous with your policy. What is often more desirable is to have your target population echoing something that suits your interests in dividing a particular society. So what I'd like to do, first of all, is to have a look at what a coherent information operations or information warfare strategy looks like. Because it's often suggested that Russia's approach is like a fire hose. I prefer the metaphor of a sorenoff shotgun where pellets go everywhere in the field of the tactics, if you like, but not strategy. The tactics are to coordinate each of the pellets when they actually strike something and then devolve a campaign around it. I think the first aspect or the first criterion we would look at in terms of an effective information warfare strategy is of course social manoeuvring. And here the Russians have recognised that in liberal democracies you can get at least 25% that will be receptive to fringe messages. Or receptive to messages that provide easy blame for perceived ills. Now in the American context of course this was and in Europe as well these have been the critics of globalisation. Now globalisation was a lie. Globalisation through the European Union through open regionalist free-trading agendas was a grand promise that everybody would become wealthy but in fact it has made a small section of the population wealthy at the expense of others. You can use that message and then you can tie it to another one that says and guess what, you've lost your job and guess what, that job was taken by an immigrant. So it is highly useful and cheap tool to promote what is not necessarily something that is echoing Russian policy on a specific issue but it is echoing a goal that is fundamentally statist that is fundamentally challenging to the dominant types of norms or rules patterns of behaviour that are pursued by major political parties within the West, mainstream political parties. So social manoeuvring can reach a lot of people. As we know with the Facebook ads purchased by the Russians it is very, very cheap. With $100,000 you can reach 60 million people with targeted ads and the goal of course is also to create division. We have a situation now where we can see Russian bots dueling with one another. The NFL is an excellent example where you have bots that are busy saying defend the rights of oppressed black footballers to take a knee and at the same time you have bots saying defend the NFL for its crippling inability to crack down on the terrible behaviour of its players. Again, it's not necessarily to create any particular line it's to create division, argument, polarization and so forth. I commend to you the website Hamilton68 for those who aren't familiar with it which will allow you to track Russian tweeting more or less in real time and have the top hashtags and generally they are things like Civil War 2.0 they are Hillary and various permutations thereof but increasingly when it looks as though there is coherence and a lot of it is dictated directed around the White House and the behaviour of Trump increasingly when there is more coherence in the Trump administration you've seen things like Sack Kelly Sack Mattis of the political centre tailors very nicely with info wars with Breitbart and the Bannonites the right of the world. On its own I think social manoeuvring is unable to completely achieve the goal of, you know, harnessing a society's vote or completely disrupting an election. I don't think it's fair to say that Russia stole the American election away from Hillary quite simply because there are too many variables attribution is impossible and we will never ever know. But a coordinated information war strategy would then, I think link up with things like diaspora populations which the Russians have used of course in Crimea and in eastern Ukraine which serve as conduits quite particularistic ones they are only really useful for harnessing a specific ethnic constituency and the other reason you would use diaspora populations is if you were trying to control rogue voices within them and a good example I think is Chinese behaviour and online shaming of people who articulate Chinese people in Australia who articulate a more progressive more liberal type of view.  What else is important? Well, compromise is important compromising information that can be collected against individuals whether they are officials or perhaps politicians and it can be also used on mass against groups. Compromat for instance if you are able to collect enough data will provide you with quite useful means or vectors for attack as an example a hack of the blood bank on donor data and a hack against public government's employment records that allows you to triangulate quite neatly who in a specific department has or has been an intravenous drug user who has HIV AIDS for instance and this can be used potentially in negative messaging. The other theme I think is cyber. We make the mistake of saying that information warfare is cyber and cyber is information warfare and the tour synonymous it's not so but the future strategy I think of information warfare will be very much dictated by cyber activities whether it's commercial interests information theft attacks against critical infrastructure cyberjacking whether it's attacks on power grids as of course has happened in Ukraine which makes cyber more than just a weapon of mass discomfort. We tend to say that cyber is something oh you know it's terrible the lights oh that's bad but it actually has real kinetic effects what happens if you're on life support in a hospital and your hospital doesn't have a backup generator what happens if you're in an aged care facility what happens if you're in school and so forth and so forth the use of the internet of things for espionage and sabotage will continue to grow I think and as Putin himself has said the country that controls artificial intelligence will control the world thankfully I don't think that's