When a threat actor performs a “Living Off the Land” (LOTL) attack, they use legitimate tools and processes within a system to carry out nefarious activities. Unlike traditional malware, LOTL tactics don’t rely on external malicious code; instead, they exploit what’s already in the environment.

It’s like a magician transforming ordinary objects into confounding illusions. However, instead of eliciting wonder and joy, “Living Off the Land” (LOTL) attacks are deceptive acts that can have grave consequences, especially in healthcare.

How do threat actors pull off Living Off the Land attacks?

While a magician may never reveal their secrets, pulling the curtain back on Living Off the Land techniques is the best way to protect your healthcare organizations and patients.

Here are four ways threat actors perform LOTL attacks:

Using everyday objects

Just as a magician might employ a deck of cards or a simple scarf, LOTL attackers use everyday tools like command-line interfaces and PowerShell. They don’t need to bring anything new because they blend in with legitimate activities to camouflage their true intentions.


The magician’s greatest trick is diverting the audience’s attention. LOTL attackers excel in this art, blending seamlessly with legitimate activities, making it challenging to detect their presence.

For example, an attacker might initiate a seemingly harmless operation like a software update or routine system scan. While the IT department is focused on this operation, believing it to be a standard procedure, the attacker discreetly exploits another tool or process in the background to extract data or gain elevated privileges.

It’s like when a magician encourages you to watch his waving hand, all the while the other hand is performing the actual trick. In the digital realm, by the time the misdirection is noticed, the damage is often already done.

The illusion of normalcy

Everything in a magic trick appears normal until the big reveal. In LOTL, everything seems ordinary because the attacker repurposes legitimate tools. They might manipulate trusted system files, hijack processes, and automate tasks—all without raising an alarm.

The grand reveal

Whether it’s a data breach or a ransomware attack, the grand reveal of an LOTL attack leaves organizations astonished and reeling, scrambling to figure out how it was done with such subtlety.

For instance, consider a health system that uses regular and trusted maintenance software for its daily operations. Over months, an attacker uses the very same software’s legitimate features to slowly and discreetly exfiltrate patient data. There are no alarms because everything seems normal.

Then, one day, the hospital finds its patient records being sold on the dark web or receives a ransom note, threatening to expose the data unless a hefty fee is paid. Much like the dramatic end of a magician’s act where a vanished item reappears unexpectedly, the hospital is left wondering how their secure environment was infiltrated without any obvious signs.

LOTL consequences for health systems

Living Off the Land attacks can have serious ramifications for hospitals and health systems, given the critical nature of their operations and the sensitivity of patient data. Here’s a closer look at potential consequences when LOTL attacks target healthcare systems:

Patient safety: The most immediate and concerning consequence is the threat to patient safety. If attackers compromise systems that are directly linked to patient care, such as medical devices or hospital information systems, it could lead to misdiagnoses, delayed treatment, diversions to other facilities, or even direct harm.

Loss of patient data: Healthcare organizations store vast amounts of sensitive patient data, including medical histories, treatment information, and personal identifiers. An LOTL attack could lead to data breaches, exposing this sensitive information.

Financial consequences: Data breaches can result in heavy fines, especially when considering security and regulatory standards. There are also costs related to incident response, notification of affected parties, and potential lawsuits.

Regulatory scrutiny: Healthcare organizations are often subject to strict regulatory requirements. A cybersecurity incident could attract increased scrutiny and result in stricter oversight, mandates, or penalties.

Loss of trust: Trust is paramount in healthcare. If patients believe their data or wellbeing might be at risk, they might hesitate to seek treatment or provide accurate medical information.

Increased costs: Beyond immediate incident response, healthcare institutions might need to invest further in strengthening their cybersecurity measures, increasing operational costs.

Ransomware concerns: LOTL techniques can be components of broader ransomware attacks. Due to the vital nature of healthcare services, organizations may be pressured into paying ransoms for swift system restoration, or to minimize the likelihood of data disclosure.

Guarding against the LOLT illusion: What health systems can do

For a healthcare organization, particularly for the vigilant CIO or CISO, understanding how the LOTL sleight of hand is performed is the first step in protecting against it.

Spot the trick: Implement rigorous monitoring and adopt a multi-layered defense strategy that focuses on recognizing the subtlety of Living Off the Land techniques

Study the performance: Ensure comprehensive logging across your systems, and collaborate with Security Information and Event Management (SIEM) providers to monitor logs, blending network intelligence for better visibility

Understand the props: Limit remote access and restrict specific services. Implement multifactor authentication, and consider advanced endpoint protection tools that can see through the illusion.

Rehearse the show: Regularly test your defenses and run drills to ensure your team is ready to spot hidden LOTL tricks

Living Off the Land attacks are like someone performing dark magic in the hidden corners of your system. Healthcare leaders must develop an eye for the unseen, a taste for the subtle, and an appreciation for the craft.

By understanding this insidious threat and equipping your organization with targeted defenses, you’ll be better positioned to unveil the illusion and protect your patients.

Learn more about LOTL and other troubling trends that have gained traction in recent months in our 2023 Mid-Year Horizon Report.