Greeting gestures, a language of paying honour, respect, love, adoration, graciousness, empathy towards each other. It is a global custom and has multiple variations. Each country has its own customized version and ritual. The most popular version i.e. hand-shake probably has its roots in Great Britain. Men in the United States will usually shake hands when greeting each other, but it’s not usual for them to kiss when greeting. Americans in addition to handshaking also do a fist bump, wave and hug.

For English people, the handshake is the formal way of greeting when meeting someone new. In informal situations, both men and women use a quick kiss on the cheek, and for women who know each other well. Handshake works universally as a professional way to greet. It is a little firm in Germany, more extended (3-step handshake) in Botswana and for Malays, it extends to touching each other’s fingertip followed by their hearts. Filipinos take a hand of their elders and press it to their foreheads called as ‘Mano’.

One of the major health and environmental challenge we face today is rapid emergence of novel pathogens. The spread of these pathogens, especially of nosocomial origin (hospital based), is often linked to cross-contamination by healthcare workers and ways of greeting gestures while meeting each other. An idea of handshake-free zones in hospitals have encouraged awareness. But also questioned how a doctor will take the physical examination without touching a patient. On the other hand, we cannot ignore the fact that microbes like Acinetobacter calcoaceticus, Enterococcus faecalis, E. faecium, and Shigella dysenteriae type 1 can sustain on hand surface upto one hour while Pseudomonas aeruginosa and Burkholderia cepacia survive up to 30 minutes. Rotavirus might survive for 20 min while the viability of human parainfluenza virus is nearly 60 min.

Studies indicate that a contaminated hand can transfer its viable contamination to seven different subjects or surfaces. One of two common items is a clean paper towel and soap dispenser with average transfer rate ranges between 0.01% to 0.64% and 12.4% to 13.1% respectively. We touch our face nearly 2-5 times a minute i.e., 2000 to 3000 times a day. In fact, whatever contamination we have on our hands is also getting transferred to our face. We may wonder whether our hand soap is capable of killing all the potentially pathogenic microbes. Are we washing our hands correctly and does it really help? We often use hand wash, sanitizers without giving attention to their content and standards. Do they qualify for antimicrobial purpose? Moreover, our greeting gestures further contribute to the spread of the germs.

For healthcare workers, the protected physical contact is a non-avoidable choice. Healthcare workers and doctors should change their gloves while switching from one patient to another. Avoiding greetings which involve physical contacts especially during outbreaks can provide a preventive approach to managing outbreaks. Hospitals need to improve compliance with hand hygiene. Handshake free zone can be one alternative in hospitals. But they aren’t designed to replace hand washing but to complement it. Creating handshake free zone will also bring attention to the hands as vectors for disease. It will also improve compliance with hand hygiene and an easy and inexpensive way to reduce infections.

It is rude to not to shake a hand if a person extends its hand towards you in the name of trust and honour. We can’t be rude to others but why not to adopt ‘Anjali Mudra’, Wai, Namasté, Wave, Bowing or Adaab to greet. This respectable way of greeting with no physical contact should be adopted in the healthcare settings. In India, by adopting our age-old greeting method especially in a healthcare setting can shield us from many invisible microbial infections. We just need to adopt, practice and re-practice these gestures to decrease the spread of infections.

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Introduction

The famous Silicon Valley investor Marc Andreessen says, “software is eating the world”. By, which he means that increasingly we are bringing software into systems to increase efficiency, lower down the cost or time involved in the process. Interestingly, humans also do software writing and humans are prone to make mistakes. It is estimated by various experts that 1000 lines of code (KLoC) has approximately 15-50 bugs present. Bugs here mean mistakes made by the software programmer while writing the software code. Bugs often result in some kind of malfunction or wrong output. Some of these bugs can lead to exploit by a third party making the larger system vulnerable or as we call hackable. As long as humans will write software, bugs will be there.

In a typical software company as bugs are discovered, new code is written to fix these bugs. The new code might further result into new bugs hence the cycle continues. At the consumer end, we keep receiving software updates over the air, as we use our phone / laptops or other devices, which are many times an attempt of the software company to overcome the past mistakes.

