Ira is the Solon and Betty Gershman professor of colon and rectal surgery at Washington University Medical Center in St. Louis. He's the director of the WashU Center for the Study of Ethics and Human Values. Ira has been a real leader in surgical ethics education throughout the U.S. and has been instrumental in helping over 45 and 45 surgery programs develop teaching in ethics. In addition, he's had leadership roles in numerous colon and rectal surgical societies. He's authored or co-authored over a hundred peer-reviewed manuscripts, book chapters, etc. He will speak to us today about ethical challenges resulting from the stress of a career in surgery. Ira. This is going to be a different kind of talk. We're starting with concerns in the delivery of healthcare, complicated by a system where our patients purchase the cheapest healthcare when they're well, but they use it when they're sick and they want the maximum without regard to time and cost. To summarize, they want to pay for a Kia but drive a Cadillac. No one's ever come in and said, I don't expect you to do everything for mom because I know I bought the cheap policy. The relationship with our patients is changing. It's one from paternalism where everybody said, I'll do whatever you tell me doc, to a more shared decision making to one based on real informed consent. This presents dilemmas, one of which is never written about. We talk a lot about autonomy of the patients, but no one talks about the autonomy that extends to the surgeon as well as the patient. We really should not be forced to perform surgery that we think is scuttle, and yet many of us do. The surgeon stays, I hope, as part of the palliative care team. It's changing because we actually know the patients and the families sometimes more than the primary care because we spend more time with them, especially under stressful conditions. We are the ones who have to guide patients and families to these appropriate decisions in their care, perhaps even for generations if these are genetically based problems that they have. With respect to many of my colleagues, I'd say that no one or few can understand the anxiety of going to bed at night and realizing what we have to do in the morning if we're facing a horrendous life-threatening operation. I do make the point that I don't think anyone can identify with the situation in the operating room when we burn the bridge, and we can't go forward, but we can't go backward, but the end isn't in sight. This is what I think in gender's bad behavior. I think in many cases we're just terrified, and yet we do stand by allowing the community, our students, our non-surgical colleagues to perpetuate the myth that we're only technicians. I'm honored to be back at the McLean Center with Mark and my teachers here. I feel like the oldest student you've ever had standing up in front of you, but they were fun in the early days when I said there were ethical challenges in surgery and eyes would roll back. Then we had the Lantos revelation when John came to visit us and you do ethics pizza rounds for the surgery service. He insisted that the medical house staff be there as well as the surgery house staff. He presented the challenge to the medical house staff first of a patient who comes into the emergency room, severe myocardial infarction, hypotensive, no matter what was done when the patient got to the intensive care unit. He couldn't be saved and he died. How many of you felt responsible? No one. He presented the scenario to the surgery house staff. The patient comes in with a ruptured abdominal aortic aneurysm, hypotensive. You've been in the operating room for six hours trying to save the life. You get the patient to your intensive care unit. You stay up all night with the patient and the patient dies. How many of you feel responsible? Everyone. The difference, the difference was stunning. But now there's a threat to their, our cherished relationship because medicine has become a business. Time is money. Reimbursement is down. So theoretically we need to see more patients to generate the same income. It's frustrating because we can't actually do more now than ever before. So in many cases we try to do it for as many people as possible. Plus too many of my colleagues in surgery, this was alluded to yesterday, respond to the business model. There's a shift in attitude within the profession. Business jargon has become commonplace. Patients are replaced by consumers. Eventually they become customers. Patients were treated like family members. Customers come to your business to purchase health care. And the less time you spend with customers, the better your bottom line. It's difficult to demonstrate that restoring the doctor-patient relationship is going to save money for the business. So who supports the surgeon? Where do we find help? We have our personal values. Our mentor system is corrupted by their reduced working hours and the less time we spend with our mentors. We have advice and stories from respected individuals. And as I'm going to finish the rest of my talk, we go to literature and history. If we were really good, we would create and participate in an effective support system for our trainees and ourselves, but that's for the future. So I'm going to refer to a mentor and teacher, Tom Krizik, who spent much time here at the University of Chicago. And I'm going to his ethics lecture presented to the College of Surgeons in 2001. He starts stating that four surgeons committed suicide in one year. They were all fellows of the college. They were all involved in academic medicine and were considered successful. How utterly complete was their impairment? That surgery itself might be an impairing profession is a troubling thought. And he made the point we may not be as supportive of each other as we think we are. Perhaps the very profession of surgery may be impaired. He defines impairment as an impaired surgeon is one who for physical or psychological reasons is no longer capable of performing in a professionally safe fashion. Our standards are high. Injuries and age related problems may be a little consequence and non-surgical specialties, but can significantly impair and incapacitate surges. Significantly, we tolerate such problems poorly. Our bar of safety for surgical performance is set high. Complications and problems are easily identified. We work in a very public environment. Accusations are too easily made. The challenge is to measure and evaluate competence before preventable complications occur. He goes on to say impairment is a secret sickness. Impairment from alcohol and drugs associated with higher incidents of mental illness, divorce, accidents, premature mortality and suicide, as he states among his four friends. Are we in a impaired profession? It's one whose virtues of courage, veracity, fidelity, dedication, including the social virtue of caring are threatened by external goods of power, prestige and money and whose identified purpose fails to unite its members. He states of surgeons don't function with a unity of vision or spirit of caring for each other. The profession is fostering the growth of impairment. In the 50s and 60s, it got worse with third parties and Medicare as they established an unfortunate expectation of fee for service. Dr. Chris makes the point, how does an individual or society value the special skills available nowhere else that make the difference in life and death? And yet we run the risk of exchanging virtue and respect for money. The most impairing facts of our profession, he says, have become that we've become rich. We expect to be rich in society does not highly regard the rich, unless you're a sports figure or a rock star. He faces the crisis of decreasing compensation and inflating expectations. The major battle has become financial. If you look at the life, the productive life of a surgeon, we can practice at age 30 to 35 years and we quit 22 years later, a tragic waste of resources for society and for surgery. External goods threaten virtuous and caring behavior. He makes the strong point academic surgery is dog eat dog. But he clarifies it that private practice is the opposite. He goes on to imply that the seeds of impairment are sown in the educational process. When we seek surgeons, we look for those with intensity and drive but not too intense and not too much drive and not too ingratiating. It's difficult to predict who will handle the potentially impairing stress surgery is supposed to be different. There's problems with workload changes in the doctor patient relationship and diminishing reimbursement. Still, the excitement of surgery and performing operations seems to be no less intense. He claims it can even be seductive. He goes on to describe the good role model our mentors who stresses the ability to be humane as a key of the profession of surgery. They teach us to handle the experiences that change us. None are abusive or harassing or impaired or impairing. But yet if you look at the negative role model, this person may be abusive, harassing or themselves exhibit a form of behavior or personality impairment. The result in a hostile working environment inside and outside the operating room. Particularly true when there's a power differential and when women trainees are placed at risk. And yet others see these as often hyper forming, competitive, successful in academic and financial areas and in fact can be seen by others as entertaining and charismatic. He finishes by saying the mistakes are impairing. There's no greater challenge to us than how we handle mistakes. Public disclosure is a serious ethical issue. Anticipation of silence, disapproval or litigation precludes wide disclosure and truth telling. It's profoundly human to seek forgiveness. And yet too often in our profession, there's no place where we can actually ask for forgiveness. If you look at the support systems, usually there's 20 people for the average person in society, friends, relatives and neighbors. It drops critically in the first year of surgery residency. There's a nonhuman part of the time, usually a cat or a goldfish. It never returns to the level that many people in the rest of society enjoy. Surgery is competitive and can be a very solitary profession. Unidentified colleagues are presumed to be sharks until proven otherwise. We're advised not to bleed because it attracts sharks and we're advised to get out of the water if someone else is bleeding. He finishes by suggesting that perhaps we should choose the middle path as taught by Buddha. Like the Buddha, we are early exposed to old age, illness, poverty, blood, pain and death. And we can never go home again once we've seen these images. We become joined with humanity in ways that others cannot be. To find the way one must be guided by a master, by our mentors. Just as we learn virtue and caring, we can learn how to apply ethics and morality to the practice of surgery. He finishes, surgery may be an impairing profession in many ways, but it doesn't have to be. Thank you.


