The great survivor: another 60 years

Liam Donaldson looks to the horizon and considers some of the issues that may arise for health servi

The founding fathers of the National Health Service (NHS), calling to mind the decline in major infectious diseases, foresaw a future for the NHS where it would be concerned primarily with the maintenance of health. They even predicted falling demand for its services.

Current predictions about the challenges for the NHS in the short and medium term point to the "usual suspects": an ageing population, advances in medical technology, growing consumer expectations and burgeoning pools of chronic disease.

It is difficult to contradict the assumption that, a decade from now, the NHS will face more of the same. Need and demand for healthcare will continue to grow, particularly among an elderly population where many individuals no longer suffer from one disease but several: so-called "co-morbidity". A woman in her late 70s who has had a minor stroke but also suffers from diabetes, arthritis and heart disease is not an unusual patient. However, she would have been when the NHS was founded.

The care needs of millions, often compounded by absent family support, will turn on coordination of care and long-term support to maximise independence. Add to this the ethical and anti-ageism point that new drugs and other treatments should not be denied to older people and the inexorable rise in the volume and complexity of NHS workload will continue unabated.

In response, the NHS, a decade ahead, will surely have shifted its organisational structures and processes towards integration of primary, hospital, community and social elements. Currently, they are too compartmentalised and patients move across care boundaries like ships in a storm. Many of the structures of the NHS were designed to provide reliable, comprehensive care for people with health emergencies and one-off illnesses. New models of patient-centred care will engage expert patients in the long-term management of their own health, with clinicians there to advise, guide and support their choices. These services will need to be planned and designed in a way that has never been done before.

The consumerist nature of an increasingly demanding society of baby boomers, generations X and Y and their successors will require a significant shift from the stoic "make do and mend" of the wartime generations. While there are differences between the roles of patient and customer, these boundaries will blur. Advanced internet systems will enable patients to consult with expert doctors across the world. Pressure to go with the digital, rather than traditional, referral channels will be enormous. The NHS will have adapted to this, incorporating a new notion of customer service into its ethos and functioning.

A future service must be free from the geographical variations in quality of care that are too common now. The new focus on quality that has emerged from Lord Darzi's NHS review will have driven the service towards a radical reinvention, where decisions are made to enhance quality rather than minimise cost. Quality will be the currency of the NHS a decade from now.

Over the horizon, into 2030 and beyond, new medical frontiers will have opened up. Today's young Turks of medical research will be stroking their grey beards with satisfaction as science and technology bring untold benefits to the bedside. Stem cells will repair damaged, diseased and ageing organs and tissues; gene therapy will cure inherited diseases such as cystic fibrosis and muscular dystrophy. Techniques that can control the immune system will switch off autoimmune disease; drugs and cell manipulation will suppress many forms of cancer; and robots will allow surgeons to perform intricate operations on the beating heart.

Three decades from now, it will be routine for babies to have their genetic profile stored on a microchip for life. Faulty genes will be corrected. However, only a proportion of disease is genetically determined and, with the growth of new therapeutic opportunities, most of us will be patients. Advances in diagnostic equipment and scanners, their miniaturisation and intelligent features will move them out of hospital and into the hands of patients.

The impact of these changes will be profound: patients and families diagnosing, monitoring and treating their own conditions will bring about a sea change in the traditional relationship between health professional and patient and the organisational structures of the NHS.

Underpinning all this is the hope that citizens in all walks of life will take responsibility for their own health and its maintenance. In some ways, this is the most uncertain field of prediction, given the intractability of unhealthy lifestyles, addiction and health inequalities. Yet, surely future generations will look back with incredulity at newsreel footage of smokers, obese children and city centres swarming with binge drinkers.

With all these changes must be the imperative to transform global health inequality, with new generations of vaccines and the benefits of advanced technology and medical science.

Predicting the health and healthcare landscape on the 120th anniversary of the NHS, 60 years from now, requires a step into the kingdom of futurology. Here, what wonders could the "medicine of the impossible" yield? Walk-in, walk-out chambers which diagnose disease and then reset the body's functions to normal? Replacement of diseased or aged organs with advanced tissue engineered or digital alternatives? Doubling of the human lifespan? The digitisation of the human mind?

The NHS has been remarkably resilient in absorbing 60 years of change in disease patterns and advances in medical science. There is every reason for us to be confident that it is a success story that will run and run.