A lone computer hacker or an organized crime group looks at these software updates (sometimes called patches) very curiously as for them this could be a chance of hitting the jackpot! They reverse engineer it and try to understand the bug, that the patch is trying to cover. Very often systems are not updated with latest updates. Leading to most system having a known vulnerability, which the hacker can take advantage after understanding it well. Hackers further can create a simple script (programming code snippet) to some sophisticated software, which can then take advantage of the vulnerable system. We often call such a program as malware, as it is built with bad intention.

Today, as we talk it has become from a hobby crime to organized crime! Software companies regularly receive communication from bounty hunters about exposing their critical software bugs and in exchange not to do so, hackers want to charge them bounty money. Some software companies have gone further and engaged these bounty hunters to reduce security risks in their software.

In some cases the hacker is not interested in the bounty money (hence they do not inform the software maker) but rather interested in exploiting the bug. Sometimes, the bug is not known to the software maker or anyone else in the world and can be converted into a lethal attack. Such attacks are known as a zero day attack! As prior knowledge of such a vulnerability does not exist. Hence, most software security solutions, like anti virus software do not work on them. Further selling the knowledge of exploit as lethal software is now called as a cyber weapon. Nation states are now engaged in buying or building such software to infect systems of enemy states. Hence, we have come very far in the business of software bugs, where the enemy could be a lone developer, an organized crime group or a Nation state.

How is software eating the health sector and the threats linked to it?

In the above section we discussed in general, how the exploitation of software is increasingly becoming a serious business. While, we have seen many examples in last 30 years from a hobby software programmer to Nation states taking advantage of the software driven vulnerabilities. We would like to share some examples closer to the health sector.

1. Malware affecting data systems

Hospital information systems and similar information systems as part of the healthcare delivery have become very commonplace and one of the core component of the system. As pointed out in the introductory section, organized crime groups are now looking to exploit software bugs for commercial purposes. One of the ingenious way that they have developed is a malware known as ransomware . Ransomware is a malicious computer program which when executed on a system encrypts the data with very strong encryption making it unusable for hospitals or any other care provider to access patient records or other vital information. It then demands a ransom inform of bitcoins (a crypto currency) in order for the victim to have the key to decrypt the vital information. In recent incidents of ransomware infection, some hospitals in USA have even demanded millions of dollars as ransom and some have even paid.

The mitigation strategy for countering ransomware for any organization would be a strong backup of data. Also, creating awareness among the employees on sources of malware and reducing the chances of accidental infection of the workplace systems.

The long-term solution of tackling such organized crime is a better international legal framework, which allows international prosecution and cooperation among law enforcement agencies.

2. Denial of service attacks on ehealth services

In 2007 there was a distributed denial of service attack that took place in Estonia. A statue of the Russian soldier was removed from the Tallinn Square, capital of the country. Which sparked a response from sympathizers from Russia and it brought down the Estonian economy for three days. Estonia being one of the most advance countries when it comes to take up of e governance services, ehealth being one of them. The entire attack costed less than 50,000 US dollars. That was the first Denial of service attack the world saw at the level of a nation state.

The basic premise behind such an attack is that you have a service (e-service) to be provided to citizens over Internet like their own health records for example. The provider would have some finite amount of bandwidth and computing power at the backend of the service correlating to the average load on the service. In a distributed denial of service attack, the attacker uses compromised computing devices (commonly known as a bot) to access the Internet service. The botnet, which is a collection of such bots could be having thousands or millions of such devices that simultaneously access the service. The service provider is not able to distinguish the normal traffic from the bot traffic and often the server crashes under the heavy load. For a normal user trying to access the service, the service is unavailable because of the finite resources of the server being exhausted by the bot traffic. Hence, it is called a denial of service attack.

Hence, when a city, state or a nation is considering providing an eservice to citizens it could witness such attacks. One strategy to mitigate such attacks is to have tracking of the server traffic for any anomalies and having redundancy available in the system. This is achieved many times by putting the service on a cloud, which can tolerate such traffic fluctuations.