As I said when I mentioned this book in my last monthly roundup video, this was a real find. The book contains two short novels by Joan D. Vinge, one Fireship. It's about a criminal who appears to have multiple personalities. It turns out what he has is an experimental supercomputer that he can plug into his spinal cord and the resultant gestalt personality is superior to both of them alone. It's a good story and pretty interesting but it ends just as it's getting started. The real find here is the second novella called Mother and Child. This is such a complex story, it's hard to know how to describe it in just 30 seconds. It takes place in the far distant future when a distant earth colony has long lost contact with earth. In fact they call their own planet earth, they have collapsed into a divided medieval society. Half of them considered more primitive and more pastoral than the other and there are giant powerful aliens that have taken up the roles of gods. Joan Vinge has masterfully condensed a five book epic cycle into barely 150 pages here. I went into this having never read Joan D. Vinge before and I'm leaving with mad respect for her writing ability. You can support 30 Seconds Sci-Fi and my other projects by becoming a patron. There's a link in the description below. I highly recommend that you get a copy of this book and experience it for yourself. This is not difficult to find and not expensive. I do have to say though I have not figured out where the word fire ship comes from. I've never figured out what that word actually means.


So welcome to the third day of this workshop, somewhere near midway point. So I hope you have been learning useful things and even if not all the time, at least half the time. So let us continue that effort, the journey. So today I have planned one and a half hour lecture on security assurance, a system administrator's perspective. So I can do without a network connection, I can do without live demos because that's always a risk. So everything is in the slides but luckily since everything is working, I will also switch once in a while and show you the live demonstrations. So the three parts in which I have divided the talk, the first two parts are just so that we get the perspective. Hopefully we can be done with the first two parts, the good and the bad in about ten minutes and that is just to set the stage and the third part is what we call the ugly. So everything looks good from far. So as you go closer and closer, which is how do you defend, how do you build your services on the network so that security is not an afterthought. Security is while you build the design and also the most important message that building a good, secure architecture for your network and services is not enough. What happens after that? You have to watch, vigilance, audit, react, not later, not after the horse is gone. So that is the focus of the lecture. Assurance means that, that I want a guarantee, I don't want just best effort, IP is best effort at IP datagram. So security assurance can be given. So you have to assume along with me that today we are all system administrators whose job it is to do this, although we are all faculty and teachers and all that, put yourself as a system administrator and management, the director or the dean or somebody keeps asking you all these questions. You have to answer. So that is the role. How will you give that answer? How will you give that confidence that what is going on today in IIT Bombay's network is secure, is safe, is stable? So we will go into that. Okay, so those are the third part I will, I am sorry I didn't put those two words on this slide. The two hopefully new things which you may not have seen before, which I would like you to take away from this lecture in terms of learning and teaching in a course. So one of them is, the broader name is firewalls. But the method I am going to use is what is called IP tables. So just, it is not a quiz, just a quick show of hands. How many of you have used or worked with IP tables in some form before? Okay, so a few that is good. So please bear with me if it is a little slow or introductory, but that is an important part, where we say how to configure the network in a secure way to restrict the access to control who can do what, IP tables is like a Swiss army knife. You can do so many things and we will give a flavor of that. That will come two-thirds or about 60% into the talk. And the next thing, and again I would like a show of hands, so the broader framework is centralized logging and log management. But the software that I will introduce to you is something called R syslog. Anybody has used that? Syslog, you all know syslog? So this is like instead of a network-based intrusion detection, a system or a host-based intrusion detection. And the setup for that means that you have to know what is happening on the network, what is happening on your servers, what is happening with your users, who is doing what. So that would be the two softwares that I would like you to take with you the power and the scope. And when we teach a course, then exploring this in more detail will be good. So one last remark before I proceed, that tomorrow's lab is not on these two softwares because that's very hard to set up in a single PC and give you access to all the environment demos I will give a little bit today. So tomorrow in the lab you will be doing two other softwares which are subpieces of this, which will help to build a bigger and more secure system. That is tomorrow morning's lab. And one of them is called AWSTATS, which is for log analysis in a real-time manner as events happen to generate logs. And the other one is something called OSSEC, which is a host intrusion detection system, which will give you that ability to give the guarantee that if something bad happens, then with 99% probability I will know within two minutes. You can't give 100%. But you can at least say that I have set it up such that if, what is the meaning of something bad? So let us start with that. In IIT Bombay campus network, what is the meaning of something bad happening? From the security perspective, network services and security perspective. So many things, right? Your web service stopped working, people cannot access your web page, your mail stopped, or somebody broke into your main computer, your academic office grades, or somebody stole your cash. So many things. All we talk about has security problems or misuse, students bringing down some server or hostels doing something bad. So you understand the scope is vast. So when we say something bad, this is where we have to start. This does not need any computer knowledge. This is where the direct. Then you prior the cap of director and dean. Something bad is something that the director will say should not happen. He will not tell you use IP table, say W stats, OS second, all that. He will say if something like this happens, if a student in the hostel in the night logs into this server or tries to break that server, I want to know. I want to know next morning on my desk. So can you do it? So I won't build up too much because if I do, then you'll ask me, are you doing it? So we are trying is all I can say. But we are an academic institution. So we do not take this so seriously.  So is this clear? This is the perspective which we will spend the next one and a half hours. So I would also like to make, I don't want to make too many disclaimers in the beginning. It is very difficult to pace such a lecture and finish exactly and so on so forth. So I request you to bear with me in case sometimes it is slow, fast and so on so forth or we rush at some points because I'm not trying to teach you everything in 90 minutes. I'm trying to give you the flavor and hopefully spark that interest in you to go and do these things along with the next main course that we offer with the other participants and so on and your students and so many other things. So let us start. So this is just 10 seconds. We all know this. I won't read it out. So this entire topic of security is like this. Everybody has their own perspective. What is security? Today I'm giving us a sad perspective. There's a network perspective, there is a, like I said, the management perspective and so on. So this is called the blind man and the elephant. So this is a little more serious and this you can, I would not claim is 100%. I would say 90% of all topics which have to be covered related to security are somewhere there in this mind map. And in this course, I don't know which parts you're touching, which parts you're not touching and so on. That is for you to figure out. So basically there are threats, there are vulnerabilities, there are requirements and there are mechanisms in the left corner, a lot of mechanisms you're learning in this course, authentication protocols, SSL, they are all mechanisms for what? For doing this security. And today's focus is this green one on the right side called assurance, that we want to monitor and we want to do emergency response and we want to recover after a disaster in case it happens. And we have to be ready for that. We have to be prepared for that. The rest of it, of course, is all important and without all that you cannot do this, but this is sort of giving you the landscape. And today's focus is somewhere here. So I won't spend too much time on the other parts, which the rest of the course in reduction would have done. This again just a few minutes, like I said, perspective only. The olden days is on the left side, when we had books and libraries and paper and microfilm and pieces stored in dusty rooms, you know, where nobody goes and so on and so forth. Today, everything is digital, everything is online, information explosion, all those sort of phrases that you have heard. What I would like you to focus on is that keeping up, there is this again this standard thing they say, you know, information, knowledge, wisdom, moksha. So I think that we should position ourselves in wisdom, right? It's not that you need to know everything, raw data, information. You don't even need to know knowledge. You don't even know, you don't need a Cisco CCNA or Microsoft IIS expert. That I would call knowledge. Information is everything on the internet. That is how to do a specific tool or a specific application. Wisdom is what? Hopefully that has teachers, that is the role we should play as teachers and researchers. What to learn? How to learn? What to check? So that as technology changes and as data and information changes, we are able to still make some impact. Of course, the last one is just a joke. In our philosophy, we don't even need wisdom. What do we need? Moksha means what? Zero, mind blank. So anybody has heard that joke? So the Americans were doing some excavation at 100 feet. They found a lot of copper wires. So they said what? Look at our ancestors. They have used networking and then new lands and vans. So the Russians went a little further. They found optical fiber. We were using fiber. We were using only copper. What about India? We went one mile, two mile, nothing came. So we said we were using wireless. So that is Moksha. So you don't need, without anything, you can still be happy. So it's a state of mind. Again, just 10 seconds on this, Apple falling on Newton we all know, Ramanujam writing everything in one notebook or two notebooks, have you heard of this Ramanujam notebooks?  