criminals, and they try to get it back. and there's one scene where ben kingsley who's this kind of evil mastermind who used to be a college roommate of the lead good guy hacker, played by robert red forth, there's this -- redford, there's this whole monologue on the roof, you know, marty, the wars now it's not about bullets and bombs, marty, it's about the information. it's about 0s and 1s, about we're in a war, and it talks about who has the most information. so mike mcconnell sits up in his chair, and he realizes, this is our mission statement now. and so he goes back, and he gets the last reel of this film, and he has everybody in the senior executive at the nsa watch it. he tells everybody to go watch this movie, even take off the afternoon to go watch this movie, this is what we're doing now. he takes one of his best field officers, brings him back to fort meade, creates a job for him called the director of information warfare. and then all these kind of nascent cyber-type outfits

around the bureaucracy and the military all of a sudden call themselves -- this is when the air force information warfare center. information warfare is the new thing. that's where the money is, that's where it's happening. but what they really did do, and then when haden came along, they created something called the tailored access office, t.a.o. .. from the internet and crossed over the air gap. something called the information operations center which is a

joint operation, they would go over and plant a device like a thumb drive and insert malware and the nsa gave it to them from that. that is how it happened. people ask me, they knew i was doing this book and they said what can i do to protect myself? if all you are interested in is keeping out petty criminals and kids trolling the net there are things you can do like putting a lock on the door. . as someone who really knows what he is doing and once something you have especially in the nationstate there is nothing you can do.

a few years ago the defense court had a special panel on cyberwarfare and they concluded the inherent fragility of our architecture, the inherent fragility, all these things that built over time and it was an arms race, they reported, looked at the records of a lot of wargames and were tasked to hack in and always got it. the buzzwords in pentagon circles they don't always talk about prevention. you don't leave your doors open. they are talking about perfection and resilience, to

detect when someone is hacking really fast and resilience, stick them out and repair what damage you can. the game is lost on kicking people out. you don't want to give up the game. they are going to get in. this i learned after i wrote the book. the navy for example is teaching people to used sextant's because they figure the data linked to gps might be hacked. there is a lot of worry, our entire qualitative advantage is built on things that are networks and they can hack into that, it is back to m-16 rifles. what are you doing? . that is what people in the military are very worried about.

>> one of the other things is the dual use nature which raises the important question of what this means for the nature of warfare going forward. it is all about information, civilian systems as easily as military systems as easily well protected. what does this mean to national security? >> it is a game changer. >> it could be. there are a lot of vital military networks that are not classified. somebody once said there is

logistic and professional, logistic. how do you get food and water? a lot of that is on open networks. they play wargames where people mess with that. they go over here, supposed to meet up with the refueling plant which is over here so it crashes into the ocean. a lot of funny business with that so you don't know anything happened. the vulnerability of infrastructure, i don't know how much i buy this, the scenario in some was trying -- china putting pressure on taiwan or the south

china sea and they say take your aircraft carriers out of here or we are turning off all the lights on the eastern seaboard. then what do you do? china becomes more plugged in and deterrence sets in because we can do the same to them. could be like north korea, air and, they don't have anything to hack so what is the response? i don't know but things like that could conceivably happen in the interesting thing about the civilian infrastructures over the past few decades as the military has become more aware of this, the number of intersections between their own network and the outside to about 8. used to be numb 100 or 150. the intersection sits on those intersections, they can do that legally because they have the

legal right to do this, they can actually see when someone is coming over. civilians, even civilian governments, there are hundreds, thousands, there is no way, even if the nsa has a legal right there is no way the department of homeland security which -- they know how to do this but they are really out to lunch on all these things. this is what has led to a policy of offense. they came up with three terms, computer networks defense, computer network attack and something in the middle called computer network exploitation, a double-edged sword. it means you want to get inside the other guy and see what is going on. you could say this is active

defense because the only way is to see what they are doing. at the same time it is one step short, you are in there, all you have to do is push a button and you are attacking. we are into their stuff. it is generally accepted that they can do this and they can do it to us. to what extent, how much, i don't know. for years ever since reagan plan in 83, this directive and clinton as well, they tried to get critical infrastructures which are privately owned, man up on this and get some security going, banks have done pretty well, into taking your money and making you feel trust and you

trust your money won't get lost. there are some good information security departments and we care a lot about that but there are thousands of attempts a day, not very many get in. power companies, electrical power grids, dams, things like this. they are not paying much attention because you have given us some advice on best practice and maybe i will spend on $10 million getting there but it seems to me the other guy, the bad guys work the way around that and -- the amount of money it costs to do this presentable he isn't much less than the cost to me of cleaning it up afterwards and maybe i can get you, the government to pay for this anybody but no incentive to do it and one thing was to lay down some mandatory security

requirements or critical infrastructure, secretaries of the treasury and commerce, you are going to impede, make servers slower, reduce competitiveness all of which is true. these people are not evil but they have their own self-interest and it is contrary to this. >> the last few years regulators have come forward -- appreciate how far back the tension is with the rest of the government. exactly how much -- >> president obama signed cybersecurity national action plan which if you read the book

sounds a lot like eight or tween 9 other commissions that have been formed or planned over the last 20 years. one thing is he created a chief information security officer. there is no executive order giving him the power. he is like the director of national intelligence. he doesn't have any authority to hire anybody or fire anybody. a real guy like this would have authority to go to an agency where they have passwords like 12345, i am kicking you off the internet. you are off the internet and you have a month to fix it. no one has the power to do that. something several people told me

they learned about the executive branch in general, people go to the executive branch and think i will set policy. 10% is creating policy and the other is diplomat, going back time and time to make sure it is still and this implementing part, except in the defense, is what has always been lacking. this is something that is not new. it has been known on a presidential level for more than 30 years. >> michael daniel and his wife rolled out incentives that one reason to benefit the commission, to take ideas --

