horse with a speed of light, a cloud of dust, and a hearty high old silver! The Lone Ranger! General Mills, makers of Cheerios, the old cereal that's ready to eat, Betty Crocker mixes, and Wheaties, the breakfast of champions, present by special recording, The Lone Ranger! Say kids, I bet your mothers remember when baking an angel food cake was a dreaded task. Well, it's a joy with Betty Crocker angel food cake mix. All the fine ingredients are right in the package, including the whites of 13 eggs and a special General Mills angel food flour. You just add water, beat, and bake. That's all for the highest, lightest angel food you've ever seen. In fact, it bakes up higher than any cake you can bake with the whites of 13 eggs. And so delicious! And there's no guesswork. To turn out a perfect angel food every time. In fact, Betty Crocker guarantees a perfect cake. Angel perfect every time you bake. Cake after cake after cake. Absolutely perfect. All right, General Mills, Minneapolis, Minnesota, for your money back. And Betty Crocker angel food goes so perfectly with any one of your favorite summer ice creams. You'll want to have it often. Someday soon, ask mom to bake up a perfect Betty Crocker angel food cake. A light summer dessert for the whole family. With his faithful Indian companion tanto, the daring and resourceful mask writer of the plains, let the fight for law and order in the early western United States. Nowhere in the pages of history can one find a greater champion of justice. Return with us now to those thrilling days of yesteryear. From out of the past come the thundering hoof beats of the great horse, Silver. The Lone Ranger rides again! Come on, Silver! What's going on? I'm Silver! The Lone Ranger and tanto had ridden all night to reach Boomerang Canyon soon after daybreak. As they neared the canyon and the partly finished bridge that spanned it, they permitted their tired horses to move at a slow walk. The bridge seems to be coming along well, tanto. Uh, bridge means plenty to west. Trains go over bridge, save plenty miles. The successful completion of the bridge means more than that. Mean more? Yes. Washington, the committee of Congress found that there's been a lot of graft in government contracts here in the west. A man named Hale was involved. Himfeller, who built Snake River Bridge. And several others, but four times what the cost should have been. Him go to jail? No, but he lost the contract for this job. Another engineer, John Connors, got the contract. Look like him. Do a good job? Kimusabi. Added a great saving to the government. I'm glad to see the bridge so nearly finished. I thought Hale might make trouble for Connors to lay the work so the bridge couldn't be finished by the time limit. You hear him? Who's over who? Who's over, scout, Boomerang. Someone in bottom of canyon need help. We're coming! Come on, Silver! Get him up, scout! Followed by Toto, the lone ranger guided Silver down a steep and narrow trail to the floor of the canyon. Then across the rocky ground to the side of a middle-aged man who lay beneath the bridge. Oh, no, no, no, you said it before. Get the canteen, Toto. Me, get him. Life still will help you. Mask, mask. Of all the people who might have written by and hurt my house for help, I have to get an outlaw. This mask marks me as an enemy of an outlaw. I don't care what you are.  Here, water. I don't need water. I need something for a busted leg. Dad, we're out of luck. We have all people, now of all times, to get a busted leg. Some boards over there, Toto. We'll put Splintz on the leg, then get this man out of here. I got a log house up above. There's a ladder over yonder. It goes to the top of the canyon. Yes, I see it. Someone's coming down. Here, here, Splintz. Meet tight, tight. Let me see who's coming.  Take it easy. Oh, that's Lance Kirk. He's my foreman.  My name's Connors. John Connors. Oh, and you're in charge of this bridge. Yes, you're am. Daddy taught him. Why else would I get up before dawn to come and look things over? Hey, you Kirk! I shouldn't yell so. Mr. Connors, what happened to you? What did you look like? I fell, busted my leg. Lucky it wasn't my head. Some jug head left planks on the bridge without nailing them down. Your mask? Mr. Connors made the same observation. Dad had it in the union trying to kill me. Me? Sorry. Must I Splintz when it's right? That mask calls for an explanation. An explanation, my eye, Kirk. A friend of me don't have to explain a darn thing. Very well. What'll I do, Kirk? How in turn can we finish the bridge with me laid up? Now don't worry about the bridge, Mr. Connors. I'll see if the work goes on. You'll have to watch out for it. Oh, nonsense. Heals hundreds of miles from here. Don't be sure about that. But he is. I had work from a friend who saw him in Washington only two weeks ago. There you are, Connors. Now we can carry you up the ladder. Connors was taken to his home. Tahoe remained with the injured man while the lone ranger rolled to the nearest town in search of a doctor. Meanwhile, Rance Kirk supervised the men who worked on the bridge. It was mid-afternoon when Kirk sought the side of a tool shed where it was shady. When he saw a man approaching on horseback, he glanced furtively around to make sure none of the others were watching.  Will you receive my message, sir? Yes. Steve said his stranger handed it to him last night when he was in town. I recognize Steve's description he gave me. He didn't know who I was. I was surprised to learn that he'd come west. Isn't it a little dangerous to come here? Not unless Connors happens to see me. No one else knows me. Connors had an accident this morning, broke his leg. Good. Oh, and look, Steve is working on the donkey engine over there. Yeah, whatever. He's using a very old cable. Should have been replaced. Now look at him. He's trying to lift too many timbers with it. That cable snaps and those heavy timbers cough. Watch that! There's a cable. I'd better get over there, Hale. Go ahead, Kirk. I'm satisfied. Hale, wearing a smug smile of satisfaction, rode away while Kirk hurried to the house where Connors lay on a bunk with Tato sitting in a chair nearby. And that's how it happened, Mr. Connors. The cable was old and Steve put too much weight on it. Why, in Sunday wasn't the new cable installed. Dad ready. Who's anyone hurt? Timmons was down below. He was killed. Boys are getting them out of the canyon right now. Carelessness, downright carelessness. See here, Kirk. We can't spend two weeks repairing that damage. We can't lose two days of progress on that bridge. Don't know what we can do about it. Dude, we can get more help. Maybe Mass Friend have ID when him get here.  