So these guys are getting so much credit for being brainy and scientists and all that. So we have everything in one notebook or one page. Can we do like that today? So we are very, very unlucky, you know. We need collaboration. We need gigabits of data. We need computers. We need Hadoo, Pihu, clusters, all simple things, F equal to MA, K series sum, all that these guys have done and got awards. So today we cannot live without any researcher in any field, that's all I want to say, which we all know. Again, I don't want to waste too much time on this. You know all this. That just like mathematics was the supporting science for all discoveries, physics or electronics or this or mechanical or civil engineering, mathematics is the core. Similarly, computers are becoming a core now. Without computers, advancing the state of the knowledge in whether it's biology or diseases or malaria, you name, or even today sociology, who will vote for whom? Who voted for whom? Why they voted? Previously, they would just with one page, one guy will act like a boss and tell everything. Today, there also you need data, big data, analytics, you've heard all these words. So the good part is just that without computers nothing can happen. Of course, slowly I want to introduce the bad stuff also, real-time internet security, real-time fraud monitoring, real-time screening of who wanted to do that, screen Facebook and Google posts, social media. Remember, there was a rumor that in Assam, Bangalore people started fleeing in trains to Assam, North East people because they were going to be beaten up and all that. So they blamed social media for that. Anyway, we won't go into politics today, not the right time. So the last slide on the good part that we all have to, we cannot deny, we cannot live in denial. We need computers, we need network, we need internet, okay, we need, I don't know whether we need Facebook or WhatsApp, but let's say we need Facebook, we need WhatsApp, okay. So because mathematicians have found that, they can't do, live without that, bankers have found that, okay, nobody is using banks anymore, everything is online, payments, this, that, everything more or less. It's an exaggeration, especially in the Indian context, digital divide and all that. But you understand what I'm saying, that this is where we are heading, okay, all transactions, PayPal, Bitcoin, you've heard of all those things? Security is important there also, but we are moving away without that, and last one is us. So please don't take all this seriously, especially the one about Akash, the tablet that will cure all the education ills of our country. Yes, no, maybe, maybe, let me at least get a maybe. That's what we're doing here. So that is unfair criticism. We should only say that it will not cure all ills, but it can help. It's one of the factors and there are many other factors which is without the teachers and the training thousand teachers, ten thousand teachers, one of the initiatives we cannot do without the human in the loop. But there's no denying that our students do not think of us as the repository of knowledge and wisdom, okay. They can access any lecture they want on their own. Do they need teachers? Do they need us? See now it's harder, it's getting closer to the bone. I can tell you that on security, take any topic, authentication protocols. The world's best lecture, five, let me not say the best, top five lectures are available. And I come and do it, it'll be this, I may be better than the top five, very slight probability. But it doesn't matter much, I can't be so much better. There are very five, very good lectures, yes or no? Take any topic you want, best professors, okay, I'm better than them, all that we can concede. I'm not saying you're not better, but they're not bad also, right? They're also okay. So why do they need us? So answer that later at your convenience, okay. So now, let me do a live demo. Next five slides was canned demo in case the live doesn't work. There's a site called atlas.arber.net and I'm going to go to that site live so that I can skip the slides later. So let me start with the home page. So you can see it later in detail. All I'm showing is that this is a site, anybody can access, no special privileges. And you go to this, that summary, I hope you can see attacks, botnets, dot attacks, pass, flux, bots, global activity maps, phishing, scans, all these words make sense to you now? Phishing is? Yeah. Yeah, what's a botnet? So shall we scan what is botnets, what they're saying about botnets? So I go here, and it will show you, we just have to wait a bit. That here are the number of servers, percentage, that botnets is not showing a map. Which countries are having servers, botnet servers are servers which control these bots, which are spread over and infected many computers all over the world. And when they want, they can activate them to do what? Bad things.  So let's go to something else, activities, attacks. So here this is, this is Sunday because this is US time. It's actually Monday, and for them it's 10 o'clock in the night. And it is, I will not read out everything. It is telling you which type of attacks are happening. Okay, VNC is virtual network that terminal, SSH brute force login attempts, Microsoft window trans header attempt, some PHP access, DNS versions. These are the type of attacks that are happening. Attacks per subnet changed from yesterday as it increased or decreased, they are plotting, okay? And you can see this, you can see this live, anybody can see this live. And if you go further, you can actually see by country, which country, and India is also figuring. So let's go to India, attacks from India are happening. So our students are doing this, not faculty, okay? They're scanning, this is India. And you can see that they're trying to scan telnet, TCP ports, this port, scanning for open ports on other servers all over the world, okay? So attacks like that, recent activity, that rank. So which is the biggest threat and all that, we will not worry. You can see that later, whether it is China or whether it is US or whether it's Iran, every country now has hackers who are serving their country. Here it is, US is first, Chile, Canada, so on, which are the threats? So you can read this at leisure. And you can go further and find out. So let me go back to the talk. So this is showing which are the sites in India and Bombay. There are some, this one is the phishing websites, which is trying to act like state bank or city bank. And trying to steal passwords, they've set up servers like that. Who has found out all this? How did they find out? Should they find out? If they found out, why is he not arrested? So all these questions you have to answer yourself, top threat sources. I am sorry in case it's not fully visible. But this website is mentioned on the title at plus.arber.net. In the lab, if you are bored and you know everything that we are asking you to do in the lab, go to the site and browse. Or later go and see, okay? So it's saying, in India, this is a little old dated data. It is saying again the same thing, and next slide may have more information. Who is scanning? This even telling you, and I hope you can read this from there, that Tata.com subnet has generated 20% of the attacks. And BSNL and Tulip from subnets owned by them, attacks are emerging. So let's just take 10 seconds. What did, how did they find out this or what, who found out this? So let me tell one attack, scan. What is scanning, you know that, right? So suppose I'm at home and I have an internet connection. Can I run a software that goes to, which site do you want to scan? Let us take a site in US, some bank, citybank.com or whatever. So suppose I start writing a script or a program or using some of these tools, which tools does all this? Nmap is an example tool. There are many others, so on so forth. And I start scanning, what do I scan? What is the meaning of scan?  Will you walk in through the main door first? What will you do? One day you will walk around, right? And you will see, are there doors open, windows open? In the side is there a way to climb? Is there a tree branch nearby? Without doing all this, if you do, it's okay.  So amateur thieves are what is this is catching? But they're simply using tools without masquerading or doing something to hide their identity or source. And they're sending out packets. Is this packet open? Is that packet open? And that packet has to flow through routers, various routers. If you want to reach US from India, your packet can't jump in escape velocity of Venus or whatever. Some of our politicians have said no. It has to go through some wires and some routers. And many of the routers are controlled by whom? Different countries. And they're able to tap that traffic. Wire shark, yes?  But you can analyze a pattern and you can say that from this IP. And then you can find out who owns that IP. Can you find out or no? Internet is still not chaos, right? IPs are registered. There's an app, Nick, I'll show you some of that. So then you can show this data like this. So now we're in the bad. This is happening today. It's happening from all over the world. So you set up your college server. Will anybody attack it? So that's why we're living in comfort. Nobody cares. IT Bombay server. There are very few people who want to attack it. But the State Bank of India server, so very different, right? So we have to lower threat perception, risk perception. And as teachers, we should teach our students to defend against the best criminals who are for hire from various countries who know all this. So let's move on. Again, it is saying in India, there are people hosting phishing sites. So some, they are created their own website, which looks like State Bank site or looks like Citibank site or looks like some other site where there's a username password. They're hoping people will come there. How they will come there? They will get an email from Reserve Bank, saying you have $1400,000.  