Airborne diseases include those spread by aerosolized viruses, commonly influenza or human rhinovirus [1]. These pathogens disperse when an infected individual sneezes or coughs, releasing microorganisms into the air which are passed on to a nearby individual. Now however, with the digitisation of our surroundings, the manner of airborne disease dispersal is changing. The increasing interconnectivity of our environments has brought a new host of pathogens to the airwaves - ones that can travel via WIFI, bluetooth and radio waves.
In 2020 the Electromagnetic (EM) spread of disease to servers around the country resulted in a series of seemingly disparate, but truly connected, digital outbreaks of epileptic seizures. Byte-by-byte malware was distributed to vulnerable individuals in their homes, resulting in severe morbidity and risk of mortality.
Virtual assaults on patients with photosensitive epilepsy have been increasing over the past decade. In 2008 Wired reported the ‘first physical attack over the internet’, in which hackers used JavaScript code to embed flashing animations into an epilepsy support forum to trigger migraines and seizures [2,3]. The impact on patients included loss of motor function, disturbed speech, headache and seizures [2,3]. In 2020 attackers selected a new disease vector, releasing a series of coordinated tweets with GIFs capable of triggering photosensitive epilepsy - the attackers exploited research describing the dangerous effects of specific light frequency ranges and colours in existing epilepsy literature to optimize their attacks for maximal harm. The hashtags of #seizure and #epilepsy were leveraged to widen the impact of the digital outbreak.
These cases of digital harm require both a individual level and public health lens. At the individual patient level, when epilepsy sufferers seek care for a seizure relapse it may now be relevant for the clinician to question screen-based triggers. Presently, seizure relapse is often associated with missed medications or underlying infection, questioning patients on the possibility of targeted GIFs is a novel concept. Yet these presentations may be slipping under the radar, as malware induced seizures materialize in clinical settings but remain undetected.
If detected, a second question arises regarding the public health risk of these digital pathogens and how to coordinate an appropriate response, for example should such presentations be considered a notifiable disease in the same way as meningitis or scarlet fever. The need for a centralized system that can track these outbreaks seems as necessary in the digital context, as it has been historically in our traditional population health practice.
To draw parallels to the recent COVID19 pandemic, in which public health response teams had to rush in with new protective equipment, we now require digital equivalents of these safety measures. During digital public health outbreaks, our masks become cybersecurity software, our response teams require computer programmers, and we must differentiate between non-malicious sources of disease (accidental software bugs) and malicious sources requiring forensics investigation (intentional attacks).
Initial digitally-induced seizure outbreaks have predominantly used computers and phone screens as the disease vector that interfaces between the malware and the body. More recently, South and Borkin have described emerging issues in virtual and augmented reality [5]. The authors describe a case in 2018 in which a player in virtual reality online world (‘VRChat’) suffered a photosensitive seizure while wearing a full-body tracking suit, allowing nearby players to witness his convulsions first hand [5]. The emergency response was then digital. The online players alerted a moderator, who contacted the local police for a welfare check - this in itself demonstrates a wanting pathway, for the protocol prioritised a criminal justice response over immediate medical attention. The growing technologies of Google glass, Oculus rift and the range of AR and VR entertainment venues, all provide new interfaces with our retinas, the exploitation of which places us at risk of photostress induced events.
Since John Snow, the father of public health, mapped sources of Cholera to water pumps in London, epidemiology has emerged from the intersection of geography, statistics and medicine. In our digital world we now have a new map to draw, one that is made up of servers, routers, smart devices and electromagnetic communication. Similarly to the invisible pathogens John Snow was seeking out in the 1800s, we are also blind to the electromagnetic transmission of diseases in the airwaves. The modern John snow would be sniffing out Wifi routers, analysing network traffic and spotting the digital epidemiological patterns that emerge around the country as novel patient presentations.
References
[1] Wang, Chia C., Kimberly A. Prather, Josué Sznitman, Jose L. Jimenez, Seema S. Lakdawala, Zeynep Tufekci, and Linsey C. Marr. ‘Airborne Transmission of Respiratory Viruses’. Science 373, no. 6558 (27 August 2021): eabd9149. https://doi.org/10.1126/science.abd9149.
[2] Poulsen, Kevin. ‘Hackers Assault Epilepsy Patients via Computer’. Wired. www.wired.com, https://www.wired.com/2008/03/hackers-assault-epilepsy-patients-via-computer/. Accessed 16 Jan. 2023.
[3] Denning, Tamara, Yoky Matsuoka, and Tadayoshi Kohno. ‘Neurosecurity: Security and Privacy for Neural Devices’. Neurosurgical Focus 27, no. 1 (1 July 2009): E7. https://doi.org/10.3171/2009.4.FOCUS0985.
[4] Busby, Mattha. ‘Malicious Tweets Targeting Epilepsy Charity Trigger Seizures’. The Guardian, 15 May 2020. The Guardian, https://www.theguardian.com/society/2020/may/15/malicious-tweets-targeting-epilepsy-charity-trigger-seizures.
[5] South, L., & Borkin, M. (2020, October 23). Ethical Considerations of Photosensitive Epilepsy in Mixed Reality. https://doi.org/10.31219/osf.io/y32td
Comments