going to be Russia because it's broke or it's near on broke it has an economic model which is fundamentally unsustainable perhaps it's going to be the United States perhaps it's going to be China and then I think the next the final part of an information warfare campaign is of course as the Russians have demonstrated in Crimea, Moscow military arts by deception the actual formal use of irregular units in order to seize territory coupled to massive info ops in the future I think two things out of all those categories two things are likely to develop one you will see more and more frequent and more creative use of combinations combinations of compromise combinations of social maneuvering and social maneuvering will become so sophisticated that it is well it's already frankly but it will be able to be targeted quite specifically at each and every individual in order to spread a certain message the other thing that I think will evolve is a sense of timing in terms of deployment of information war whether it's a drip feed or a storm and I think that gives us a useful early warning system or a useful indication about intentions because if you see information war being used as a drip feed then that is an attempt to undermine confidence of society in its government in its key industries in its key decision making processes but if you start to see information warfare used as a storm used together with a variety of other aspects then that's more indicative of an attempt to bring a society to a complete standstill in the words of Vladimir Ilych Lenin what is to be done well it's really quite difficult anyone who is has any type of schooling in this type of field will tell you that deterrence is something that doesn't yet work very well I see our Estonian colleague in the audience and I want to commend the Talon manual both 1.0 and 2.0 but as a legal normative instrument in a way the norms are getting ahead of the ability or the willingness of states to adhere to them it'll be a while before I think deterrence in the information warfare space really takes hold there's some scholarship emerging on deterrence in cyberspace and particularly arms control in cyberspace but for the moment I think that it does favour the offensive and that means that performing denial and deterrence functions are ultimately going to be much broader based than they are or have been seen as traditionally traditionally we have viewed being able to protect societies against propaganda or something for government to do well increasingly industry is going to have to do that as well increasingly software companies are going to have to do it and ultimately this is going to be an exercise in education I don't like falling back on slogans such as cyber hygiene which is something that we're attempting to promote it's good to be generally hygienic I think and in cyber why not as well and the Australian population in particular seems to have demonstrated reasonable capacity for learning that's now the case no longer the case that an old lady who sends her pension routinely to the person who advises them that they have won the European lottery and can collect 100 billion euros by opening account and sending 75 bucks and she does that 40 times a few years ago that was viewed as oh that's dreadful that's terrible nowadays we view that lady as being stupid and had it probably had it coming to her now that's harsh but it is a demonstration I think of more rapid learning the trouble is the sophistication of information messaging and of social manoeuvring is going to be so adroit so subtle that it's going to be very difficult to notice the ability for instance for software companies to do things like propaganda filters might work with so-called news content but the amount of data is huge in the social media space it's very hard to see how that's going to be regulated cyber literacy therefore is something that's likely to be iterative that's going to take at least 10 to 15 years in order to inculcate a new generation of Australians because quite frankly the current generation of Australians is perhaps ill suited at the national security college we have been giving away free USB sticks as part of our propaganda here have a course booklet have a USB stick when we know that the very first and the last thing you do you're supposed to do is take a free USB stick and jack it into your computer and yet we've been encouraging it so now we're going to do data blockers but unfortunately they are just as prone to manipulation USB data blockers so it is going to be an iterative process it's going to take a long time my worry is whether in fact we catch up quickly enough whether in fact we do create the conditions whether legally and normatively whether in terms of deterrence and denial the costs outweigh the benefits of participating in the thank you very much folks thank you very much Professor Sussex was really an ill-intentioned sharp assessment you painted a very nuanced picture and challenged some of those common assumptions so we've got some time for questions now you might take a couple of questions at a time and then we'll let the panelists answer before we maybe have time for another round of questions I think there's some robbing microphones going around so if you want to ask a question raise your hand please thanks with the Facebook ads you referred to the $100,000 I think it came out that a large majority of those actually didn't get bought during the election and they often weren't recommending voting for any specific candidate and also with Hamilton 68 that was started by the German Marshall Fund who actually founded a different organization just to run that website and it's very opaque in the way that they actually choose what is a Russian bot obviously they want to avoid lawsuits but how can we trust that the information that we're getting in regards to this is reliable when there is kind of a want for it to be Russian