We'll transfer it to you. Reserve Bank Governor, who is the governor? Raghuram Rajan. So the guy will have, who doesn't want money? So they'll go there and click it. And what will come on their screen? State Bank of India, username password, everything will come. Unless they look with a microscope or they look at the URL, just a phishing site. So he has sent an email, trapped them. Now, how many people do you think will do this? Percentage. So it's less than 0.1%. So he sends a million mails, 0.1% a million is still a reasonable number. If 100 people fall for it, that's enough for him. But he has to send a million mails for that. And what is that million mails called? Pam or phishing mails. So he's a new sense to society. But he's preying on the weakness of a small segment of the population and causing trouble to the whole community. So these people are trying to find out that. Now that they have found out, they don't have the legal authority to take it down. This is where certain comes, that I am seeing what is public information. Please do not assume it's 100% correct. It is possible to doctor this information. It is possible to make it look like attacks are coming from some place. Why they want to do that? Have you seen our news opinion polls, exit polls? It is possible to give any number, make it look like this fellow or that fellow. But so with a pinch of salt, computer is certain, has the authority, they have special status, they get more access, they can actually track it proactively or our cyber crime cells can track it proactively. Provided there is some legal understanding, cooperation, willpower and all that. So they have to tackle it along the priorities. For us, this may be the world's most important threat in India, but for them it is not. They have so many other crimes to worry about. So anyway, so this is still too much time on the bat. Let's come to the ugly. Then there are malicious servers and so on and so forth. Malicious servers means what? In their definition it is that in their webpage there are embedded either cross-site scripting attacks or worms or some other data is downloaded. If you go to that website, you have risking infection of your computer with a bot. So they found out that which servers are hosting such bad binaries and this and that and so on and so forth. So we'll conclude the bad by just talking about what you must have seen in various ways. Why all these bad things are able to happen? Because it can be application level security, overwrote the application, made mistakes, SQL injection, this that and so on and so forth. It could be host security, services are not configured properly, ports are open, passwords are weak, or it can be transmission security, network security, somebody is able to modify, block, change, man in the middle attack, that's why SSL and all that. So we won't be solving all of this. All I want to say is that you have been asked to spend five days learning all this, but the people who are doing bad things need only five minutes. Why? Do they need to learn all this? Nmap, this, that, ports, SSL, handshake, this protocol, that, what encryption, elliptic curve, cryptography. They don't learn any of that, what do they do? Double click, triple click, type the IP, attack that IP. So this is called cyber crime tool kits, okay? So you can go search for that, you can reduce it, but you can search for that. And this slide is borrowed from training material at CERTIN, CERTIN leaves a lot of useful material, and it has a lot of values, so I left it. Please don't try to read everything there. It is giving in a nutshell the attack timeline starting from the 1980s. The first one I remember was a poor student who Morris Worm, it is called. Anybody knows about that? Yeah? In Cornell, one student, yeah, what was that? Then you think some terminal in a type two, no, all the little parts, by using the terminal. Slightly different, this is, he found Sendmail, have you heard of Sendmail? MTA, the one that actually routes mail across internet. Not the client, not the front end. You have to make the mail reach the other side. So he was able to find a hole in that, and he wrote a mail that would multiply itself and send 20 copies, 20 copies, 30 copies to other people. He just wanted to check, test it, and he wanted to do it once, but unfortunately an error in his script caused it to exponentially blow up, and it never stopped, and it took 10 days for the sysads of internet to clean this down. And he was a bright student, so the codes let him off. So that is the type of security problems then. Today it's very, very different, okay? So today we have information warfare, I told you, countries fighting with each other, military, Stuxnet, I think Professor Fatak was mentioning the wrong example about Russia attacking Estonia or something. Have you heard of Stuxnet? Anybody has, S-T-U-X-N-E-T? What was that? US implanted that stuckness via worm into the facilities of, I hope, Iran. Iran, yeah. So the nuclear centrifuge of Iran, this is manufactured in Germany, Siemens, okay? Yet their firmware, what is firmware? Washing machines have software today, you know that, right? Are your washing machines on internet? Should they be on internet? Why should they be on internet? I want to hang up the clothes, this is not true, okay? So when I come back from home driving in the traffic, I press a few buttons, my washing machine starts, when I enter it ends, I take the clothes and put it in the dryer. I don't want it to run in the daytime, okay? I want it to run just before, finish just before I come. That's one reason, another reason. There's firstly logic 2.0, it makes my clothes 90% white. Now there's firstly logic 2.3.1, it makes my clothes even better. So the firmware has to be upgraded. So should video cons send as engineer to every person and change that software on that machine? No, if it's on internet, you can press upgrade, ta-da. Okay, your clothes will be brighter. Anyway, so telling all that, then centrifuges which were controlling the nuclear equipment in Iran, that is for making the heavy water or extracting the uranium, they managed to tamper with that software to make sure that it didn't work properly. And it took a long time for Iran to figure out, okay? So anyway, don't worry, all countries do this. And the next slide says that attacks are no longer by a single person, like a student. Attacks are orchestrated. So denial of service attack, you've heard? I don't want from one machine, because then I'll be caught. How do I want a denial of service? I want machines in different parts of the world to simultaneously bombard, that's botnet, we've already seen. So these slides are giving you this perspective, which is the bad part, that first I said it's good, without internet teachers can't be there, mathematicians can't be there, banks can't be there.  And therefore all these requirements that my director will want, that there should be confidentiality, nobody should see anybody else's mail, there should be integrity, nobody can send mail on my behalf, authentication, what is non-repudiation? If I send my students a mail saying that their quiz on quiz three is canceled, then I cannot later say I didn't send it, I'm giving failed grade to everybody, they should be able to prove that I sent it. Other way also, okay? So then there is availability, all this. And the last line is the punch line. We should assure all this on internet, using a protocol called IP, which is like a postcard, everything that you write there, the to, the from, the data, without SSL, without encryption, without all that, it's visible to everyone, okay? So we know that this is a very hard job and other parts of the course are telling you how cryptography is the key, sign, go on, without that nothing. Post-setting up all these protocols, mechanisms, concealing the information, making sure integrity is there, hashing functions, so on, so forth. Today we are going to take the other job, like I said, as you said, we are coming to the ugly part now.  So this is our critical, is it a critical national infrastructure? What is this? Does anybody care if we just slip into this lake or that lake, we are mistake between two lakes? So suppose something comes and we fall into this lake or we fall into it, will anybody care?  So this is a joke because critical national infrastructure usually means banks and atomic energy and space and ISRO and all that, okay? So this is how the US homeland security and all have classified it. And so I'm just, for a joke saying that you are asked to protect IIT bomb-based networks, saying that this is the world's most important resource for India and if our server gets broken in that main building, then India will face a big prestige loss, therefore protect it, this is your job. How will you do it? So our solution is very easy. In Pohai Lake, we have crocodiles. In Vihar Lake, we have leopards. I let me tell you, it's more effective way than what we are doing for the cyber security, okay? So because fiber cuts. If anybody wants to cripple IIT Bombay, all they have to do is go into that main road. I won't tell you where. There are two, three yellow fibers coming out like this, just cut it. Nobody's guarding it, okay? Cutting it is a two-minute job. You don't need even power hacksaws, even a normal hacksaw may do. All the, why we are serving is because nobody knows where that wire, where that wire is coming. So we are surviving. So that's why all this, okay? And they don't need to come through main gate and show their whatever badge or cards and all that. They can just swim across the lake, right? That's why we put crocodiles in Pohai Lake, okay? So that's not it. So let's spend two minutes. What will an attacker do? Let's say the attacker is not allowed to come near IIT Bombay. We have done the magic. He has to sit at least in Pune or in China or in Pakistan. He can't come within 100 kilometer radius. Can he still do damage? That's the type of attacker we are worried about. Not somebody who comes here with a hacksaw blade and all that, okay? So what will he do? So I won't do the live demo. There's an example, dnsstuff.com. You go to a site like that, type IIT Bombay.in, AC.in, and it will tell you so much information about IIT Bombay. What is their name, server? What is their IP address? And luckily for us, I did this yesterday. We have not failed, zero. We have set it up properly. There are five warnings, but 30 of the tests we have passed and five more information, extra information items about us. So all this information is public. And you can do this for any domain. You can check out a lot of information. So the second information that it says is that we have passed the mail's MX records. This is important. Do you know what is MX record? That if somebody wants to send mail to us, what IP they should connect? Which means what? That mail relay and mail relay to 10321, 125, 126 is what? Public internet IP. And that should run all this command. So they are actually trying reverse, there should be reverse lookup, I will not explain. It should also have from the address to the name mapping. Otherwise, it's untrusted IP. But if you have both, then you know that your server, which is your mail server. And if it is public IP internet receiving mail, it should allow anybody to connect to port 25. If you don't allow them to connect to port 25, they can't send you mail. Yes or no? So we should be running some service. And once you run some service, you are using some software, with software. So this is the send mail or the queue mail or the post fix. So all this software written by you, no. Microsoft Exchange, MS. Also written by you, can you see the source? So again, please, I'm not anti-Microsoft, although I don't like them too much. But suppose, is it conceivable, that if you're using MS Exchange mail server software, that there is a subroutine there, which says that on May 23rd, you please do this. Send a copy of all some mail going to the director at ITB to postmaster at microsoft.com. Can there be some hidden, what is it called? Root, kit, Trojan, whole. Yes or no? Can it be there in send mail or post fix? You know the difference between send mail, post fix, queue mail and this other one, MS Exchange. These are called FOSS or FOSS, which means what? Free, free means what? Free has two meanings, zero cost. Free also means unrestricted, you can use it without licensing, 10 users, five users, three MB, 20 mates like that. Free, open source. Open source means what? Code is not only available, you need not install binaries. So if you have the time and energy and you have the knowledge, you can read every line of code, you can compile the code yourself, get the binary and run it. And if you find code buggy code like that, saying send mail to post for Microsoft, you can remove it. Not only you, anybody in the world, all of them are seeing the code. If anybody finds any such bug, they will tell the others. Microsoft binary only. So we