>> when it worked it worked. it is a way of slopping it off. >> for all of us we are rather hoping. >> in this case it is a little late. this will land on the doorstep of the next administration. they picked the commission, the head of the commission two weeks ago. i don't know if other commissioners have been chosen. this could take months. it will land on january 17, 2017, and treated by the next administration the way everything from the previous administration is treated by the next administration, which is something to sit your wobbly desk on top of. inch the administration got into

the office and readjusted. present a copy of your book, what lessons should they take about going forward, what can they learn from the history you just wrote? >> i don't write books that have explicit policy directive that the end but they would look at that and i hope some of the lessons are taken from the subtitle, there is a long history of this. it has been going on for a very long time. recent history, case studies and see why this happened and why this didn't lead to anything and try to make it seem like -- the thing you do need, i think, just

ignore the resistance, you need someone in the executive branch who doesn't have a lot of power. one of the most overused words in washington, the energy czar, you need to create a czar who has direct access and a president who is at least kind of interested in this. i don't know how these people work in places like the white house. i would not be able to stay away. you have 20 crazies hitting you up from 30 different subjects and someone says we might have a problem with critical infrastructure. excuse me. i have people being kidnapped and killed and you are talking about cybersecurity like all the

president's men, home rule might have a chance this time and we should put this on the front page. let me know. very theoretical to a lot of people. it is something distant. when you have something that has to be decided tomorrow it is difficult to focus your attention on something as complicated as this and there doesn't seem to be an obvious solution. let's flip this switch. if it were that easy it would have been done a long time ago. >> we have a room full of people want to talk about this issue. we are taking questions. when i call on you identify yourself, give your affiliation, keep your questions short.

gentleman in the room. >> three major computer systems all came down simultaneously. think that was coincidental? >> i don't know. some things really are coincidental. the wall street journal, the syrian electronic army or something like that. there are now 20 nations with military with explicit cyberunits. some are better than others. the cyberelectronic army is good at hacking into the new york times and the wall street journal. they have their security so it is a little harder now. so i don't know of anything --

another thing, somebody launches a ballistic missile that you, you can trace the arc and see where it came from. they are getting much better at tracking this. you are launching a cyberattack you can hop from one place to another. you can disguise where you came from. they are getting better at tracing that but it is not a numb 100% thing. you want to know the reason why we know the north koreans attacked sonja? you want to know? they were not doing this in real time because there is no reason to. we are so infiltrated into the north korean computer network it is going into the files, the delete nsa hackers can watch on

their monitors what the north korean hackers are watching on their monitors when they were doing the hack the fbi said we have high confidence north korea did this, unusually certain language. a lot of computer experts said i don't know, looks like an inside job. they absolutely knew. >> the gentleman in the back and then over here and then over here. >> my name is ethan berger, cybersecurity. wondering if you looked at the stock market, commodities,

exchanges, etc.. from my perspective a bunch of numbers on the screen you mess up the economy of the country being an insider etc.. and do a lot of damage to the country's economy. have you looked at it? >> it wasn't the focus of my book, but that is part of it. one thing that is interesting, the intelligence community knows how to get into every foreign leader's bank account. they have made an explicit decision, mister president, we know where slobodan milosevic's bank account is. we know where the bank account is and there has been a decision made by the cabinet that we do not want to go down that road because it could go the other way.

they did miss with the bank account of slobodan milosevic's cronies but there is an explicit decision because of the backlash. they don't want it happening to us. somebody could do it to us anyway. they have everybody's personnel records which were not protected at all. they asked clapper about this, he said what kind of retaliation are we plotting against china? this wasn't an attack, it was an intelligence operation and there are certain things we do sometimes. i don't blame them for getting into this. not like they were attacking anything, they were getting information. in terms of messing with the stock market or been tabulation, it is all out there and open.

this has been going on for decades and only now is there a defense science board panel writing a report on cyberdeterrence. one of the things they are trying to do is define what that means. what are you trying to deter? is it the government's responsibility to deter an attack on a bank or two banks or ten banks? is it just government facilities? nuclear deterrence it is clear what deterrence means. cyberdeterrence what are you trying to deter q robert gates when he was secretary of defense asked at what point does an attack like this constitute a

war. two years later the defense department rebecca under certain circumstances this could. nobody -- it is not an issue for lawyers in the pentagon to define. with nuclear weapons there is a thick red line between using nuclear weapons and not using them. that is a reason nobody has used them because you don't know what is going to happen afterwards which insider, there are cyberattacks going on thousands of times a day and no one knows where each individual country's cyberline of attack is. the first time a president said we are going to retaliate against this attack was when the north koreans attacked sony over a movie. who would have thought that?

there are many opportunities for misunderstanding, miscommunication, things getting out of hand because one person's nuisance is another person's grave national threat and what happened on day 2? i was interviewing one guy pretty high up in intelligence, interviewed him a few times before, he says what is your thinking about cyberdeterrence? i don't know. i am trying to find that out and nobody seems to know. i am on a panel, i thought you might want tbe on it. i would never do it because it is classified but they are so desperate they are asking me if i am interested in joining this board on cybersecurity. it is something they have not thought through. part of the reason is for decades has been tied up in the

nsa. the joke used to be nsa stood for no such agency. even when the bomb went off in 1945 certain things about that were classified but the general working affects were well understood and from the very beginning you had civilian strategists thinking about what does it mean? how does this affect war? what does deterrence mean in this context? can we use these weapons in a war? people who were not wrapped up in classified things with the military were thinking about this and having influence. cyber, until very recently, you had to have fbi clearance to even know about a lot of things going on. there is nobody who can think about this who is in a position to think about it seriously. the title of this book, "dark territory: the secret history of

cyber war" , where the title comes from is a pretty good story. when i write my book i know the title will emerge from my notes. it never does. and colleagues -- thinking we need to get together with other major cyberpowers and figure out some rules of the road. what kind of targets we can't attacked. the darkest depths of the cold war, americans and russians didn't kill each other's buys. something as simple as that, didn't happen. there is nothing like this where you can tell people we are wandering in dark territory. there is the title of my book. "dark territory: the secret history of cyber war" . then i looked it up, what does this mean? i don't want to have some

obscenity. turns out this is a term in the north american railroad this signifies a stretch of track that is ungoverned, that is just perfect, perfect metaphor. i wrote an email and said did you know this? marco yes, my grandfather worked on the santa fe railroad in kansas for 50 years, topped terminology around the house all the time. that is a perfect description of what is going on. engineers are unknown, the consequences of a collision are far more cataclysmic than two trains running into each other. that is the situation we are in. >> no interest in speaking for the us government but beginning -- the state department established norms in relation to

the chinese. >> they are talking about setting up a forum to discuss the process by which they can discuss -- but now, you were talking about there is russia, israel, france, china, how do you bring north korea and iraq and and syria -- how do you bring these guys into this cooperative back room meeting, back room some place to discuss the heroin market, how do you do this now? it is a tough one. one of the documents ed snowden put out, cyberoperation policy, it had certain things different departments were going to do and one of them was setting rules of

the road and there was a progress report a year later pending. the hardest thing in the world to do. if you are going to say okay, let's stay out of each other's whatever, electrical power plants, you got to stay out of the electoral power plants too. how do you verify, how do you know? the one time, the first discovery of a known intrusion into a classified network happened in 2008 in an operation called buckshot yankee. they discovered soviet russian ips and things, the way they discovered this was the interest points lost.

