Security of Health Information
The world is racing to contain the new COVID-19 virus that is spreading around the globe with alarming speed. Right now, pandemic disease experts at the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and other public-health agencies are gathering information to learn how and where the virus is spreading. To do so, they are using a variety of digital communications and surveillance systems. Like much of the medical infrastructure, these systems are highly vulnerable to hacking and interference.
That vulnerability should be deeply concerning. Governments and intelligence agencies have long had an interest in manipulating health information, both in their own countries and abroad. They might do so to prevent mass panic, avert damage to their economies, or avoid public discontent (if officials made grave mistakes in containing an outbreak, for example). Outside their borders, states might use disinformation to undermine their adversaries or disrupt an alliance between other nations. A sudden epidemic — when countries struggle to manage not just the outbreak but its social, economic, and political fallout — is especially tempting for interference.
In the case of COVID-19, such interference is already well underway. That fact should not come as a surprise. States hostile to the West have a long track record of manipulating information about health issues to sow distrust. In the 1980s, for example, the Soviet Union spread the false story that the US Department of Defense bioengineered HIV in order to kill African Americans. This propaganda was effective: some 20 years after the original Soviet disinformation campaign, a 2005 survey found that 48 percent of African Americans believed HIV was concocted in a laboratory, and 15 percent thought it was a tool of genocide aimed at their communities.
More recently, in 2018, Russia undertook an extensive disinformation campaign to amplify the anti-vaccination movement using social media platforms like Twitter and Facebook. Researchers have confirmed that Russian trolls and bots tweeted anti-vaccination messages at up to 22 times the rate of average users. Exposure to these messages, other researchers found, significantly decreased vaccine uptake, endangering individual lives and public health.
Last week, US officials accused Russia of spreading disinformation about COVID-19 in yet another coordinated campaign. Beginning around the middle of January, thousands of Twitter, Facebook, and Instagram accounts — many of which had previously been tied to Russia — had been seen posting nearly identical messages in English, German, French, and other languages, blaming the United States for the outbreak. Some of the messages claimed that the virus is part of a US effort to wage economic war on China, others that it is a biological weapon engineered by the CIA.
As much as this disinformation can sow discord and undermine public trust, the far greater vulnerability lies in the United States’ poorly protected emergency-response infrastructure, including the health surveillance systems used to monitor and track the epidemic. By hacking these systems and corrupting medical data, states with formidable cybercapabilities can change and manipulate data right at the source.
Here is how it would work, and why we should be so concerned. Numerous health surveillance systems are monitoring the spread of COVID-19 cases, including the CDC’s influenza surveillance network. Almost all testing is done at a local or regional level, with public-health agencies like the CDC only compiling and analyzing the data. Only rarely is an actual biological sample sent to a high-level government lab. Many of the clinics and labs providing results to the CDC no longer file reports as in the past, but have several layers of software to store and transmit the data.
Potential vulnerabilities in these systems are legion: hackers exploiting bugs in the software, unauthorized access to a lab’s servers by some other route, or interference with the digital communications between the labs and the CDC. That the software involved in disease tracking sometimes has access to electronic medical records is particularly concerning, because those records are often integrated into a clinic or hospital’s network of digital devices. One such device connected to a single hospital’s network could, in theory, be used to hack into the CDC’s entire COVID-19 database.
In practice, hacking deep into a hospital’s systems can be shockingly easy. As part of a cybersecurity study, Israeli researchers at Ben-Gurion University were able to hack into a hospital’s network via the public Wi-Fi system. Once inside, they could move through most of the hospital’s databases and diagnostic systems. Gaining control of the hospital’s unencrypted image database, the researchers inserted malware that altered healthy patients’ CT scans to show nonexistent tumors. Radiologists reading these images could only distinguish real from altered CTs 60 percent of the time — and only after being alerted that some of the CTs had been manipulated.
Another study directly relevant to public-health emergencies showed that a critical US biosecurity initiative, the Department of Homeland Security’s BioWatch program, had been left vulnerable to cyberattackers for over a decade. This program monitors more than 30 US jurisdictions and allows health officials to rapidly detect a bioweapons attack. Hacking this program could cover up an attack, or fool authorities into believing one has occurred.
Fortunately, no case of healthcare sabotage by intelligence agencies or hackers has come to light (the closest has been a series of ransomware attacks extorting money from hospitals, causing significant data breaches and interruptions in medical services). But other critical infrastructure has often been a target. The Russians have repeatedly hacked Ukraine’s national power grid, and have been probing US power plants and grid infrastructure as well. The United States and Israel hacked the Iranian nuclear program, while Iran has targeted Saudi Arabia’s oil infrastructure. There is no reason to believe that public-health infrastructure is in any way off limits.
Despite these precedents and proven risks, a detailed assessment of the vulnerability of US health surveillance systems to infiltration and manipulation has yet to be made. With COVID-19 on the verge of becoming a pandemic, the United States is at risk of not having trustworthy data, which in turn could cripple our country’s ability to respond.
Under normal conditions, there is plenty of time for health officials to notice unusual patterns in the data and track down wrong information — if necessary, using the old-fashioned method of giving the lab a call. But during an epidemic, when there are tens of thousands of cases to track and analyze, it would be easy for exhausted disease experts and public-health officials to be misled by corrupted data. The resulting confusion could lead to misdirected resources, give false reassurance that case numbers are falling, or waste precious time as decision makers try to validate inconsistent data.
In the face of a possible global pandemic, US and international public-health leaders must lose no time assessing and strengthening the security of the country’s digital health systems. They also have an important role to play in the broader debate over cybersecurity. Making America’s health infrastructure safe requires a fundamental reorientation of cybersecurity away from offense and toward defense. The position of many governments, including the United States’, that Internet infrastructure must be kept vulnerable so they can better spy on others, is no longer tenable. A digital arms race, in which more countries acquire ever more sophisticated cyberattack capabilities, only increases US vulnerability in critical areas such as pandemic control. By highlighting the importance of protecting digital health infrastructure, public-health leaders can and should call for a well-defended and peaceful Internet as a foundation for a healthy and secure world.
This essay was co-authored with Margaret Bourdeaux; a slightly different version appeared in Foreign Policy.
EDITED TO ADD: On last week’s squid post, there was a big conversation regarding the COVID-19. Many of the comments straddled the line between what are and aren’t the the core topics. Yesterday I deleted a bunch for being off-topic. Then I reconsidered and republished some of what I deleted.
Going forward, comments about the COVID-19 will be restricted to the security and risk implications of the virus. This includes cybersecurity, security, risk management, surveillance, and containment measures. Comments that stray off those topics will be removed. By clarifying this, I hope to keep the conversation on-topic while also allowing discussion of the security implications of current events.
Thank you for your patience and forbearance on this.