can, okay, use trusted binaries because it's faster and better. But in principle, he can now probe, see which software is running, whether you're using vulnerable software, even good software, even open SSL had a hot bleed. Did you know about that? So it is not that open source is not having errors or faults. Just that it is open, more people are fixing it and so on and so forth. So he can find out from these IPs what services are running and so on and so forth and he can try and get the attack. And he can find out now that server tells him that there is a web www.itb, it's a different IP address and it has all this, it is enabled, it is SSL enabled. This is the certificate that IT Bombay is using for its web server. I didn't put the whole thing, it tells all that. Now if you're using a compromised certificate or there is some problem, he can again attack. There are many, all I'm saying is wealth of information is coming to him by just using a public website to check. He can trace the route to try to find out what are the van links, which service provider they are going through and trace route ends up at a Bombay VSNL site and beyond that we are not responding to pings. We are trying to mask some of the data so that we don't want to unnecessarily give extra information to others and very sophisticated tools are available to attackers. That is not part of today's lecture but I'm sure in the rest of the course you will see it. So let us get back to defense. So this is the problem statement that the big bad wolf is not only on internet. They are there in hostel five, hostel six. They are there in the main building. They are there in the residential network. We have to allow access to our network and resources to vendors, to alumni, to outsiders. Those who want to apply to get. So that's the top line. Saying that there are so many users, there are so many applications. There are research, Moodle, our web pages, our other CDP lectures. We have to interact with the world. That's our mandate. And there are administrative software. People want to pay fees. This, that online parents want to see grades, secure way, so many other requirements. Then there is so much system software that we need to install. Then there is the OS level firewalls, LDAPD and some of which we'll see today, databases. Then of course the part that we won't see today. The pre-seize, the printers, the modem. Suddenly power goes, something burns. More important, the fiber also. The UPS, AC, cables. So I have heard in my 20 years here how many times the rat has eaten that important optical fiber. I don't know, they like all those places where we do all these important connections, the rat goes, eats it. Biggest security threat. Cannot be solved. So but anyway, we have to do all this. And here are the requirements that we have a huge academic area. We have hostels, we have residential network. Okay, we need performance, we need at least mail and web browsing. We need so many other things, Skype and video conference and NKN and all that. And then we have users and management where the nightmare begins. Misuse, then we have so on, so forth. Okay, so without further buildup, little bit. This is, now I'm going to the next 10, 20 slides are not live demos. I hope I'll have time to show you today's network, today's setup, which is let's say 25% different from what I'm going to say in the next 10, 20 slides. These next 10, 20 slides are what it was five, 10 years back, five years back. The reason being, I don't want you to attack our network. So you work with old data, it is more or less similar, but we have made changes, we have improved, we have added newer software and so on, so forth. But this would be a good case study. So that is the thing that we have. And here is an example of a open source router. Today, everything that I am saying and using a software, there are equivalent commercial products. There are boxes, routers which are very compact and sleek, but we are using a Linux box with five network cards and connecting different parts of the campus. Why the residential network is coming through a separate router, more control. That's one more place where we can monitor. And why residential network is separated from the rest of the network, so that different policies can be set. About which time, what they can access, how much for speed they can get in the bandwidth. So the IPs they use have to come via this router. So IP tables can be configured and I'll tell you how. To allow better performance when you're working in the department and worse perform, I'm not saying that's a good policy. I'm saying that if you want to have different policies for different parts of your network, then you have to architecture should support that. So in some sense, this is the ResNet architecture. And this picture, I'll spend a few minutes. Again, I apologize in case it's not big enough, but you will all get the PDF slides later and you can study it in little more detail. This again is not today's setup, but basically this is what is called the demilitarized zone. We are going to focus not on the end, what is in the desktops and workstations and department level servers and so on. We are going to look at the central facilities, which we will call the demilitarized zone. So what is below this is the IIT Bombay land. So there is one internal firewall. Have you heard of the word demilitarized zone? Pakistan Army is on that side, Indian Army is on that side, in between is. So usually they should fight each other, but sometimes if spies are coming from here, also they will block. So internal firewall is there so that our internal users also cannot do bad things to our servers. An external firewall is there, it's in the top, which prevents the big bad internet from doing bad things. And these two firewalls have to work in cooperation with each other and in between, and again I'm sorry the picture may not be as clear to you, there are all these servers. So I will try to just say a few things which are interesting. So we have called here LUM1, LUM2. Load balancer is the official name of software like this. What is load balancer? That when I want to browse the web, there are now 10,000 students, okay? Total 20,000, 25,000 people have access inside IIT. Should they all try to go via the same proxy server? No, so we have several cluster of proxy servers. And this now redirects the load and balances the load in either round robin passion or load basis. So we need that. Similarly, on the other end we need load balancers for people coming in to send mail to us. We can't have only one mail, one machine receiving mail. Just a quick guess, the answer is coming later for five years back. How many mails does outside internally leave? From outside IIT Bombay, IIT Bombay, how many mails comes every day? So think about it for your institute then think about it for IIT Bombay. Okay, so five years back it was 60,000 mails per day. Now I'm sure it is at least 10 times that. It's not a guess work. You have to know this, right? You can't just guess. Why should you, should you know this if you're interested in security? So why should you know this? Why should you know how many mails come? So my slides are there, I'll explain. But let's just try this one interaction. Is the number of mails coming into IIT Bombay every day something that a system administrator should track? When there is an attack, he would be able to detect that. Excellent, give him chocolate, eclair, whatever, okay? So this is the first principle of security. If you don't know what is business as usual, if you don't know what is normal, what is abnormal, you cannot be secure. So if you are getting every day 50,000 mails or one day you get three lakhs, are you just going to say, okay, today three lakhs, again 50,000. Like that every Thursday you get three lakh mails, other days you get 50,000, are you going to keep quiet? Is there a security implication? It may be harmless, it may be on Thursday, somebody is very interested in praying, which God is on, famous on Thursday, they don't know. And he's sending all these mails saying Jai Hanuman or Jai. It may be harmless, but probability of it being harmless is less than probability of it being harmful. So this is what is called knowing the status, knowing anomalies, anomaly detection. Okay, so we are going to see that. That load balancer makes our hard job harder, that all the mails are not coming to one place. They're coming across many machines. So when mails are coming, and they're coming across many van links. So where is this information? How to consolidate? How to analyze? That's the goal, okay. That's where the next two things are going to help, that RCS log. Okay, I won't explain everything. We have machines for sending mail, we have machines for proxying, when internet access quit, it is called. Then we have machines for the rivers, we host. I'll explain that again, and maybe the slides will be easier to follow if you just do this thought experiment with me. You went to the lab, and you tried to find out the IP address of www.csc.itb.ac.in. CSE department's web server. What do you think the answer will be? No, but what should it start with? Guess. 10 point something, right? 10.105 is CSE department subnet. Okay, so 10.105. That is the CSE server. E will be 10.107.u.v. Civil engineering will be 10.101. Or something like that. We have decided to split our subnets like that. Each department is getting a 10. something something. Yes? Now you are outside, you are in Japan. What should be the IP address when you ask for www.csc.itb.ac.in? It cannot be 10. Why? Only one IP address. Firewall IP address. Network IP address. So there are many ways to do this, but it has to be a public IP address. It has to be an address which is reachable by rest of the world. So that can be the firewall if you use what is called natting. And don't, but it can be a, like in our design, we have what is called a virtual host. It's a reverse proxy. It's a real machine. It's running Apache software, or something similar. NGINX is the current version we are running. Earlier we used to run Apache itself. It will accept requests, but it will see which domain you're asking for. The outside person in Japan. If he's asking for www.csc, it will from the inside firewall, go through that and get the data from sir and give it out. So he's not having any data of any department. He's acting as a reverse proxy. Proxy we all know, right? We have to send the request to the proxy. Proxy gets data for us. This is the reverse. Outside us is sending request to this. And that is the machine shown in the left as a cluster of machines. That cluster is also important to analyze. Why is it important to analyze? Who is visiting? What they are visiting? What they are trying? Which type of request they are sending? Are they sending payloads which are? What's a payload? In the request you can, all these crossfade scripting or many other things. So if you don't watch that activity and that activity is not visible in your server, right? You're www.csc. Sometimes it's better to do the control there rather than let every department control everything and analyze. So centralization, the power of centralization. First of course, IP addresses forces you to centralize. Second is application level means more logging, more control. Firewall level if you do the natting and translation less control. So these are design choices. So this is where I wanted to give you a flavor.