what if somebody was already in their you go and look for the network and see if anybody is in their and they discovered somebody in there. we are talking about things where you have zillions of lines of code, mauer taking up numb 150 lines of code. how do you even detect that? 150 lines of code, millions of lines of code, really difficult. >> buckshot yankee is significant for one of the reasons -- >> on a friday afternoon the guy in charge of the information assurance directorate comes to the directorate, i know we have a problem.

within five minutes they come up with the concept. within 24 hours they devised a solution, tested it and put it in motion. general gaetz is watching from the pentagon. they are counting the number of computers that might be affected. here i am, this has been going on so he did what people were doing for a while. that is when the unity of offense and defense happened.

and technology, and completely out to lunch on it, $7 billion have linked with all the combatants, devising work plans, all kinds of attack plans, that is where the area of growth is. a few minutes ago no one knows, no concept of deterrence or what happens the second day of cyberwar, it is incredibly classified, this machinery growing up, you are going advance the technology field before the thinnest layer of policy and strategy have been cemented onto the foundation. kind of a dangerous thing.

>> tested in the middle and implemented. >> answer my question. >> dave spencer, georgetown student and army officer. where do you propose we respond to strategic level cyberattacks? >> what do you mean? >> actual cyberattack rather than cyberespionage, strategically or hypothetically in this situation, not energy but transportation. >> one thing about our economy,

it is not centralized. you shut down the subway session in new york, it does not affect what goes on in washington or san francisco. some countries shut down transportation in tokyo, do what you can. and electrical power, they are extending the grid likely smart grid which is like stupid grid. it doesn't take up the entire country. in some ways, you know about data, computer networks, for perfectly rational reasons, economies of scale, you have personnel and everything monitored by sensors, makes

perfect sense. i can't even remember -- everything is controlled by computer networks. they didn't shut down centrifuges, they manipulated, and the centrifuges, it was a control device, controlling the amount of water. the voltage flowing through the electrical line, and in some ways, once these networks are set up it is hard to come up with a way to defend them.

it was more and more centralized going on the entire southwest regional scotland. the commission clinton set up, talk to the industry head, and a train company, they looked at them, what do you mean? to make these networks more secure, once it is more secure, the barn door has been opened for years, short of signing all over which no one is going to

do, it is like -- they go to the government, they say one thing we can do is have the fbi sitting on your network. not really. we can give you some ideas, things obama has set up and some things we do. coming from the secret briefing. again -- this is a tough one. this is not a book with a

terribly happy ending. >> a couple decades -- we haven't had a devastating attack and you might argue -- deterrence within cyberspace. >> the government has said it was by non-cybermeans. russia and china have more stocks to the computer networks. he mutually assured destruction thing. the wandering dark territory part, there is no solid red line. >> southern frontier and all the

way back. could you wait for the people who are online? >> a question. in many areas the us is the technology leader. everything i have seen suggests government has be lined technology. as far as you are aware has government done anything to create a classified aura or safe environment for our technology leaders, to be talking to them, to be aware to leverage that. >> that sort of thing in the defense industry, there was something created -- there are lots of interchanges like this like lockheed martin and three

defense companies, doesn't require that much but there are things like that. in recent years, information sharing systems, here is what you do. when dick clark was the cyberguy in the white house, he wanted to control everything and lay down mandatory security requirements and create something that was basically an internet for critical infrastructure where their internet is hooked up something like a government agency which would be able to tell when they were being

hacked, amendment, private industry didn't want that. the commerce department didn't want it and the treasury department didn't want it. it went by the wayside and you accept the whole package. most people don't want the whole package which is why the nsa by statute is doing certain things. and domestic context, must have had a court order, the attorney general, there were some very good people, even the head of private industry in the nsa share their stuff. >> lockheed martin -- [inaudible question] >> they are slow. >> speak into the mic please. >> lockheed is very slow. >> so i am thinking the

government should make the effort to make innovative companies or make them comfortable, it would be an advantage for the us. >> a big corporation trying to do that. one of the hackers in my book works for darkness for 18 months and created 140 projects, the most expensive of which cost numb $100,000 which all kinds of interesting things in cybersecurity. he hacked into a jeep cherokee to show people this is vulnerable, you got to do something about this. the obamacare online program is such a mess because they gave it to an aerospace company. what they should have done, the top ten graduates from caltech

and mit giving them a couple hundred thousand dollars apiece and put them in a room, that would have been a better way. you are absolutely right. too bureaucratic and it takes a couple years to get people going and there have been three cycles upgrading the cyberarms race. >> in silicon valley, announced the establishment of the advisory board with the chairman of the board with eric schmidt. >> get us off of it. >> what do you say about what we have with the commerce secretary holding from dhs with

public/private partnership? >> a retired physicist, spent a lot of my career at ibm, a vulnerable place to attack or intercept signals would be the drone program. and going over the air someplace and be subject to fiddling with -- any stories? >> the thing about drones, they are very vocalized. and the signal goes to the command post, they would have to have -- they would have to have

certain things located in the signal. and they change channels. it is worth expending a lot of one drone, and even signaling drones or surveillance. it is a lot of effort to go after one thing to do much to your own interests. in the network, one of the early cyberwargames. 609th -- the head of the

wargame. and the traffic orders, that kind of thing is very vulnerable. a very narrow band, they change it a lot, and you don't know what this drone is doing, a potshot. and the drone crashed. and isn't a pilot in their. there were rumors, a couple things that crashed in iraq and someone claims we hacked into it.