Sir Liam Donaldson is chief medical officer

This article first appeared in the 02 February 2009 issue of the New Statesman, Interview: Alistair Darling

NEAL FOX FOR NEW STATESMAN
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They know where you live

Imagine your house being raided by armed police. That’s what happened to Mumsnet’s Justine Roberts after she fell victim to an internet hoaxer.

At around midnight on Tuesday 11 August 2015, a man dialled 999 to report a murder. A woman had been killed in her London home, he said, before hanging up without offering his name. A second call followed. This time, the man claimed to be the killer. He told the operator that he had now taken the woman’s children hostage at the Islington address. They were locked with him inside a room in the house, he said. The police responded with reassuring speed. Fifteen minutes later, eight officers, five of them armed with automatic weapons, accompanied by saliva-flecked dogs, arrived at the scene and took up position in neighbouring front gardens. When one officer banged on the front door of the house, the team was greeted, moments later, not by a masked murderer but by a blinking and bewildered au pair.

Justine Roberts, the woman whom the caller claimed to have killed, was in fact nearly 2,000 kilometres away – in Italy, holidaying with her husband and children. After explaining this to the police, the au pair called Roberts, who assumed that the incident was an unfortunate misunderstanding, one that could be unpicked after the vacation. It was no mistake. Roberts had been the victim of “swatting”, the term given to a false emergency call designed to bait an armed unit of police officers to storm someone’s home. It wasn’t until a few days later, as the family was preparing to return to London, that Roberts discovered that she had been the target of a planned and sustained attack, not only on her household, but also on her business.

Roberts is the founder of Mumsnet, the popular British internet discussion forum on which parents share advice and information. A few days before the swatting incident, members of 8chan, a chat room that prides itself on being an open, anonymous platform for free speech, no matter how distasteful, had registered accounts on Mums­net with the aim of trolling people there. When legitimate Mumsnet users identified and then ridiculed the trolls, some retreated to 8chan to plot more serious vengeance in a thread that the police later discovered. Roberts wasn’t involved in the online skirmish but, as the public face of the site, she was chosen as the first target.

After the initial armed response, Roberts’s perception was that the police were unconcerned about the swatting attack. “We were told that there was no victim, so there was not much that could be done,” she told me. The hoax caller, however, was not finished. In the days after the incident, there was chatter on Mumsnet and Twitter about what had happened. A Mumsnet user whom I will call Jo Scott – she requested anonymity for her own safety – exchanged heated messages with a hacker who claimed responsibility for the 999 call.

“It descended into jokes and silliness, like many things do,” Scott said. “I didn’t take it seriously when the hacker said he had big surprises in store.” She doesn’t believe that what happened next was personal. “I think I was just easy to find.”

A few days after police were called to Roberts’s home, Scott was in her bedroom while her husband was sitting downstairs playing video games. At 11pm, she heard a noise outside. “I looked out of the window and saw blue flashing lights in the street,” she recalled. “I could hear shouting but I didn’t pay it much notice.” Then she heard her husband open the front door. Police rushed into the house. An armed officer shouted upstairs, asking Scott if she was hurt. When she replied that she was fine, he told her to fetch her two young children: he needed to see them. Scott shook her sons awake, explaining, so as not to alarm them, that the police had come to show the boys their cars. As the three of them went downstairs, the officers swept up through the house, repeatedly asking if there were any weapons on the property.

“I was beyond confused by this point,” Scott said. “Everyone was carrying a gun. They had little cutaway bits so you could see the bullets. My eldest asked one of the officers if he could have a go on his gun and went to touch it.”

As Scott sat with an officer downstairs, she asked what had happened to her husband. “I later found out that the noises I’d heard were the police calling for him to come outside,” she said. “He dropped the PlayStation controller as he left the room. It was only later that we realised it’s a good job he did: in the dark, the controller might have looked like a weapon.”

Outside, Scott’s husband had been surrounded and arrested. Other police ­officers were on the lookout in the front gardens of nearby properties, having warned the couple’s neighbours to stay indoors, away from their windows. “One of the officers said it was beginning to look like a hoax,” Scott said. “Then he mentioned swatting. As soon as he said that word, I twigged that I’d seen the term that day on Twitter in relation to the Mumsnet hack.”