So our first speaker, Eric Pradikslis, sorry if I put you that, is a Rubenstein fellow at Duke University where he focuses on data science that spans medicine, policy, information technology, and security. Eric is also lecturer in biomedical informatics at Harvard Medical School and strategic innovations advisor to Mendicine Suns Frontieres. And now without further ado, please welcome Eric Pradikslis. Thanks, Eric. Thanks, everybody for coming. How's it going? There you go. Can you hear me OK?  So Nina asked me not to wear my jacket. She's a little stiff for this crowd. It's like she's going to halfway through this talk. I beg you, she asked me to put the jacket on. So anyway, I'm going to start off. I'm going to talk about medicine. I'm going to talk about infectious diseases. I'm going to talk about medical misinformation. And I want to start off and say, if you can actually be dispassionate about medicine, which is something scientists and clinicians are taught to try to do, is be dispassionate, then medicine actually starts to look a lot like math in some ways while you're being dispassionate.  So you want a little math in the morning. We'll do a little math. What's 100,000? Odds of death from getting a measles vaccine. 1 in 3,000, odds of being hit by lightning. 1 in 250, odds of having identical twins. 1 in 50 children is me. I have a peanut allergy. 3 out of 300, odds of catching the measles of exposure after getting the vaccine. But the case will be much more mild. Not to catching measles if you're unvaccinated. Rare. That's side effects. No, just so you know, I'm actually not in love with these numbers. And I'm going to pick on this a little bit. And so I don't think that telling somebody something is rare is that helpful when you're a sleep-deprived new parent with a baby and you're really worried about something that you read. So I think everything is benefit-risk. So whether it was my time as a drug developer, my time at FDA, or whatever it was, there's always a calculus in this. And it's actually really hard to do. But you've probably done it. If you ever tweaked your knee and had your ACL done, the anesthesia is like, well, there's a 1 in 20,000 chance you're going to react to this thing. And you know what?  And so I wrote a paper in JAMA about using cyber techniques against medical misinformation. And I got a lot of shade and a lot of hate for it. But I read through them. And of course, I found at least one of the email that I knew I would get and that I wanted to talk to.  So to that one person, that one child, that 1 in 200,000, that really sucks. And I could see how that could change and color your opinion for the whole rest of your life.  OK, so we'll get to that in a second. So these are all about numbers. You know what the odds of 10 out of 10 are going online saying something and meeting an asshole?   And I think this is kind of the basis of what we're talking about here. Keyboard courage can be a really dangerous thing, especially to unknowing and unwilling folks. Now that said, there are different types of misinformation. And I'm going to be really careful about this. So I may say this 10 times. I actually have no problem with individual citizens, even if they're whacked, sharing their opinion that's their right.  I have no issue with that. Right? What I'm talking about, organized, anti-science, anti-population misinformation and mal-information. This is how they're described. So I spent September on Rohingya Service with Dr. Laub-Borders. And you know, these people were mowed down because they were updating their status on Facebook. Someone was looking for one of them. I'm okay. Where's this going on? And next thing you know, the government was using Facebook to target this population. Somali population in Minnesota was targeted by anti-vaxxers and had an outbreak because they're a marginalized population and they're vulnerable. So I'm going to talk a little bit about that. But 2015, I'm working with Partners in Health, my last Ebola mission in West Africa, and we're looking for the last patients. And it was actually something kind of new because no spacesuits. One of the first times we went into the village is why?  People run from people in spacesuits, right? This isn't good. Remember, a lot of these cultures are actually used to what we're learning, that governments can be overtly corrupt and overtly self-interested. Because if you grew up in Africa, that was your reality, depending on where you lived. Is that anybody with power would use it to hurt you and for their own gain. We're just starting to see that here in this country, but it's real. So these people look really happy to talk to me, right? And you know, in this particular village, there was a man who had a stroke. He didn't have Ebola. We got him transported. But we found a lot of kids with measles. We found a lot of cholera, right? Because there was a full quarantine, schools were closed. Everything was closed. The hospitals had been shut down because of all the workers who had been infected with Ebola. And so the idea here is that messaging really matters. And trust me, I'm a doctor. No, trust me, I'm a scientist. No. And the really thing about this is that a lot of scientists and doctors don't get that. They don't get the fact that a lot of people don't realize it, are we kind of part of this issue? So just a few pictures of babies with measles. I'm only putting this up for one reason. And that's that. It was an interesting study that I was watching. So New England Journal published this thing a few weeks ago. It's all about measles, it's fine. This person asked some really good questions. And you know, really detailed questions. Like where did you get your safety data? Did you get it out of VAERS? Which is the FDA Virus Adverse Event Reporting System. If you got it out of VAERS, everybody thinks VAERS is wrong. Did you apply the multiplier that Harvard Medical School says you should apply? Blah, blah, blah. Funny thing is I was previewing this. And I'm gonna tease them with former FDA Commissioner Rob Califf before I flew in. And he got all hot about this. He was like, well, you know, if you share data, they just attack the data. I'm like, then don't share bad data. But you have to at least try to answer the question.  Now in fairness, I actually looked yesterday and the author did put up the answers to these questions. So good for them. Good for the New England Journal. These were fair questions.  The other thing about this is the idea of public health. The idea of public health is that you're protecting the public more so than the individual, right? So herd immunity matters. Here's a really sad story of a young man with leukemia who died because he was exposed to measles. So we're in a room right now. We're all together. We're all breathing the same air.  Probably not. So there is an idea here. Now, public health, you know this. Why were we, when we come back during the last Ebola outbreak, why were they allowed us to put us in jail for three weeks every time we came back? Because it was a mandatory evacuation order for the countries we went to. We broke the law by going and so it was their right to imprison us when we came back and we did. They were nice. They put me on house arrest. I had friends that went through a lot worse for three weeks every time. But you know, we knew it when we went. So I think the idea here, public health and that where people need to help people. And also we have to, you know, you don't want to hurt somebody on accident. And so I get the whole, well it's my body, I'm going to do whatever, but you know, you get schools being closed in New York right now with little kids and stuff like that. So it's a tough issue. Interestingly, medical charlatanism is as old as it gets. So everybody's heard of caveat emptor, buyer beware. The first known case, 1603 in England was somebody basically selling an intestinal stone that allegedly had magical powers called a bazaar stone. Chandler versus Lewis, this is fascinating. It actually was medical charlatanism. And basically what they decided was because there was no warranty and because the buyer couldn't prove that it wasn't a magical bazaar stone, they found for the plaintiff. So the other thing to think about here is that is that in medicine, the customer isn't right, you know, and that you have to watch out for you. It's caveat emptor. So when we're looking at what goes on in healthcare, self-educating, making your own decisions, these aren't easy things because not everybody's gonna understand the science or even the beginnings of the science. The other thing is that medicine is always playing catch up. You can't regulate something bad if it's not illegal yet. So I was at the FDA for this. How many people remember the New England compound and pharmacy thing? These people committed mass murder, right? They really did, right? They had basically dirty drugs that get injected right in your spinal column and people died. Here's the thing, being on the inside of the FDA, when this is going on, a reporter of the commissioner actually knew the inside story on this and what was killing them about the inside story is, of course, as soon as this happened, FDA, what are you doing about it? The FDA had actually tried to sue these people multiple times on anything they could think of because they were pretty sure they were doing bad stuff and they lost every lawsuit they filed. And then after this, and then as you can see from eventually after this bad thing happens, well maybe you should regulate compounding pharmacies. In 1910, people were selling belts with radiation on them as a cure for diabetes and stuff like that. So there's always been charlatanism, you know, the vaping stuff today. If it was really about anti, if it really about smoking secession, why was the first flavor bubble gum or one of the first flavors if you weren't trying to attract kids? So the people have to beware and they've got to watch what they're doing. But if something isn't illegal yet, is it illegal? Right, so if is targeting a community on Facebook, going into that community with pamphlets, talking them into, talking them out of doing medical care that leads to injury, illness or death, a crime. Today, not yet. Should it be? Good news, I'm not a lawyer, I don't want to know. I know what I personally think that I see a lot of sick people and I prefer that people don't get sick. But at the same time, it's a tough thing to do. But is it harm? Is it harm like yelling fire in a theater? Or is it harm like plowing your car into those same Somalis in Minnesota that were targeted?  