i don't know if it is verified. >> watching the us -- >> there could be that. what is this drone looking at? you could learn things about what the us is interested in. >> the last few questions, full questions. >> on this side, behind, if we have time, we will take them. >> i am a graduate student at george washington cybersecurity. you would talk about it earlier and circle back to that, why do you think there has not been a

cyberterrorist attack of any note? >> they don't have a way to do it. you don't need to have a manhattan project. you need to have a room full of people who are adept at computers and the computers to do it. i don't think isis has that. i don't think al qaeda has that. there are reports that they are shopping around for freelancers to do that but maybe there are not that many freelancers who could do this and are willing to work for a terrorist organization. the intelligence community has its eyes on certain hacker groups that do work for bad guys like dark soul in north korea out of singapore and thailand. they know what these guys are

doing. it is not something that is inherently impossible. isis, they do get a permanent foothold, they could get invested in. al qaeda was a little early in their heyday so it is not out of the question that the convergence of forces hasn't happened yet. >> the impact -- >> my name is ron robinson. i am interested in your opinion on the struggle between the fbi and apple, talking about industry being ahead of government.

>> the elaborate thoughts -- both sides are being a little bit disingenuous. the public statements on both sides do not coincide what they are up to. fbi doesn't need the information. they already have the metadata, the business records of what numbers the iphone has dialed, that is already out there. they could have gotten that from verizon or sprint, the intercept -- interstate director said there is no formula for the metadata. i don't know what is in this phone. if they really wanted, they thought there was something in there we need right now for national security purposes, they could send the letter to the nsa, the nsa believes it, the

attorney general -- in certain ways it did not require the act of cooperation. at the same time, apple is right about this, they are looking for a new legal president that gives them the authority to do this kind of thing before encryption gets really hard. it is going to make it much harder for law enforcement and intelligence, not impossible, and a talked with a number of people, white house hackers and people in the intelligence agency and i am pretty convinced there is a way apple could have cooperated without writing a new operating system.

they were being forced to do by their first amendment rights and commercial energy. the fbi, the way this works, if you know, apple has done 70 times so the principle of cooperating is a little blown to begin with. there is a security feature, if you type in ten passcodes, what the fbi could do, you create a program, don't have to be in the same room, change that so the data is erased after 10,000 tries, then you could coming because there is commercially available password sniffer programs. brute force, 5000 passwords a second, we need to have you take

away this layer. i am not a computer scientist. i am told even by people very much on apple's side that there is a way to make that change without finding a new operating system. what they are concerned about is it could be the precedent for succumbing to other things or the chinese saying that thing the fbi had you do, we want you to do that. the chinese will do that anyway. i think it is a peculiar case for tim cook to make this a big -- on apple's side i don't know about that. what we are talking about, no privacy rights because he is dead. san bernardino county has

already given their consent, do whatever you want. we are talking about a guy who shot up a room full of people and been in touch with isis. for legal reasons, constitutional reasons, practical reasons and political process, looks like a great case for apple. also, brethren in silicon valley writing briefs, here is the thing. you have a contract with the government which apple doesn't and i do, you want to sell and often system to the government it has to be vetted for security by information. the first windows program that went through this process, the nsa found 1500 points of

vulnerabilities. they have a few captchas and left a few open. microsoft knew that and were fine with that. a few years ago google's chrome system, the source code was attacked by the chinese. there has been a 2 way street. when the head snowden stuff came out, i liken it to i am shocked, shocked that there is gambling going on here. there is a bit of hypocrisy. tim cook, partly his commercial brand, he does believe in this very strongly. somewhat at nsa told me, we have a meeting to talk about interests and issues with mutual interest. tim cook has never had one of these meetings. he is not interested in that.

among the industry of libertarians he is aiming for purity. maybe he was not chair when he opened up these other sectors. the way both sides have elevated this battle, it could end up having -- let's say they win the court battle. what i am worried about is somebody passes a law. senator feinstein has a law that would require companies to strip away their encryption and present with a lawful warrant. that is going a lot farther than what the fbi wants apple to do especially in the current climate of terrorism and people worried about elections where the opponent in the primary accuses them of being soft on

terrorism. the backlash of this could be reeling blues not sure why he decided to make a big political issue. this is a test. >> a member of the president's review group, featured in the book coming to debate the phrase to join us. >> final word, what is the one thing we should take away from your book? the one thing people should buy this book for? >> it is a lot of fun to read. how many ciderbooks can you say that about? >> thank you for coming. [applause]

[inaudible conversations] >> on sunday, april 3rd, book tvs live with author and publisher of forbes magazine steve forbes on in-depth, our live monthly call in show. mister forbes has authored many books which focus on politics and economics. in his book reviving america, he argues for a replacement of the current tax code and repeal of the affordable care act. other recent titles include power, ambition, glory, which compares great leaders of the ancient world with modern business leaders.

and how capitalism will save us, free people and free markets are the best answer in today's economy. in 2014 mister forbes appeared on books he be discussing his book money. the topic of money is straightforward and simple. even though it is shrouded with a lot of jargon and equations, the idea of money is very basic. we have gotten away from it and our policymakers today no less about money, monetary policy than they did numb 100 years ago. sincerely 1970s even though we had booming decades in the 80s and 90s overall our growth rates after we went off of the gold standard in 1971 the us average growth rates were less than they were before 1971. .. policymakers

>> good evening, everyone. good evening. i would like to start by thanking everyone for being here at our first event here at the collaboration of politics and prose as we embark on our first series of many readings. i would like to remind you to

turn off your cellphone or noise-making devices. feel free to order food or drinks. there is a question and answer question after the reading. if you have a question i will come give you a microphone. and after the question and answer we will have a signing. i am christopher jay and welcome you here. we serve over 500 locations a year including this one, king street, and different venues across the city. we have literary trips and children's program year around. we have c-span tonight. so you would like to see events like this and going forward subscribe to our youtube channel. i am pleased to welcome dayna

matthew as she discusses her debut text "just medicine: a cure for racial inequality in american health care" she is a professor at the university of colorado law school and the colorado school of public health. she serves on the faculty of the university of colorado center for bioethics and humanity and the cofunder of a mission who is bringing good health to low-income patients. she illustrates the implicit race bias in the health care system that results in the loss of 84,000 lives yearly.