propaganda no that's two very interesting questions I mean the Facebook ads one it doesn't really necessarily have to be an election cycle in order to be potentially effective you can shore up support for something that is dwindling you can create support before you need it it's interesting that the Russians in terms of our best guess and of course the attribution bar now goes down in intelligent circles it used to be that we had to have very high confidence in something now we have mid-level confidence before we say oh it's probably this it's interesting that the Russians of course were campaigning or promoting campaigns for both Sanders as well as for Trump any one but Hillary in fact so they did play both sides of the ideological aisle in terms of what types of information we should believe or we choose to believe unfortunately I'm a student of Randall Schweller who wrote a very good article in 2010 I think it was called Onui Becomes Us and in it he raises the problem of the infosphere in which people's views, opinions are conditioned, constrained so closely by the patterns that can be matched in relation to their preferences they live in a perpetual echo chamber and that was in 2010 before we had discussions about digital tribes before we had discussions about people who effectively limit themselves to their feeds cracking that cracking that code so that everybody does it you look at my feed it's Politico, The Hill CNN, all fake news MSNBC, fake news they should have their license taken away apparently do I read Breitbart? Sure for the giggles and Fox as well but I don't choose to believe it breaking down that will I think require the manufacturing or the remanufacturing of trust in news organizations and news institutions partly that is I think the responsibility of journalists but partly also it is the responsibility of government and it's also the responsibility of society because ultimately most of the mainstream media can be trusted on most things it's just that in Australia we haven't really had a decent conversation with the political centre and I think that's a problem in the European Union where the centre is taken for granted and I think that's been a problem of the United States as well which itself is very fractured into two competing camps I mean you're either a democrat or you're a republican or you really just don't care it's finding that don't cares it's finding those who are in the centre across those two political parties that I think is really quite vital I wouldn't say it's a crisis of liberal democracy but I would say it's something that we do need to pay more attention to that we haven't in the past Any more questions? Is there any hands up? It's a very fascinated audience they just don't have any questions maybe no one? Can I just offer one anecdote in this context which I hope these are very difficult questions Matt said what is to be done but I think some of Peter's remarks this morning Peter Grass' remarks were absolutely crucial we have to watch so terribly carefully that this absolutely fundamental notion of the freedom of speech but the freedom of journalists to do their job if we don't have that I mean there are two things that matter there's that and there's an independent judiciary that is division of powers to me these are the absolutely crucial things but my anecdote is this lest it be thought that what I had to say was Russophobic I simply wanted to say to you that in Moscow today there's a very remarkable radio station and it's called Echo Moscow Echa Moskwy it's a very very good radio station in terms of its analysis of what is happening in Russia and what is happening on the planet and its existence is an anomaly one of its major journalists a woman called Latina was just forced to leave Russia she had been had feces thrown in her face her parents had been attacked and there's a real irony in this because she was in fact a real Russian patriot and she was an asset to the Kremlin she was an asset and she's been forced to leave like many others have been forced to leave Irirpin who painted those barge haulers was forced to leave look at almost all the great Russian painters all the great Russian filmmakers Tarkovsky, Eisenstein they were either poisoned or they had to leave Echo Moskwy is this last year I was in Moscow in June and I was in a conversation where the editor of that radio station was asked by someone at a reception why it was still open he assumed that he was being hurt it was a diplomatic reception and he said well we're still open because we're useful to Putin I see Putin from time to time and he has told me that he learned stuff from us that no one will tell him and that he learned from us for instance that there were indeed anonymous graves in Pskov of Russian servicemen who had died being killed in the east Ukrainian campaign no one dared to tell Putin that or they decided it was not in their interest to tell Putin that and Putin learned that from and he rang up this editor whose name is Vinidiktov and said is that true and Vinidiktov said to him I don't lie to you we had a correspondent in Pskov they were attacked it was true so to me the great irony is Vladimir Putin who is so concerned about controlling being an engineer of human souls what is in the minds of his people and yet at the same time he recognises that without really reliable source of information his chances of being an effective ruler of Russia are zilch thank you yes please can we get a microphone to the front it just seems to me that there's an awful as you mentioned there was the shotgun effect coming out of Russia what sort of body armour do we put on to protect against that I mean again we seem to be the same sort of situation that we've been talking about all day with Islamist info wars where there is such a volume of it coming streaming at us that we don't seem to have the capacity to turn back our own shotguns or hose pipes or whatever