And again, I'm not talking about my aunt who may want to say, do not brush your teeth with that water if it has chlorine in it. She can tell anybody she wants about that. Or she can advertise anything she wants. I'm talking about organized campaigns of disinformation and malice information. Here's the thing. So as somebody who's faculty at Duke, Med School and Harvard, we're a big part of the problem. That whole rare reaction is rare. What does that mean? How rare? I mean, are we giving people? So I really like the line that what we have is a medical problem with a media dimension, not an information problem. That trust in medicine, trust in science has flagged over time. Then, and sometimes for good reason, who knows if it's really smart and healthy to eat eggs? Dietetic epidemiology, are you kidding me? I'm 52 years old, at least 10 times in my life I've been told the opposite of what I have been told. Now, the fact that science changes that we learn and grow doesn't make science bad. It does make it imperfect. It does open it to criticism. So living in an open society where it's okay to challenge whether or not eat eggs, I think that's fine. But I do think that we have to understand, the public has to understand that the World Health Organization leads patient harm as the 14th leading cause of illness and disease on the planet. There was a study out of Johns Hopkins a few years ago that said it might be his highest third leading cause of death in hospitals. So people do get hurt in healthcare. So we in medicine have to be better. The hospital, we have to figure this stuff. We've got to own part of it and not just discount people out of hand. Now, what I like about this is I love the Facebook post from BCH, not just some faculty there too, on the right here, because what the mom really says is, you know, they treat us intelligently. That's what we like about this place. They listen to us and our voices matter. They're not talking at us. So I do think that even scientists and doctors can learn how to do this stuff. So spent most of my time, I was a J&J for 20 years. I was an FDA and went to doctors above borders and places like that forever. And I've worked on a lot of compliance. The CIO would change, I was a CIO at FDA, so I've worked on a lot of compliance. You know what happens when things go wrong, at least this is my opinion, is that most of the time it's a mistake and then sometimes there's a few bad guys, right? Most of you work at device companies like that. Things go wrong.  There's a breach. Someone wasn't trained well. They made a mistake. I mean, when I was, I worked on the harvesting organs and tissues when I was in undergrad. And I actually shipped off expired tissue one day. I had to reread the SOP and do that, figure it out, right? You make mistakes. But what about the bad guys? So what I wanna talk about the rest of the talk is what should we be doing about the bad guys? I know they're in the minority, but they might be really bad. So can you do it by a counter messaging? This is an interesting thing, right? You know, in general, and I'm no expert on this stuff. I'll be the first one to say it. If for anyone else here, there's better experts in this. Most people actually say that counter messaging isn't that effective. A lot of people will say, and actually some of y'all that were in the device thing yesterday, we said it, right? We said, don't answer question number two because it validates the question if you try to answer it, right? So you back away from that. But, you know, the best study that I think on this has actually been anti-terrorism. How do people become radicalized? So counter-marriage messaging, we know because we've seen really good people try to do it. And I spent three years going back and forth in Arabia building a cancer center in the 2010 timeframe for the only large cancer center in the Arab world that imams getting up and saying violence is bad and hasn't stopped extremists from doing violence as much as they respect their imams, it hasn't happened. So counter-messaging, what appears to work is more like alternative messaging. You tell a different story instead, but don't directly go at what's going at. So credible voices, all of these types of things are somewhat difficult. My favorite headline in a while, read the two tweets, it's the best. A lady posting on an anti-vax site, what do I do to protect my child now that there's a measles outbreak? And then I don't think this, while this gentleman's response is funny, I don't know that it's all that useful for this poor lady who's now worried about her kid. And by the way, still deserves to get to protect her kid. Even if she is on a different website. And what really is going on here is everything else, it's also polarized that anybody that wants to be in the middle and be normal or be smart and be reasonable, they get shouted down by the two extremes that are trying to fight it. How do we get kind of towards the middle? So positive case studies work, learning by history and role model tend to work. Alternative messages and work. If any of you followed on Twitter, there was a great piece that was put up by the Hunger Games Cast in 2015 that I put up. You can look at my Twitter and you can find it. What was awesome about it was they basically just said how they're trying to calm down all the hype, you're gonna close the airports, they're gonna close the port. There was a story of like in Ohio of someone who came back and went into a wedding dress shop for bridesmaid dress and that shop actually went out of business because nobody would shop there because somebody who had done a bowl of service had been there. And the whole thing, so the Hunger Games Cast put out this kind of cool message. What was really cool about it and what was first about it for me is one, Paul Farmer, my boss at PIH was in it. More importantly, my daughter was 12 and couldn't tell anybody in her school, middle school where I was. Could you imagine what Playground Talk was like when all that hype was going on on the table? She could say I weren't anybody. Her best friend's parents knew, we knew. And so that video was awesome. Gender, faith, ideology-based messaging and need for specificity. This last one's, the second and last one's really important. How do we match the volume and velocity? Because I've seen this. I have colleagues that will get an article in JAMA saying look, at the end of the day your statins are probably good for you and they get 5,000 people banging on them. What are you, one person, what do you do? I think we need a troll army of med students but I'll talk about that in a few minutes. There they are. How to accomplish better messaging. So at this point, the rest of this talk is my shameless ask for your help. You people know this stuff better than I do. I am looking for, I'm gonna be running some experiments. We need to try some things.  And I think the cyber community can be one of the communities that can actually do something that can make a difference. Oops, sorry. So how do you fix it? You know, how should patient groups convey their concern? I was looking at Andrea here. How do they communicate? How do they do things like that? How do you know when it's going on? So one of the experiments we're gonna run is a great guy, colleague of mine at Boston Children's Hospital named John Brownstein, built something called the vaccine centimeter. It measures a centimeter of vaccines on all social media platforms. Built it in 2014, shared it, nobody would fund it. So if you looked at my little chart about measles has gone up, I wish the CDC had funded it, or FDA or somebody had funded it, but we'll fund it. So go into these communities, measure what's going again. Not so much to say this community is bad or good because of sentiment. I wanna understand signals. I wanna understand that if I sort the social media by communities, am I seeing targeting? Am I seeing ethnic groups being picked out? Am I seeing, that's what I wanna see. I wanna know if that's going on because that's a signal that's maybe worth managing. What's the correct oversight? Who watches this stuff? One of the things, one of the comments Jim had took out of my paper, I say, so how does the AMA deal with the KGB if it happens to be state sponsored? That's a one-sided fight, isn't it? How does that really happen? So there's that. So we're gonna do consistent messaging pilots, counter messaging, trolling and adaptive pilots, and then measurement to see how things go on. And I'm looking for people to help with that. I'm looking for people to teach for that. I will put you in rooms full of med students that wanna do that. So do we need a CVE list for healthcare? Right? Chris is here. He's been helpful to explain this. Chris from MITRE explained the CVE list to me and how it works. It's not exactly, but do we need to know? Especially again, I'm talking about the bad guys. I'm talking about targeting of groups. So if you look at the breakout in the Orthodox Jewish community in New York, if you look at the Somalis in Minnesota, while they weren't targeted online, those were low tech. That was pamphlets, that was talks, that was phone calls. How do you think the people organized to do it? That was online. So you would have seen, should have seen leading indications into it. So this concept, how would you do it? So this is one of the pilots I'd like to talk to people. How do we set, what would you do? What would you watch? What would you change? We've got the epidemiology side. People have mapped the whole ethnography of some of these groups. How do you know when it's going on? What if it does look like it's state sponsored?  