she is proposing reform on specific sections of the civil rights act which she claims to provide a legal bases to hold liable those who discriminate and would help to establish a new standard in medicine. and michele goodwin holds the book as a massive written, capitating narrative that is at once stark and grisly and so provocative and well-written one can't stop reading. a page-turning award winning book. a medical apartheid. please join me in welcoming ms.

matthew. >> thank you, chris. that was an awesome introduction. i mind i would like to package it and take it home to my kids. i want to get right to the meat of the matter and talk about unconscious racism as it affects the health of the united states. i want to pick up on the number of 84,000 people. that is the number of people that the 16th surgeon general of the united states estimates dianne -- die annually because of health disparity in the united states. 84,000 people. that is a very big number. let that sink in and we will talk about why they die in a minute. my objective is to leave you

with food for thought. i i want to leave you with five m's. unconscious racial bias being moral, monterl, manageable, and just massively urgent. i had an experience when i was nine years old. i remember because it was my first experience with explicit racism. the explicit impression i was an inferior person to the speaker because of the color of my skin. i was on a playground and a

nine-year-old girl made it clear by using the n-word why she would not play with me on the playground and made it clear to everybody else on why they would not play with me. i had no doubt about her motive and no doubt about my position in her mind of self worth. that is called explicit racism. i remember it well. but that is not what this book is about. but an unscientific study ask have three kids in their 20s and asked them if they remember their first experience with explicit racism. they are in their 20s which tells us the generation between the two of us have not changed the experience of lived explicit

racism in this country. but in the book, i am talking about implicit bias, and unconscious racism. let me define these terms. unconscious racism is what happens when your stored social knowledge, the information you take from the music you hear on the radio, the movies that are presented to you, the television stories, if you have been watching the political debates, this is all social knowledge stored in the unconscious part of your mind. it is triggered when you encounter a person of another race involuntarily. you bring up the knowledge unintentionally and informs your decision making, conduct, and interaction of people with a

different racial unintentionally. let's be clear. the difference between explicit and inplicit is very important. studies show us that most people in the united states today are not going to identify themselves as explicit racist. well that was before the presidential election cycle we in all. probably more than we thought would identify with explicit racism. but explicitt racism is kind of out of style. it is not what we do, who we identify ourselves our, or who we have as people. here is what the book is about. the book is about finding out by reams of data that even if you explicit preferences are egalitarian and are to be a

fair, non-prejudice, person your implicit bias will trump those preferences. your implicit bias will do more to inform and direct your conduct than will your explicit preferences. why is this important? it is really important in health care and why i came to write this book was because health disparity, what we politely call health disparities, is killing african-americans in this country daily. if i were so inclined i mind run the data on just that fact. in 2003, the institute of medicine published an important work call unequal treatment. it cataloged 25 years of data. the fath that infant mortality

in the african-american population is twice that of white populations. the fact that you are 75% more likely to die if you are diagnosed with coronary arterary disease if you are a person of color than white. these are the kinds of data, the kinds of statistics that will be replicated no matter what the leading cause of death is. with respect to cancer, whites and blacks diagnosed at the same time have a 33% difference gap in their five-year s surriveability rate. this is not true if they receive similarly intensive treatment, education, screening. if these treatment disparities are eliminated then the

difference in survival rate disappears. the medical profession agrees to do no harm but if you read the oath it talks about justice. it talks about being a provider and a treater of an entire patient. a whole patient in context. when that is not the case, implicit bias change the way that people are treated. let me turn now to the content of the book the institute of medicine study done in 2003. how is it possible that

physician bias may have a causal relationship with health disparities. because individuals were bias on race, ethnicity, sexual orientation, and other grounds that might influence their treatment decisions. but at the same time they said they don't know how those mechanisms work. the point in the work is to try come up with an n understanding of those mechanisms and how physician bias translates into poor health outcomes for people of color as compared to whites. so i looked at the empirical literatu literature. i looked at the studies and they are copious with respect to implicit bias and health care.

i organized them into six method but i will only talk about one tonight. i organized them in a way that suggests there are six different pathways or mechanisms by which physician bias translates into health disparity. one of the most important contributio contributions i hope my book makes is not only these mechanisms to discuss and research but the fact one of them, dirty little secret, involves explicit bias' that patient's hold. if we get these from our knowledge, all of us in the united states get the same social knowledge, and the literature tells us patients as well as providers have implicit bias. one study tonight, if you are interested in the other five we

can talk about them during the q&a, but the one i want to talk about is implicit bias changes doctor's treatment plan. this is a direct mechanisms between bias and disparity. between bias and poor health outcomes. why? well the studies that are in the treatment space say this. i am thinking of one by alexander green. they say if a patient has coronary artery disease and we present that patient as a black woman, then white woman, then black man and then white man. but we use a script that tells us about the predetermined indicatored and facts about their history, and personal

background and family connections so all of those individuals are identical to the physician but for their race and gender. if we do that then we can see that race and gender inform the quality of the treatment decision. second step of the study, and probably the most troubling for my work, and the reason i went to do this work, if we also measure the implicit bias of the physician making the diagnostic and treatment decision there is an inverse relationship between the level of implicit bias and the quality of the treatment decision. that is to say the more implicitly bias a physician is, the higher on the implicit association test, and if you like i can talk a little bit about that test, the higher the implicit association test scores

the physician's implicit bias the more likely they have to provide an inferior treatment modality to patients of color as compared to patients who are white. the reverse is true the lower their implicit bias measures the more likely they -- this is from a study of coronary artery patients who needed the treatment of choice for their coronary artery disease -- the more likely a physician of with a low implicit bias was to prescribe that treatment of choice. that tells us there is an evidenced relationship between implicit bias and the quality of treatment a patient receives and that results in different health outcomes because different treatments will be afforded to people based on the color of their skin. the other mechanisms have to do with the conversation or