analogy you want is there we're very good at looking at this stuff of analysing it saying well this is what they're doing but we don't seem to be able to come up with our own tools to either defend ourselves or undermine it or expose it in a way that seems to be effective so what is there a kind of way of pushing back against this thanks Peter Australia is almost alone in terms of countries that have cyber security policy that says we perform active measures in other words we do offensive cyber virtually no one else owns up to it the Prime Minister said so when he launched the cyber security policy now does that mean we do offensive cyber in that we are trying to influence what Russians think no probably not does it mean that we try and protect, defend Australian interests in the commercial space yes probably does it mean that we have the capacity perhaps to intercept rogue activity when it happens yeah I think so there is I think that it favours the offensive other countries do it too I mean the official position of NATO is that NATO doesn't do active measures offensive cyber but you can bet your bottom dollar that it's participating member states do and I rather suspect that when the risks or when the costs start becoming too problematic I think we are locked in at the moment the first bits of an information war it's going to get worse before it gets better but I think the rationality and common sense will probably prevail will come to some kind of understanding about tacit rules of the game these are the things that you can do in cyberspace these are the things that you can't do in cyberspace and won't do that's the sort of if you like adherence to norms of information warfare and I'm not referring of course to radicalisation I'm talking about state actors here because if many states have the capacity to hack back and have the capacity to inflict harms on others then ultimately it's a self-defeating type of issue it's pointless so I think you will get to that at some stage I just don't know when in terms of protection I mean the Australian approach has been very much about deterrence and denial it means good safety in critical infrastructure it means also I think and I give credit to industry in Australia for this that in the past industry has viewed this as government's problem and government should pay for it whereas government have said well it's industry's problem industry should pay for it and I think we have moved beyond that it's going to take some time as again to get everything working properly in a way that you will have companies freely reporting oh we have been hacked oh we have had certain information stolen but it will eventually happen when? I don't know can't guarantee any timeline whatsoever but if you can't protect your critical infrastructure then that's a really bad vector for a state to attack and unfortunately it's a sort of sword shield dynamic better sword better shield unfortunately thank you so much I now invite you to please join me in thanking our panellists for their contribution


I changed the title to engineering healthcare systems because I'll tell you a story about the way we're doing it, but the way we're doing it is influencing the way other people are doing it, in part because of NHGRI support. I'll have to start by thanking the organizers for inviting me to be the mousepiece for this electronic medical records kind of effort. So this is the map that you've seen before, and if you haven't, I don't know what rock you've been hiding under. We are... I'm going to talk about this space right here, genomic predictors of disease susceptibility and drug response, and then I'm going to talk a little bit about engaging the electronic medical record for discovery purposes, not for patient care purposes, and then I'll talk a little bit about engaging the electronic record for delivering genomic medicine. So there are many definitions of genomic medicine. I'm part of a working group at NHGRI that has spent an inordinate amount of time working on these words. And these are the words for better or worse, and when I argue with Eric about changing those words, I get told that the words are done, let's work on something else. So... And I think that this is a very reasonable definition. I don't want to say that it's not. I will say that genomic medicine is part of a greater vision of what I think... People are calling precision medicine or personalized medicine. I like personalized medicine better than precision, but that's a debate we can have later. I think... Because precision may overpromise, and personalized means you're taking care of a single patient. I'll come back to that theme later. Any clinician who wants to give a talk has to quote or at least acknowledge William Osler. I'm a Canadian, and William Osler was a Canadian, so I have to acknowledge him twice, and so he'll say that the good physician treats the disease, the great physician treats the patient who has the disease. So it is an important part of what we do, and it has been an important part of medicine all the way along. The addition of genomic information just makes it that much more complicated, but that much more personalized. So here's one view of the vision, published in the New Yorker in 2000 when that famous press conference happened, and this woman is handing her sequence to a pharmacist, not to a physician, but to a pharmacist. So it emphasizes sort of that this is going to be team sport. She also has it written down on a piece of paper, so almost certainly that's not the way it's going to work. He's pretty confused, and that is certainly the way it's going to work. I was of two minds whether to show this other part when Francis Collins was appointed director of NIH. He was asked about a lot of things, but he was asked about pharmacogenomics, and this is what he had to say in one paragraph, because pharmacogenomics is the easy stuff. You can read it. I'll just