You know, you're gonna win an election that way? Maybe, I don't know. But if we see it, do we recognize it? And then once in a while, you gotta hack somebody. So if we find something's really, really bad, right? What do we do? If we see a community's being targeted by a group, what do we do? I actually have no problem dreaming of a world where their websites go off for 24 hours and I have no problem dreaming of that world. They have their right to do whatever, but if I see targeting or something like that, I don't have any issue with that. Let's talk about it. So there is the idea of saying, what do you actually do? We are doing honeypot experiments, working with some experts and honey tokens. If anybody wants to see that, we're gonna put up data, we're gonna see where the data goes. Anybody that has expertise and wants to see that, we gotta do it. Right now, everything I'm talking about is diagnostic. Not talking about any retaliation, I'm not talking about hacking, I'm not talking about any of that stuff. That's for law enforcement to decide. I'm talking about as a scientist, I wanna diagnose and I wanna figure stuff out. So because we don't learn our lesson, we've got a bowl again, right? Really bad. So guess where I'll be heading in a couple of weeks? So I'm gone again. I gotta say bye to my wife and kids because we don't learn lessons we should have learned two years ago. It's not easy to think about infectious diseases. My mentor was my great uncle. Graduated Harvard Medical School in 1943. We shipped right to the Battle of Britain. Was there at 48 concentration camps? Came back, practiced 50 years. Grew up right after Spanish flu, thought the world was gonna be taken out by an epidemic. This little guy, we're trained not to touch people. That's not me, that's my friend, Tim, holding that guy. Because the ambulance drivers were the first ones to go in Ebola, put the people in the back of the car, close the door, nobody opens it until it gets to the clinic and we can take them out. That little guy was with his mother, his father, a cousin and a grandmother and when we opened that ambulance he was the only one who was alive. And all that happened during the six hour ride. So we need to work on these problems and the world is a lot smaller than people say it is, right? And by the way, stuff works when it works. So here we are going over to help Africa with Ebola and you've got places like Rwanda where cervical cancer is the second leading cause of cancer death and they're killing it with campaigns. We know the HPV vaccine is a huge success. So anyway, there's that. I love this tweet. I haven't met Jenny, I'm stealing this tweet. I do think y'all are the immune system of healthcare. Thank you. That's kind of a great question. Complaints, criticisms. Okay, yeah, it's a great question. I don't have a definitive answer. All I can say- Keep the question, please. Yes, sir. I'll do it with a microphone. The question is, in the conversations with people, how do you meet people in common ground when you've got somebody who has strong opinions and they're trying to manage a lot of stuff, right? So it's a great question. My answer is what I've used as patients and I think that's why we need an army, a troll, you literally need an army of people and trust me, just so you know, I'm absolutely not the phenotype for some of these conversations but I've got friends and colleagues that are. Now, you can't get sucked in and you can't take forever with it but you've really got to look at it and be very fact-basic. This is what I think and this is kind of where it is. You also have to try to conduct something outside. If somebody is like, if somebody, I had no idea if I was going to have someone call me out in the first five minutes of this talk but if they did, I would answer two questions and ask them to shut up so I could finish my talk and then I would have bought them lunch but, you know, just, but I can do that. You can do that one-on-one. When you're managing a group of 20,000 you can't necessarily do that but I do think people have to get there because, again, that one voice can cause a lot of trouble and it really amplifies. So it's a great question. Sir. It's more a question about the campaign. We see issues in modern US medicine at a peer-to-peer level especially when we're looking at areas that are underserved. If we can get other physicians to agree and to come along with modern messaging and evidence-based medicine and sticking both practices they know work, how do we expect this is going to work in a moderately educated society? Yeah, that's a great question. So the question was is that it's hard to change everybody's mind, even experienced doctors and how do you do it in a thing? I actually think we have to land in a different place. That's why I like the idea of medicine is, medicine is a medical problem with immediate dimension. I don't think 10 years post the internet where anybody has the authority they used to have as a professional anymore. I don't care what your profession is. You can be an architect, you can be whatever. And so I think a lot of people aren't used to dealing with that but I do think it's more of a conversation now and that it's going to be a mixture of what people are doing and the next generation of clinicians as we train them have to figure that out because they're not going to have that white coat authority and I don't know that that's a bad thing. They're being trained by the ones who do, med students, residents, fellows through the program having the same traditional values in a world that's changing outside of them. There's a lot of... There's a lot but at least what I see in the classes, I work on, for example, at HMS we did a computationally medicine medical class where we actually had med students rotate into a pharma company and figure out value and pricing. I do think it's going to take stuff like that. I think we have to change the way we're medicine. I actually think that we should be more selective and opportunistic about what med students do in their third year. I think physician scientists get this all the way through but I think that third year is just a prime spot to go work with me at MSF, do whatever is your passion, figure it out and find it. It's a great question. Any other questions? Thanks guys, see you.


Hello, I'm Catherine Branson, Innovation Hub Coordinator in the Office of Innovation here at the National Archives. The hub has a unique way to collaborate with the public to make records accessible. Our scanning room is open Monday through Friday by appointment for researchers and volunteers to use our equipment to scan records held in the National Archives building. Right now, you're able to come in and scan certain types of military records, including Civil War-compiled military service records and pension files. You can take a copy of the scans with you and we'll put a copy into our online catalogue. By putting these files online, we're making them available for researchers who aren't able to visit DC to view the files in person. Our current volunteer projects include pension files of Indian scouts and buffalo soldiers who served in the post-Civil War Indian Wars and compiled military service records of the 20th Main Infantry Regiment who fought during the Civil War. You can also use an online pension or service record index to identify other files that you're interested in. Military records can be a great source of genealogical information, such as names of family members, home addresses, and details about the pension applicant's life. They can also be useful for historians, students, and others who are interested in firsthand evidence of the experiences of 19th century soldiers and their families. To find records that have been scanned in the Innovation Hub, go to catalogue.archives.gov and search, in quotes, Citizen Contributor. Here are a few highlights. Photos are a rare find, but every so often there's one in a pension. This is John Gordon, who enlisted at age 15 after the Union Army emancipated him and the other enslaved people on that plantation. This affidavit is from Running Wolf, an Indian scout who just missed the Battle of Little Bighorn. Benjamin Clifford served in the 20th Main. He was wounded in the face by gunshot during the Battle of Gettysburg and received this certificate of disability for discharge. This is a copy of a naturalization certificate sent to the pension office by Goma Roberts to prove his American citizenship. The Innovation Hub has been open since 2015. Since then, citizen scanners have contributed over 700,000 pages to the National Archives Catalogue. Thank you to everyone who has come in to scan. If you'd like to help out, please email innovationhubatnara.gov to make an appointment to scan.