***

The term “swatting” has been used by the FBI since 2008. “Swat” is an acronym of “Special Weapons and Tactics”, the American police squads routinely called to intervene in hostage situations. It is, in a sense, a weaponised version of a phoney order of pizza, delivered as a prank to a friend’s home, albeit one that carries the possibility of grave injury at the hands of police. For perpetrators, the appeal is the ease with which the hoax can be set in motion and the severity of the results. With a single, possibly untraceable phone call, dialled from anywhere in the world, it is possible to send an armed unit to any address, be it the home of a high-profile actor whom you want to prank or that of someone you want to scare.

In America, where swatting originated, the practice has become so widespread – targets have included Tom Cruise, Taylor Swift, Clint Eastwood and the Californian congressman Ted Lieu – that it is now classed as an act of domestic terrorism. In the UK, where Justine Roberts’s was one of the first recorded cases, swatting is classed as harassment, though that may change if these and other forms of internet vigilante attacks, such as doxxing, become increasingly commonplace.

Doxxing involves the publication of someone’s personal details – usually their home address, phone numbers, bank details and, in some cases, email address – on the internet. It is often the prelude to swatting: after all, the perpetrator of a hoax cannot direct the police to the target’s home address until this is known. (During the week of the Mumsnet attacks, one of the perpetrators attempted to locate another target using their computer’s IP address, which can identify where a person is connected to the internet, often with alarming precision. Their calculation, however, was slightly out; police were called to a neighbour’s address.)

Though doxxing has a less dramatic outcome than swatting, the psychological effects can be just as severe. For victims – usually people who are active on the internet and who have outspoken opinions or who, in the eyes of an internet mob, have committed some kind of transgression – the mere threat of having their personal information made available on the web can cause lasting trauma. A Canadian software developer whose home address, bank details, social security number and email history were published online in 2014 told me that he now keeps an axe by his front door. “I still don’t feel safe here,” he said. “It’s terrifying.”

Christos Reid, a social media manager for a software company, was doxxed last year. Reid’s information came from a website he had registered seven years earlier. “I woke up one morning to find a tweet announcing my personal details,” he told me. When he asked the Twitter account holder to take down the address, he was told to commit suicide. Reid said he was “OK for about half an hour”; but then, after he went out, he broke down in the street. “I’ve become more paranoid,” he said. He no longer gives out business cards with personal information.

Reid lives in London, but at the time of the doxx he was attending an event in Nottingham, home to the British police’s largest cybercrime division. He was impressed with the police response, even though they told him that they had not heard of the term “doxxing” before. “I was interviewed by two separate people about my experiences who then compiled everything into a case file and transferred it to the Met. When I arrived home, an officer visited me to discuss what happened and my options.”

The policeman explained harassment law to Reid, and offered advice on how to improve security at his flat and what to do if someone hostile turned up at the address. Reid shouldered the repercussions of what had happened alone; no suspects were identified. A spokesperson for the Metropolitan Police similarly said that although detectives from Islington CID have investigated the swatting attacks made on Roberts and Scott, no suspects have been identified “at this time”, even as “inquiries continue”.

Doxxing may seem to be a mild form of harassment but it carries with it an implicit threat of impending violence; the worrying message is: “We know where you live.” Unlike swatting, which is always malicious, doxxing is sometimes viewed by its perpetrators as virtuous. In November 2014, hackers claiming to be aligned with the internet group Anonymous published personal information allegedly belonging to a Ku Klux Klan member from Missouri. The hackers said that their action was a response to the KKK’s threat to use lethal force against demonstrators in the city of Ferguson, Missouri, protesting against the killing of the unarmed black teenager Michael Brown by a white police officer. In January 2015 hackers claiming to be from Isis took over US Central Command’s Twitter account and posted information about senior military officers, including phone numbers and email addresses. In each case, those carrying out the doxxing believed, however mistakenly, in the virtue of their actions and hoped that the information could be used to bring punishment or ruin to the subject.

The term “doxxing” may be new but the practice is an old one. The Hollywood blacklist revealed the political beliefs and associations of actors and directors in the late 1940s as a way to invite shame, deny employment and dissuade others from following their example. “But it has become a lot easier to find people’s private details with the help of the internet,” Jeroen Vader told me. Vader owns Pastebin, a website that allows users to upload and distribute text documents, and where much of the personal data is anonymously uploaded and shared. “People post their private information on social networks,” he said. “A lot of people aren’t aware that their information is so easily available to others.”

In Justine Roberts’s case, the perpetrator may not even have needed to look at social networks to mine her personal information. “If you’re on the electoral roll, you’re easy to find,” she said. “There’s not much you can do to stop people getting hold of your data one way or another, whether it’s for nefarious reasons or simply to better advertise to you. We live in a world that is constantly trying to gather more information about us.”