say that there must be a pointer here somewhere. I'll say that if everyone's DNA sequence is already in their medical record, it's simply a click of the mouse to find out all the information you need. There's going to be a lower barrier, and then wonderful things will happen and improve outcomes and reduce adverse events. And obviously, those of us who play in this space really buy into that idea, but I will say this, and I've said it before. I'll say it again, that I disagree with that particular word, because it's anything but simple as those of us who are trying to do it have discovered. So I think the way that this is going to happen is that some institutions and then more and more institutions will buy into this idea, and how are they going to implement? I think you have to implement by having excellence in basic science. I'm going to come back to that over and over again. This is not unidirectional. The translation and the implementation feed discovery science. There's a commitment to information technology, which cannot be overemphasized. We're very fortunate at my place to have a Department of Biomedical Informatics that has 75 faculty members, which is pretty big. And then you put your health care system to work for discovery. And I'll talk a little bit about that. And then once you've discovered something that you think is actionable, then you can start to put it to work for patient care. And the point is that this is an iterative process, and so it goes back and forth. So what we've done for discovery in a nutshell is we've created a biobank. We can talk about the biobank forever, but as of yesterday, there were samples for 163,941 patients in the biobank. Those are DNA samples, and it's a pretty large number. And they're coupled to electronic medical records. Why do you need it so big? And what can you do with it so big? I probably don't have to emphasize that to this audience, but I thought I would just walk you through a question that I was asked by one of our new faculty members. He said, you have any patients who have vitamin D levels? You have any patients who have vitamin D levels and GWAS data as well? So one of the rules of the game is once you do a GWAS on any one of these samples, it comes back to the resource. So I went to a new resource that I'm proud to show off, and I would love to do it in real time, where we just go to a website, and this is what the web interface looks like. I type in vitamin D, and I drag and drop, and it asks me what kind of vitamin D level you want, and I say any lab value. And it turns out that in our electronic medical record, there are 13,847 people who have vitamin D levels. And there is a reason that this number and this number don't agree with each other. It's not just that we add it up differently that there's a great reason somebody can ask me that afterwards. Those of them in the Biobank, that's a subset of the entire electronic record, is 5,497. Then I can ask how many people have had GWAS genotyping right now? It's more like 20,000, but there are only 10,000 in this particular interface right now, and the intersection is 1,000 people. So that's a big set. And you can get the GWAS data on these people with vitamin D levels for free, essentially. So it's an enabling resource for discovery, but the point is you start with 163,000 to get to this set of 1,000.  So I think you have to have big numbers. And what we're doing in BioView is we're looking for genomic variants that are associated with all the things that you might think of, and then we're doing an inverse experiment called FIWAS, which I'll tell you more about in a second. So rather than dwelling on triumphs of BioView itself, I'll just say that we're part of the electronic medical records and genomics network that NHGRI funds. These are the nodes in the current iteration of the network. There are nine nodes, 10 centers, and there's a reason, again, that that math doesn't add up perfectly. And what we do is we define phenotypes within the electronic medical record and then identify cases and controls for to identify genomic variants that drive those phenotypes. One of the things that we have learned over the last five or six years of doing eMERGE 1 and eMERGE 2 is that writing the phenotypes and validating the phenotypes to find cases and controls is pretty challenging. We've gotten pretty good at it, I think. We're certainly very good at finding diseases. We're not so good when I say we, I don't mean me. I mean the informatics guys who work on this. I'm just a mouthpiece. But we've gotten pretty good at that. The next challenge is finding people who have a disease followed by a drug exposure, followed by a drug response phenotype, and that's a little more challenging and we're working on that part as well. All the phenotypes are publicly posted into something called FIKB or Pharmacophenome Knowledge Base and this is what a web shot looks like. Basically all the phenotypes are listed there, who's done them, how validated they are and what's interesting is what kind of elements go into them, what kind of codes, what kind of natural language processing medications. There are all kinds of different ways that you could have of identifying and validating a phenotype and we go through a lot of hand curation to make sure the phenotypes work right. So those are there for anybody who wants to play in the electronic medical record space. I am an electrophysiologist, cardiac electrophysiologist when I'm not doing this for a living. So I thought I would show you one e-merge project that came out of an electrophysiology idea and that is we were interested in variability in the QRS complex in the electrocardiogram. That's this little dizzle here that tells you how fast conduction is in the heart. There's reasons that we think we should look at that. So the first thing we did was we developed algorithms to find patients who had a normal electrocardiogram, no heart