communication between physician and patient. i am particularly interested in the fact there is a feedback loop. maybe you encounter someone, you know they are not looking you in the eye, you know they are not giving you the kind of information you may have gotten if you were not a person of color, you know their body language puts distance between you and them, they are verbally dominant and not respecting or crediting your opinion. these signals patient pick up and when they pick them up their implicit bias' kicks in also and they say i know what that is and since i am knowing what it is i am not satisfied. and low patient satisfaction

means i am not coming back to you anymore. that is an interruption in my care. if you tell me i need to exercise i am not listening because you insulted me. my adherance and compliance is low which translate into relatively poor health outcomes. it is often the case you write a book, finish is book, and you would write another book at the conclusion of that conversation. that means i have a second book project. let me share a couple things. i am going to read one thing from the book and close on telling you what i would do to fix this and what my next book

looks like. when i finished categorizing the empirical data i set out to set-up a qualitative research asking health care providers and patients and ask them about their lived experiences and personal experiences with implicit bias or unconscious racism. what i found was i was able to confirm all six mechanisms i describe in this book. i chose a different patient to read about every time i do this. this time i want to chose a first-generation chinese man who bears out mechanisms number six. that mechanisms that says patients who feel and perceive themselves as being discriminated against drop out of the care system or at least interrupt the care system in a

way that impacts their health outcomes negatively. this is the story of a man who is an engineer by training and profession and the implicit bias he experienced really is emblemattic of what i heard from many patients. what i heard from many patients and you will hear it in his story is his view was diskrdted and perception of him as a quote unquote foreigner meant he wasn't believed her taken seriously. his complaints were ignored. and the treatment me received turned out to be inferior. picking up in the middle of the story. he had one night i found i have a clinical disease reoccurring to me which caused and came from the country side back in china. it is a mosquito. a very tiny thing. i know that illness.

basically it is hidden in the liver and it can periodically one day show up and you have a very high fever. and then you are exhausted. then you go to sleep. and he describes the symptoms. you can't walk, you are lethargic and you cannot work. i got that. it is an asian disease. when i came here, it came back, i went to the doctor and knew everything about it for sure but at the hospital nobody believed me. they took my blood and said i cannot find nothing. there is nothing wrong with you. but this thing is true. you cannot find it in the blood. but if you look carefully, it is in the liver. but i don't think they bothered to do that. and of course i can't really remember the name or the academic terminology.

so i took the dictionary me. so imagine this going to the docto doctor, taking the dictionary and found the word but they say no way. they said i cannot give you treatment and they said when you get this again, and you can show me what is making you feel bad, come back. in this system, if you don't have symptoms they only kill the symptoms. they don't treat you for what is really wrong. and if you don't speak english well you have less of a chance making them understand. this is not to say they really hate chinese. but they have some kind of prejudgment. his words not mind. they say you are wrong because you are not an educated.

plus maybe you have never met anyone like me but this thing makes you so weak it can kill you. after 15 years i got it again and i dd decided i am not going to the hospital again. i write to my friends in shanghai and tell them i need this medicine and they bring it to me after a month. if i had a psychology degree i could take apart the sense of dignity this man lost in his encounter. the sense of insult which he was quick to deny. they are not racist. they don't hate chinese. but i am not going back there anymore. his health outcomes are adversity affected by the fact this happened. i think this is medically

untenable. one of the four most disparity scholars in the country tells us it cost $1.24 trillion, trillion with a t, in lost productivity, proventible hospitalization, and increased health care cost to treat health disparities over a course of, his study was six years. it is morally, medically, and monetarily unsustainable not to address the problem of health disparities. i think the most serious causal factor that we are not talking about is unconscious racism.

what do i want to do to fix it? lots i will talk about in q&a. but i want to see more laws changed. law changes social norm and the social norm needs to be changed in this country. the social norm right now tells us it is okay because it is unintentional to discriminate. that is not not true. my fourth mechanisms -- unconscious bias is malable. people who are unconsciously bias, it can be measured, and people who are explicitly bias are told in an experimental situation their biass are not shared by 86% of their peers. then there are -- then they are

asked to sit by down by someone who is a person of color and they will sit closer if they know it is not poplar with their peers. brown versus the board of education changed the social norm. we have to do three things with respect to the civil rights act of 1964. we have to make implicit or unconscious, unintentional racism actionable under that statute. we have to reverse alexander versus sander ball. it is one of the gifts that our dearly departed justice scalia left us. we have to three replace the

private cause of action that worked so well with respect to explicit racism so it is available as a cause of action pertaining to implicit racism. how do we cabin this so that everyone who thinks a negative thought is not sued in the system that many proposing? we import a negligence standard that simply says if you as an institution, if you have as individual, have done what is reasonable shown to address implicit bias you have a perfect defense to a title six cause action. this would change the social norm, it would create a system where the institutions that employ the health care providers would do what they did with

hippa. institutions became proactive around teaching and privacy. you remember we used to walk up to the nurses' station and there would be the chart sitting there. no more. social norms changed by the law. i don't think we will litigate or sue ourselves out of implicit bias and its deadly impact on health care. but i believe we will change the social norm if we do what i propose. let me end telling you the book i would write if i were writing today. i would write more about the implicit bias that affects americans. i am holding up a picture of the poisoning situation in flint, michigan. it is my belief that this

situation is rife with implicit bias. it is pretty clear your health care alone doesn't make you healthy. so if you are discriminated against in education you will have a higher likely of experiencing poor health outcomes than those who are not experienced against. if you housing is unsanitary, unsafe, when the physician tells you to exercise better or eat better, if i live in flint i don't have a super market in my city in order to buy fresh fruit and vegetables. the social determinants of health are distributed in an unfair way because of unconscious bias. if my physician tells me i need a better diet and need to exercise more but there is crime in my streets i cannot exercise

if there are no sidewalks, parks, public places or safe place to exercise. all of this has an influence. and all of this is organized by law and we could get at the implicit bias that touches these issues if we change the discrimination actions that are available. how could flint happen? ... let me close by saying these two

last things. governor rick snyder assured us there was no racial motivation behind his decision to ignore the lead copper rule and completely ignore democracy and replace the democratically elected officials in flint with emergency managers by his decision to ignore the outcry of patients, people and citizens in flint who explain the orange sludge spewing forth from their tap water didn't smell right, didn't look right, didn't seem safe to drink for them or safe for them to wash their babies in. what could the -- what could be further from the clear, honest-to-goodness truth, this predominantly black population and those that were not black, predominantly poor population, were the victims of unconscious racism?