Jeroen Vader said he has noticed an “upward trend” in the number of doxxing posts uploaded to Pastebin in recent months, but insisted that when someone uses the site’s abuse report system these offending posts are removed immediately.

Across social media companies, action is more often reactive than proactive. Victoria Taylor, a former director at Reddit, one of the largest community-driven websites in the world, said that the rule against publishing other users’ personal information has been “consistently one of the site’s most basic policies” and that “any violation of this rule is taken extremely seriously by the team and community”. Still, she was only able to recommend that victims of doxxing send a message to the site’s administrators. Similarly, when asked what a person can do to remove personal details that have been published without permission, a Twitter spokesperson said: “Use our help form.”

The spokesperson added: “There has def­initely been an overall increase in doxxing since 2006, both on Twitter and on the internet more generally.” She attributed this rise to the emergence of search engines such as Intelius and Spokeo, services designed to locate personal information.

***

The surge in the number of dox­xing and swatting attacks is in part a result of the current lack of legal protection for victims. Confusion regarding the law on doxxing is pervasive; the term is even not mentioned in either US or European law. In a tutorial posted on Facebook in 2013, the writer claims: “Doxxing isn’t illegal as all the information you have obtained is public,” and adds: “But posting of the doxx might get you in a little trouble.”

Phil Lee, a partner in the privacy, security and information department of Fieldfisher based at the law firm’s office in Silicon Valley, said that differing privacy laws around the world were part of the problem. “Various countries have laws that cover illegal or unauthorised obtaining of data. Likewise, some of the consequences of releasing that data, such as defamation or stalking, cover elements of what we now term doxxing. But there is no global law covering what is a global phenomenon.” Indeed, Roberts believes that her London address was targeted from America – the 999 call was routed through a US proxy number.

One challenge to creating a law on doxxing is that the sharing of personal information without permission has already become so widespread in the digital age. “If a law was to state something like, ‘You must not post personal information about another person online without their consent,’ it wouldn’t reflect how people use the internet,” Lee said. “People post information about what their friends and family members have been doing all the time without their consent.

“Such a law could have a potentially detrimental effect on freedom of speech.”

Lee believes that a specific law is unnecessary, because its potentially harmful effects are already covered by three discrete pieces of legislation dealing with instances where a person’s private information is obtained illegally, when that information is used to carry out illegal acts and when the publication of the information is accompanied by a threat to incite hatred. However, this does not adequately account for cases in which the information is obtained legally, and then used to harass the individual in a more legally ambiguous manner, either with prank phone calls or with uninvited orders of pizza.

Susan Basko, an independent lawyer who practises in California and who has been doxxed in the course of her frequent clashes with internet trolls, believes that the onus should be on the law, rather than the public. She points out that in the US it is a crime to publicise information about a government employee such as their home address, their home and cellphone numbers, or their social security number, even if the information is already online. “This law should apply to protect all people, not just federal employees,” she said. “And websites, website-hosting companies and other ISPs should be required to uphold this law.”

Basko said that doxxing will continue to increase while police have inadequate resources to follow up cases. For now, it is up to individuals to take preventative measures. Zoë Quinn, an American game designer and public speaker who was doxxed in 2014, has launched Crash Override, a support network and assistance group for targets of online harassment, “composed entirely of experienced survivors”.

Quinn, who spoke about the problem at a congressional hearing in Washington, DC in April last year, recently posted a guide on how to reduce the likelihood of being doxxed. “If you are worried you might some day be targeted,” she wrote, “consider taking an evening to stalk yourself online, deleting and opting out of anything you’re not comfortable with.”

Both Scott and Roberts have changed their privacy habits following the attacks. Scott is more careful about interacting with strangers online, while Roberts uses scrambler software, which ensures that she never uses the same password for more than one online site or service.

For both women’s families, the effects of their encounters with armed police have also lingered. When one day recently Roberts’s husband returned home early from work, the au pair called the police, believing it was an intruder. And Scott is haunted by what happened.

“What if my husband had made a sudden move or resisted in some way? What if my eldest had grabbed the gun instead of gently reaching for it? What if people locally believed that my husband did actually have guns in the house?” she asks. “I don’t think the people making these sorts of hoax calls realise the impact.” 

This article first appeared in the 28 April 2016 issue of the New Statesman, The new fascism