3. Data leak and breaches

Many health systems or systems require some kind of authentication mechanism to log in to the system in order to access the service. Many a times these are text password based systems behind which, important patient profile or health records information is stored. The largest of the companies like that of Google, Microsoft etc have seen attacks where the attacker is able to leak the passwords of millions of their customers. Such scenarios result in massive breach of data privacy and compromise for customers.

Good security practices, proper encryption of data and regular updates of the system are some of the key considerations for avoiding such instances. Nowadays, two-factor authentication has become a standard practice for making the authentication systems more robust. However, still some user awareness is needed to opt for better security practices whenever possible.

4. Hacking medical devices and health system

If we look at the building blocks of the health systems, where information technology is deeply integrated. We have already covered the health information systems, eservices and patient interface of authentication into the services. However, increasingly we hear about Internet of Things (IoT) devices in the health sector domain. Which means the integration of Internet services into traditional medical devices or new age devices, which have also connectivity. For example, a thermometer which can send the temperature data to your phone or a stethoscope which can record the patient breathing sound and upload in a server for finding patterns of lung diseases. These are powerful use cases and provide great opportunity to clinicians and care providers, where they have greater computation power available to them and they are able to do more with less. However, these IoT devices are prone to the same kind of attacks as any other communication device or a software program. They can be compromised to show wrong values and totally messing up the diagnosis. There are already such instances. One such instance not related to health sector but important is of the Stuxnet. Stuxnet was designed for the SCADA systems of Iranian nuclear program by USA and Israel in order to delay their nuclear program.

5. Stealing identity information

As mentioned in the point 3, about data leaks and breaches at the system level. One problem, which can arise from such an attack, is a further more damaging attack that is stealing of identity information. In India, mobile phones to receive an sms message containing one time password is increasingly becoming a standard practise because of being cost effective, simple and secure. Any such application, which you may install on your phone, can also get access to the sms and other features of your phone. Meaning the incoming sms or calls can also be stolen by this application to complete the transaction on your behalf. As increasingly we have to prove ourselves using biometrics or passwords to online systems. It is possible for the attackers to steal these credentials and access our records without our knowledge. Hence, any third party applications that we install on our devices (especially phone) , we need to be very careful about the type of access control they have on our devices.

6. Implantable medical devices with communication interfaces:

In 2007, the former US Vice President, Dick Cheney’s implanted pacemaker’s wireless communication was disabled fearing a terrorist attack. This sounds like science fiction to many but incident has already happened ten years back! Many of the medical devices are built with a communication interface and it is quite normal for a typical pacemaker or other such devices to have a Bluetooth or a similar communication technology based interface for remote diagnosis and other purposes. While, the communication ability of such a device was planned for looking at the state of the pacemaker it was not designed with keeping security in mind. Hence, it is possible that someone can connect to a critical device like pacemaker and shuts it down remotely.

One more reason that such exploits are possible increasingly as computing is becoming cheaper. What seems strong security today might not be strong tomorrow. However, an implantable device might stay in the patient’s body for tens of years. Hence, we need to have a long-term view on the communication interfaces and their capabilities on such devices. We need to make considerations on control and information capabilities of these interfaces. Misuse of control capabilities can lead to even death and misuse of information capabilities can lead to breach of patient privacy.

Way forward: why Internet is the new breeding ground for crime?

The law of the land governs the Internet in every country and hence the legal regime globally is very fragmented. However, a user of Internet does not see any borders or walls and so is the criminal. They build their criminal businesses where they do not fear strict government action and often for paltry sums the user or the national law enforcement agencies do not pursue the criminal cases cross border.

On top of it newer crypto currencies like Bitcoins, makes it easy to make such transaction in an anonymous manner. Dark net marketplaces provide a breeding ground for criminals to conduct illegal transactions of billions of dollars without getting caught. So, the three important components, weak legal enforcement, anonymous currency and secret marketplaces are enabling the cyber crime to flourish. If we want to slow it down, we will need greater international collaboration among lawmakers and user awareness at all levels.