disease, normal electrolytes, no confounding drugs, really, really normal people and deployed it in the entire electronic record, not just the subset with DNA and found 30,000 people. Andrew Ramirez who is in this audience and who's now working on this campus directed that effort at our place and this is what the distribution of the QRS complexes look like. So these are entirely normal individuals and we're interested in why people are up at this end versus down at this end. So we did our genome wide association study supported by e-merge, supported by e-merge one and got no signal, then deployed that algorithm across the e-merge network, got lots more cases, lots more control, lots more cases because it's only case only study and this is what the Manhattan plot looks like and this is a signal in actually a pretty good candidate gene anyway. So this is the cardiac sodium channel locus that this is a cardiac sodium channel. This is a different sodium channel that people have gotten interested in because of this kind of work and that controls conduction in the heart. So it's all very well and good.  So GWAS, you take a phenotype and you say yes or no if it's a discrete phenotype and you look across 500,000 or a million or 14 million SNPs and do a test of association at each locus. What we did is we said let's take 13,000 people who have been genotyped at this particular SNP and say wild type or variants are reference or variant. I'm not supposed to say wild type. Reference or variant and do a test of association with every single diagnosis that we have in the electronic medical record. There are about 1,000 and we recognize as overlaps across those different phenotypes but we have ways of making this more and more sophisticated and this is what the Manhattan plot looks like for this particular SNP that happened to be the top one on the Manhattan plot that I just showed you. And what's interesting is these two dots here are arrhythmia diagnoses. So you sort of say, well, he's an arrhythmia guy and he started with an arrhythmia question so that's not a big deal. So at the very least we rescue the signal that we started with. But remember we started with people who had normal electrocardiograms. We didn't start with people who had arrhythmias. They get arrhythmias later because we have the electronic record that follows them for years and years and years. So what this says is that when you start out at one end of that distribution you're more likely to get an arrhythmia and here's a genomic predictor of that and then we were asked by the reviewers to look at it over time and there is a gene dose effect over time with the development of atrial fibrillation. And this is in a gene called SCN10A. SCN10A was originally cloned from the dorsal root ganglion and so the way it affects heart conduction has been pretty controversial. One of the other hats that I wear is we study those kinds of problems in my mouse and fish lab and so we actually looked at what happens to wild-type myocytes. These are action potentials from mouse myocytes at baseline and then when you put in a tiny, tiny, tiny concentration of a sodium channel opening toxin called ATX. And that's what happens in wild-type mice. We have generated sodium SCN10A knockout mice and we actually don't see that a rhythmogenic effect and in fact that's reproduced. So I throw this in just to make sure that people know that I still think about this kind of stuff every so often and also to make the point that there is this loop that has to be closed. Everybody has said we now have 3,000 more signals or 3,000 more loci to look at than we did 10 years ago and we better start to look at them because maybe this is a drug target, for example. So we've deployed the FIWAS algorithm across the entire GWAS catalog supported by NHGRIs. That's about 1,300 different tests of association. Some of them are with phenotypes that are not well captured in the electronic record.  Are you bald? Those are things that the electronic record doesn't capture very well. So we don't pay attention to those in our validation study. So here's an example of a highly platropic SNP. This is a SNP in IRF4 that determines skin color, but when you do the FIWAS, you get tremendously significant signals for various kinds of skin cancer as well as actinic keratosis. And it turns out that SNPs that are highly validated, highly replicated in the GWAS catalog replicate this way as well. And we have about 70 new associations using this approach to discover pleotropy. This is what Emerge 2 looks like the number, don't take the numbers excessively seriously, because for example, this one says 27,000, it's probably, like I said, more like 20,000, but we count immunochip and metabolichip in this as well. So there's 300,000, 330,000 or so people in Emerge 2, there are about 75,000 with dense genotypic data that we're actually putting together in a very large set. So this highlights for me the paradox of personalized medicine. As a clinician, I have one patient in front of me in the office, but what I need to do is be able to treat them differently from the average. And in order to do that, I have to have a very large data set to convince me that that different treatment is in fact justified. So that's the discovery piece, then the implementation piece. So we've been hearing all day about pharmacogenetics, that's the easy stuff, and that's probably the first thing that's gonna be implemented. I've been doing pharmacogenomics and pharmacogenetics my entire career and we're part of the Pharmacogenomics Research Network, another effort funded by NIH. Eric already alluded to the fact that there are now many, many drugs that have labels that include pharmacogenetic information. This is only for germline, the other half of the drugs that have labels are for the tumor germline or the tumor genome. So everybody says it's easy and I like to show this. It is low-hanging fruit, but it's not so simple. I'll just say that. So we were tasked by our leadership to come up with a way of starting to deliver pharmacogenomic information in a preemptive way into the electronic medical record in the fourth quarter of 2009. We were given a year to plan.  