i will give you that governor snyder didn't think he was making a decision based on the race or poverty of that population. that would be explicit racism. that would be explicit bias. but i will also give you the and assurance that whether he will admit it or not, governor snyder would never make that decision with respect to a population that looked like him, that had the financial wherewithal that he had, that didn't give him an unconscious reason to believe this group of people were somehow less then or somehow different than or somehow not entitled to the same treatment as a population of his own children. that is implicit and how massive the problem is in my view. thank you for taking time to listen to me. i look forward to your

questions. [applause] >> if you have a question please raise your hand. >> thank you for the presentation. i have two questions. i was impressed -- i didn't realize the copious and the of the research. i had problems going back and forth, why is it so much has been out there before and is just now coming through, talk about title vi, using the negligence standard which i can see for institutions. can you speak more about how that would apply to individuals? showing the burden of proof would be on the plaintiff,

showing the demographics on that point. >> let me take the second one first. i would like to see disparate impact returned to the title vi regime, reversing -- so i could statistically show health incomes on an institutional level or an individual level which are biased, premature case for having evidence that there was actionable discrimination at play. same standard would be my view. to take the steps in the literature showing me what were reversed. why is it just coming to the 4? i have been studying health

disparities for a decade. most of the attention leading to the 2003 report had to do with access. i came to washington dc because i believed in the affordable care act and that this was the step we needed to take to expand health care in the united states to 18 million more people. having said that if we had universal healthcare, universal access was to inferior and discriminatory care, what we are describing in the book. access has been the focus of the past 25 years, first generation of documenting health disparities and understanding the extent of those health disparities. all the statistics about cancer disparities, diabetes disparities, death rates for infants and they are copious but that took 25 years to amass literature and describe the

problem. we thought once we described the problem and got people access to healthcare, it would change these disparities and inequalities. it has not. 80% of disparity measures for health quality and health exits haven't moved in 25 years. pardon me but some of my best friends are conservatives but conservative point to the fact that we are narrowing the life expectancy gap. a black man in this country is going to die five to seven years earlier depending where you live and in some parts of the country your life expectancy is like that of someone from haiti. the fact that we have narrowed the life expectancy gap a little bit doesn't change death rates for infants due to diabetes and cerebrovascular disease, heart disease, cancer, asthma, people

of color die quicker and live sicker in the united states than white people do. we haven't moved the needle and we are just turning to the question of what might be the mechanism. last part of the answer i will give you is this is a sticky topic. i had to start my talk by saying i want you to know i am not talking explicitly about race, i don't want people to think i'm pointing to the healthcare profession, people who are dedicated to caring for populations, trained to be objective are themselves racist? i would shut down the conversation if i did that. although -- we are talking about implicit bias and unconscious racism and we are just getting to that conversation. >> you may have already answered

this but i want to bring it up anyway. you spoke about i am a nurse and have been for 18 years and worked in the care setting. i have witnessed a lot of what you have discussed. i have not read your book. it was a healthy discussion for me and my peers but i want to talk about healthcare is very diverse, very diverse, the ethnicity of the clinicians, and you spoke to clinicians being trained in cultural sensitivity and i don't know if that due diligence occurred to really address that. it speaks to what you talked about, the unconscious belief people have. i went to south africa recently

and had conversations with some folks there, i watch the et, that is not really america from an african-american standpoint but it speaks to the unconscious thought of what they believe it to be. i want to ask you this. how do you think the business of healthcare helps to promote this unconscious belief? healthcare facilities especially with the new affordable care act and the way hospitals are reimbursed, there is a heavy competition on being number one, getting quality-based reimbursement and being number one in the stroke center or trauma center or cancer center

that wanting to provide that level of care you are constantly having to meet those benchmarks, there is going to be work and recommendations to work toward this we have to think about the way healthcare is afforded to the people who need to provide the healthcare. >> this is rich with opportunity for discussion. i want to go to the last point about how the business of healthcare influences bias because implicit bias is what we use to organize complex, chaotic situations into manageable bites so think about what a differential bias is, a universe of possibility start eliminating those who are not descriptive of the patient and underscore bold,

very quickly tries to decide what is wrong, that exercise is an exercise of judgment that invites the categorization and shortcuts that implicit bias reflect. that is the kind of setting in which implicit bias thrives. when we have complex large decisions subject to a great amount of discretion. add to the fact the business of medicine has made those decisions have to speed up, have to speed those decisions up. to perform according to these metrics. get the patient in, get this patient out, so many i got to see, quality measures i have to meet, the fact is we created an environment where shortcuts are necessary. and and you walk across the street based on those judgments.

when the level of discretion prevents the kind of interaction that connects patients to providers, the amount of time given to make those decisions is shortened and truncated. when the level of discretion is too broad. i heard others suggest if we were to standardize some patient decisionmaking. here is where i know people go crazy. some patient decisionmaking, we eliminate the discretion that is so vulnerable to implicit bias. what you said certainly has a bearing on the prevalence of implicit bias. >> thank you for the awesome talk. my question since the identities

of the doctors affect interactions, i have been involved in a couple programs where their goal is to promote or encourage low income communities of color to go into medicine, does that have any effect on those programs, is that based -- that would interest implicit bias. >> the answer is yes and no. one of the things that makes it valuable by the literature we already have, counterstereotypes meaning simply we have studies that say if you prime someone with pictures of people of color in positions of power, not just the person who is in the room changing the bedpans, but positions of power and authority, decisionmakers, the counterstereotypes are likely to reduce the extent to which

implicit bias operates. diversifying the workforce defended in what i am describing would be actionable. a very robust outreach program, i have a pipeline program and taken reasonable steps to provide counterstereotypes to recruit or retain providers of color, i would have a defense to implicit bias action. the way i said you are making me go there, if you grew up in these united states it does not matter if you are black, brown, yellow, purple or orange, you are subject to the same social knowledge is anyone else. black physicians, latina physicians and white physicians reflect implicit bias levels as the major population, sorry to say so.