Reference:
(i) https://www.wsj.com/articles/SB10001424053111903480904576512250915629460
(ii) http://labs.sogeti.com/how-many-defects-are-too-many/
(iii) https://www.ted.com/talks/mikko_hypponen_fighting_viruses_defending_the_net/transcript?language=en
(iv) https://hackerone.com
(v) https://en.wikipedia.org/wiki/Zero-day_(computing)
(vi) https://en.wikipedia.org/wiki/Cyberweapon
(vii) https://en.wikipedia.org/wiki/Ransomware
(viii) https://en.wikipedia.org/wiki/Bitcoin
(ix) http://www.csoonline.com/article/3033160/security/ransomware-takes-hollywood-hospital-offline-36m-demanded-by-attackers.html
(x) https://www.theguardian.com/technology/2016/feb/17/los-angeles-hospital-hacked-ransom-bitcoin-hollywood-presbyterian-medical-center
(xi) http://innovatiocuris.com/looming-danger-of-ransomware/
(xii) http://www.bbc.com/news/technology-24608435

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Attractions

Advantages of medical treatment in India include reduced costs, the availability of latest medical technologies, and a growing compliance on international quality standards, Doctors trained in western countries including US and UK, as well as English-speaking personnel, due to which foreigners are less likely to face language barrier in India. According to the Confederation of Indian Industries (CII), the primary reason that attracts medical value travel to India is cost-effectiveness, and treatment from accredited facilities at par with developed countries at much lower cost. The Medical Tourism Market Report: 2015 found that India was “one of the lowest cost and highest quality of all medical tourism destinations, it offers wide variety of procedures at about one-tenth the cost of similar procedures in the United States.”

Cost

Most estimates found that treatment costs in India start at around one-tenth of the price of comparable treatment in the United States or the United Kingdom. The most popular treatments sought in India by medical tourists are alternative medicine, bone-marrow transplant, cardiac bypass, eye surgery and hip replacement. India is known in particular for heart surgery, hip resurfacing and other areas of advanced medicine.

Quality of care

India has 28 Joint Commission International (JCI) accredited hospitals. However, for a patient traveling to India, it is important to find the optimal Doctor-Hospital combination. After the patient has been treated, the patient has the option of either recuperating in the hospital or at a paid accommodation nearby. Many hospitals also give the option of continuing the treatment through tele-medicine.

The city of Chennai has been termed “India’s health capital”. Multi and super-specialty hospitals across the city bring in an estimated 150 international patients every day. Chennai attracts about 45 percent of health tourists from abroad arriving in the country and 30 to 40 per cent of domestic health tourists.

Factors behind the tourist inflow in the city include low costs, little to no waiting period, and facilities offered at the specialty hospitals in the city. Chennai has an estimated 12,500 hospital beds, of which only half is used by the city’s population with the rest being shared by patients from other states of the country and foreigners. Dental clinics have attracted dental care tourism to Chennai.

Ease of travel

The government has removed visa restrictions on tourist visas that required a two-month gap between consecutive visits for people from Gulf countries which is likely to boost medical tourism. A visa-onarrival scheme for tourists from select countries has been instituted which allows foreign nationals to stay in India for 30 days for medical reasons. In 2016, citizens of Bangladesh, Afghanistan, Maldives, Republic of Korea and Nigeria availed the most medical visas.

Language

Despite India’s diversity of languages, English is an official language and is widely spoken by most people and almost universally by medical professionals. In Noida, which is fast emerging as a hotspot for medical tourism, a number of hospitals have hired language translators to make patients from Balkan and African countries feel more comfortable while at the same time helping in the facilitation of their treatment.

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Read all the issues of InnoHEALTH magazine:
InnoHEALTH Volume 2 Issue 3 (July to September 2017) – https://goo.gl/MCVjd6
InnoHEALTH Volume 2 Issue 2 (April to June 2017) – https://goo.gl/Nv3eev
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz
InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2

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