If anything, you should just read down these things to understand that there are multiple communities that you have to engage and excite in order to execute a project like this. This is what we call our Predict Project and this is what Predict stands for. So the notion is, in brief, find patients who are at high risk for getting a drug with one of those actionable pharmacogenetic stories, one of those 58 drugs. And then you genotype them not on the drug you think they're going to get, but on a bunch of different draw, on a multiplex platform that assays many different pharmacogenomic variants. And then you do what I call the easy stuff. You store the genomics, track the outcomes, provide informatics support to clinicians who are prescribing the drug at the appropriate time. So who is at high risk? Well, one group of people are at high risk are people who populate our internal medicine clinics. We did a study in about 50,000 people in the electronic medical record asking the question over the course of five years how many of them are exposed to one or more of those drugs that have FDA labels. The answer was a bit of a surprise. There are 65% of them that get at least one drug from that list over the course of five years and 15% that get 10%, that get, sorry. 15%, 15% get four or more drugs. So that's one group of high risk people and we are actually including them in the Predict Project. The other high risk group of people are people we can look at and say, within the next week or two, you're gonna get drug X. And one of the best example of that is the people going to the cath lab at Vanderbilt. We do about 4,000 catheterizations a year. About 1,800 of those patients end up on clopidogrel. And as we were planning this project, the FDA did us a favor, relabeled clopidogrel to include this statement, consider alternative treatment or treatment strategies and patients identified as CYP2C19 poor metabolizers. CYP2C19 is the enzyme that bioactivates the prodrug clopidogrel into its biologically active metabolites. And I have to say here that it was Grant Wilkinson, a faculty colleague of mine who in the mid 1980s discovered the fact that CYP2C19 was polymorphic. He was not studying clopidogrel and remember me and many other people gave him an incredibly hard time because he was studying this incredibly obscure drug and probably a pointless line of inquiry and in fact it turned out he was right that it was an important thing to study because now it's the centerpiece of much of what goes on in pharmacogenomic implementation. The other thing we did was we took our bio-view specimens, found a group of people who had gotten a stent after an acute coronary event, looked at 30 day outcomes and found 200 people with complications and 400 or 500 controls and replicated the known signal for CYP2C19 and its variant in terms of imposing risk. So over the course of the last two and a half years, we've now studied about 12,521 patients in predict. Bruce Korf on the video that you just saw described a program where you might genotype people and then deploy the information when it became apparent and that's exactly what we're doing here. There are 334 homozygots for CYP2C19 star two and 2,369 heterozygots and what's interesting is that most people don't have a common variant. We don't actually know how many people have a rare variant. We know that they don't have a common variant and just to show you that it did give you a sense of the fact that this is actually, although it's complicated, it's even more complicated than you think. It's not just star two that are the hypometabolizers. There's star three and star four and you can be star three, star four. There's also a star 17 that nobody knows what to do with. The heterozygots and homozygots you saw on the pie chart are actually multiple genotypes and how to translate from a genotype to a diplotype to a predicted phenotype is one of the challenges in the area. When a patient who has this information in their electronic medical record has an electronic prescription written for clopidogrel and are a poor metabolizer, this is the point of care decision support that pops up that suggests two alternative drugs and we track how many times physicians look at this, how many times they change their minds and we're just learning about responses to this kind of program. And I thought I should show this picture because again, it's about personalizing medicine. This is one of our interventional cardiologists and when we started the program in September, 2010, we were really eager to find the first star two, star two patient and this is she. So she is being taken care of by him and he knows a little bit more about her now and that's personalizing medicine but he's taking care of her for a long time so he knows a lot about her and her attitudes and her other diseases and her other medications so that's what's important and there's another quote from William Osler which in the interest of time, I think I'll let you read and now you've read it or not. So we've now deployed five drug gene pairs, clopidogrel, simpastatin, warfarin, thymopurines and tachrolemus and those are displayed on the electronic medical record. This is a screenshot of what our electronic medical record looks like, I've blacked out all the identifiers except for this one here because I wanna make sure people know that I still see patients and so these are the genetic variants that belong to this particular patient. These are a partial list of his medications that actually go down here and what's interesting to me is that he's been on warfarin for a long time so we actually didn't use the warfarin information to tailor his dose