>> i work in quality measurement and we think about whether we should stratify or adjust quality measures. i am curious what your thoughts are, whether adjusting or stratifying measures on race helps point out disparities that exist or allows implicit bias where you might focus on patient outcomes for white patients or patients with higher advantages. >> i think i understand your question about data collection and whether stratification helps or hurts. my view is you can't fix what you can't measure. if it is not really clearly articulated in the data i don't think any of these problems are easy to solve or solutions proposed in this book are the full story. in a word that stratification by race and ethnicity helps, and

the large conversation going on about whether to risk socioeconomic status and risk factors are reimbursement and a large conversation going on about whether or not we should allow precision medicine to address racial differences and ethnic differences. we have been afraid of those for very good reason but you can't fix what you can't see. we have to measure it and look it in the face and address it forthright, stratification, data collection, the affordable care act by race and ethnicity helps. >> first off, i would thank you for adding a solution to this. and scratching our heads.

the solutions we provided, and we are talking about reimbursements, and something specific, what i am learning is we have a fee-for-service model and moving towards pay for performance, pay for performance being hospitals want to look at how many readmissions we have and how healthy patients are when we leave, how do you think implicit bias will play into access for healthcare when pay for performance is the model and some doctors, healthcare providers in general, salary is dependent on the health of their patient and if we are fed the same information, important determinants of health, how does that affect setting up private

practice and healthcare outputs. >> thank you for being cognizant of implicit bias, the changing of delivery model and reimbursement models of the medical student. the long-term prospects of you doing your part to eradicate health disparities is greatly increased by your awareness and conscious effort to educate yourself so congratulations to you. and and a word it helps, it helps to move the health delivery model in a way that will charge physicians with more than treating disease, but treating entire outcomes, treating entire patients, one of the most moving presentations i have heard since i came to washington was a quote doctor nicole lori made was i have failed as a doctor to my patient

if i am not a doctor to my patient's whole community. i would suggest moving away from fee for service into reimbursement models that look at value return as opposed to to just fee for service that was provided are more likely to produce doctors like doctor mona who looked at the elevated blood levels in her patients in flint and said something is amiss in the entire community, the entire population. i have to look at what these patients are living with in terms of housing, in terms of food, in terms of their educational access, in terms of their medical access, and i have to look at their whole picture. that kind of physician perspective is much more likely to result from a departure from fee for service to more

collaborative and outcome-based medicine. >> my question is two parts. the first is a medical student, what can i do to check my own personal bias and mary it in whatever way possible, and the second question is, the patient said the system takes away symptom is, in what ways the current health system exacerbates or allows the implicit bias you discussed. how can we approach it on the individual provider level and health systems level? >> great question. i will ask in two parts as well.

as a medical student, you have urchin of not yet having been indoctrinated. there is only one study, a study about medical students over three years. medical students, nursing students, pharmacy students had their implicit biases measured in the first, second, third and fourth year and were correlated, and early in their career, and the same implicit bias as the generation -- the population does and medical students in the study did not have the same correlations between their bias and treatment recommendation. they held the bias but the bias did not affect their treatment decisions in the first year, less so in the second, less in

the third and by the fourth year, bias affected their treatment decisions in the same way their physician trainers affected so the medical student, one of the things you can do, i could be internally quiet, you want to do well, i internally question why this introduces the patient as a 53-year-old black woman if she doesn't have sickle-cell or anything related to her race. why is that racial moniker important to the description of the patient other than to convey nonmedical, non-helpful and perhaps packed with implicit bias. you can ask yourself that question.

the same study although physicians in training have the same level of correlation between their treatment decisions and implicit bias, nursing students did not. pharmacy students did not and dental students, i did not have the answer for why that is. i have a hypothesis why that is. the nursing mission is to advocate for the patient as an individual. nursing student sees the patient not as a category but an individual. i don't have the data to prove i am right or wrong but you can ask yourself as a medical student what it is that is happening in your training that might lead you to change who you are frankly, and how you treat people as individuals and you can combat that. a third part of the study i

talked about was he took out of the 700 physicians he examined, 60 or so of them, disclose this was a race study, and patients who are white and what the differences in treatment are about between them. just the disclosure changed the treatment pattern. just the disclosure, knowing one is susceptible. what can i do about my biases, self-knowledge, self-awareness and the critical thinking that if that study was correct, we result in you being much more vigilant about offering care equally to patients of color. those are the things we can think of.

>> i am wondering if you see less implicit racism with pediatrics? kids would be a great equalizer. >> yes we do. there is a study done out of wayne state, michigan, actually a series of studies that show a couple things. pediatricians have lower biases than other physicians, slightly lower biases than other physicians. foreign trained medical graduates have lower biases than other physicians. others had different sets of social inputs. there is a lot of work to be done. i thought this was a

conversation starter, it was too wide and important, and the state of the research as it is now, we don't have a lot of information about implicit biases between black, white, and latino, white pairings. that is a shortcoming in the literature. we don't have a lot of information about implicit bias and what it does beyond the one study pertaining to students, we don't know about clinical pharmacists, nurse practitioners, we don't know about their bias and the influence on their treatment. if anyone has been to the dentist and had the receptionist treat them ugly, they don't go back. what about administrators in the healthcare system? what influence do their biases have? i do believe even though we are doing cultural competency today, spending lots of money on making sure people know the differences exist, we have got to go further and deeper and the type of

stereotype negation the change the habit of being implicitly biased, change the habit of thinking automatically and letting your automatic thoughts override what your preferences our. i want to close by saying ever since i was a little girl my mom would have to pull me back from trying to make justice happen when i saw that it wasn't happening. what we see in the healthcare system is not just disparities, the sterile term, it is not just automatic, not just ubiquitous and therefore acceptable. implicit biases are not quite a given and the problems they

create is fundamentally a problem of injustice. these united states cannot continue to tolerate the injustice of people use color dying, and living sicker than whites just because of their color. thank you. [applause] >> i feel informed. where can i get a copy of "just medicine: a cure for racial inequality in american health care"? given opportunity at the signing table to the right or left. before you leave we ask you fill out who you are. and have this available.

thank you so much. when i first came up here, fill this out over there. ..