but he has a loss of functional allele in CYP2C9 and he does take a remarkably low dose of warfarin, only three milligrams a day so that's probably the explanation and had we known that at the beginning we would have started about three milligrams a day. We also have to say use this kind of technology to display variants in tumors in an effort very, very similar to but probably smaller than the one you just heard from Dr. Garroway in our personalized cancer initiative and that was a BRAF mutation. The other thing, after you've deployed five drug gene pairs you can start to ask the question how many people have variants in one or more of these pathways and what's interesting is that the number that don't have anything is now getting smaller and of course every time we deploy a new drug gene pair the number has to get smaller and one way to think, I mean it's obvious and it's almost trivial to sort of highlight it except to point out that as if you're gonna do multiplex testing what you find out is that everybody in this audience is abnormal for something and we all, if you live in genome land we're like we all do, we all recognize that but these are real data that speak to that and so when I speak to lay audiences, when I speak to non-genomics audiences it comes as a surprise to them sometimes that we're all abnormal for something you just don't know what it is so this multiplexed approach I think is really the only way to go and I think that many people in this room have thought that problem through and understand that. We also engage patients so that we have a website called My Health at Vanderbilt where you can go and look at pieces of your record you can make appointments with your doctor when you look at pieces of your record you can look at genes that affect my medicines and then you can see your report for the drugs that we've targeted those are all sort of works in progress and you can see we're sort of still figuring out exactly how to deliver that information we steal from, sorry, we adapt 23andMe information to think about this because they do a reasonable job of explaining this and we think that that's something that's gonna be very, very important to engage patients in all this. So we have Predict at Vanderbilt and I'm part of the PGRN we're also part of the Emerge Network and so I was having a conversation with Terry Monoglio who directs the genomic medicine initiatives at HGRI and she said well why don't we take the PGRN's next generation sequencing platform for all those important pharmacogenes that you guys are working on and stick them in Emerge in a Predict kind of algorithm so that was an idea born at the end of a long day and we actually are doing that right now and that project is underway so it takes advantage of the expertise and capabilities of two separate networks that I think ought to be closer aligned than they are and I'm working on that. So I want to just summarize by highlighting in words what the lessons are. So first of all I think that we have not finished discovering so those of us who focus on implementation are working on trying to deliver some of that to patients but that doesn't mean that we know everything we need to know. We need to know a lot more and you've heard that all day today. The low hanging fruit of pharmacogenomics is much more complicated than we think but I think learning the lessons that we're learning along the way in this space will make us smarter in terms of delivering genomic information in the course of healthcare. More generally some of the problems I've highlighted this business of rare variants is gonna be a real problem in pharmacogenomics and everywhere else and then there's the problem of ancestries which we're only beginning to think about now. This is team science, it's interdisciplinary and you have to engage lots and lots of people not just get their grudging approval but get their enthusiastic engagement. There are huge educational needs in every constituency that you can think about. The evidence changes even in pharmacogenomics where you sort of say well CYP2C19 does this and then a year later you think well maybe it does this in some other context. So you really have to be attuned to the fact that the advice you deliver today may not apply perfectly tomorrow. It goes without saying but I have to say it that an alumina run might be 99% accurate. I have no idea what that number really is but that's not good enough for a clinician because it has to be 100% accurate and the reason is, I'll just say it, for those of you who are clinicians you all understand me. I walk onto the wards and the nurse or the resident says to me that this patient has renal failure, their creatinine is eight today and I say well what does their electrocardiogram look like, how do they feel and they feel fine and their electrocardiogram is normal, I say well that's a lab mistake. Any clinician would tell you it must be a lab mistake. But if somebody says this is a person's poor metabolizer I have no context for that. So I have to be sure that the data I get is correct. I think this is only gonna happen in an electronic medical record environment. We're thinking about ways in which to deliver this kind of thing to people who have less advanced electronic medical systems than we do but I think that's gonna happen and the only way this really happens is with institutional will. So I'll just close by talking about the teams. I've acknowledged these teams up here. These are the individuals at Vanderbilt. I can't walk my way through all of them but there are geneticists, informaticists, ethicists, lab people, fellows, translational scientists and these three guys down here who are the institutional leadership. So thank you very much again for the opportunity to participate. So our next speaker before he sits down is David Botstein from Princeton and David is gonna tell us about the fruits of the genome sequences for society.