It won't repair the damage to the bridge. Rance Kirk returned to the construction job and Connors fumed and worried for the next half hour. Then the door opened. Hale, he came back. Friendly trouble while you're gone. Yes, I know about it. I saw the bridge damaged and went to look it over. Some of the men told me what happened. Do excuse for accidents like that. You're sure it wasn't accident Connors? What'd you ask? Connors, I'm not sure your foreman can be trusted. What's that? Kirk. I heard what you said, Mr. So I can't be trusted. No, take it easy, sir. Lesson, Mr. Connors. This mass man's been snoping around asking questions. If you think... Hey, Kirk. This man's already proved himself a friend. Friend, nothing. He's trying to stir up trouble. For all we know, he might be working for Hale. I examined that worn cable Kirk. Should have been replaced. Yeah, I can't do everything. Besides, that cable would have Hale if Steve hadn't put too much load on it. You fired Steve, didn't you? Sure I did. I paid him off and fired him. Same with the fool left the loose plank on the bridge. Yes, I know. I met them both on my way from town. They were going to town to have a big evening. Tonight, they might feel expensive, willing to talk. If you say so, Mr. Connors, I'll go to town tonight and question them. But this mass man... It might be better if someone else asked the question.  Can you? That's more than I'll take. I'll show you. Oh, you missed. There, stop. I'll get you, please. Stop. Keep out of it, Donald. This'll keep you... Oh, Mr. Gannon, that's enough. No, oh! You sure nailed it. I'll stop you. Get up, Kirk. You want some more? Just swing again. Well, I'll get you, Mr. No man knocks me down and gets away with it. I'll get you. You just wait and see. Sorry about that, Connors. Mr, you've made yourself an enemy. Kirk will try to square things with him. And I wouldn't blame him. You made some pretty pointed remarks. I did it to stir things up. Look, you see, Connors, when Kirk said Hale was in Washington, he lied. What? Yes. On my way back from town, I met Steve and Skinny coming from this job. And I saw someone else heading from here to town. I saw Hale. We'll continue our lone ranger adventure in just a moment. When Bill's at Bath, the kids all shout, You can't strike that slugger out. He gets a hippie because he knows. He's got gold power from Cheerios. Yes, he's got gold power. There he goes. He's feeling his Cheerios. Cheerios. Cheerios. Sure, Cheerios, the cereal that's fun to eat because it's shaped like little letter O's. The only ready-to-eat oat cereal with this fresh toasted oat flavor. And listen, every delicious spoonful of Cheerios and milk is real muscle building food. Each spoonful contains vitamins, minerals and proteins your body needs. Yes, the good things in a Cheerios breakfast do good things for your body. Help you have healthy nerves, good red blood, strong bones and muscles. Yes, Cheerios is made to give you real gold power. So every morning, get going and keep going with Cheerios. Then you'll hear people say, He's feeling his Cheerios. Now to continue. After Kirk had left the home of John Connors, the injured contractor looked fubiously at his two visitors, the Lone Ranger and Toto. Hey, I've got to know the truth about Ranskirk. In that case, Toto, you come with me. We're going into town. On the way to town, the Lone Ranger outlined a plan to Toto. It involved the use of a disguise and calls for daring of the highest order. I'll locate Steve and Skinny while you watch for Ranskirk. Let me know where he is and what he's doing. In the shelter of a dense stand of underbrush beside the trail, the Lone Ranger removed his mask and his familiar clothing and put on shabby clothes that he carried in a saddlebag. He smeared his face and hands with dirt, and when he was finished, he looked like a vagrant laborer who had been long unemployed. Eh, I guess that'll do. Guns, gun belts look too good. I'll leave the gun belt with my other gear on Silver's back. I take Silver with you. You'll go town without gun, Kimisabi? It'll be better that way. Ah, plenty of dangers. Me not like it. I'll go the rest of the way on foot. See you later, Toto. Ah, plenty of dangers. While Toto rode to locate and watch Ranskirk, the Lone Ranger walked into town dressed in old well-worn clothing. He lounged near the front porch of the cafe. Though he seemed to be dozing, he was actually alert and watching everyone who entered the building. It was early evening when he saw Steve and Skinny go through the batwing doors. A few minutes later, Toto came by. The Indian didn't look at the Lone Ranger, but as he rode past, he dropped a piece of paper folded small. The Lone Ranger picked up the paper and read the message. Ranskirk has left the construction camp and was on his way to town. That's what I hope you do. The Lone Ranger crumpled the message and put it into his pocket, then sauntered into the cafe. It took but a moment to locate Steve and Skinny, who were sitting at a table in the corner. Steve was slumped down in his chair with his feet stuck far out into the aisle. The Lone Ranger paused and looked down belligerently. Trying to trip me?  Who are you talking to? You. When you're talking too big.  I see him. This is if you're looking for trouble. Sit down, Skinny. Keep your paws off, my friend. That goes for you too. Sit down unless you want to start cold. Boy, you can't push us around like this. Think you're big enough to stop me? Hold it. Let go of my arm. I'll let you pull a gun on me. Oh, not a chance.  What's that?  You're asking for trouble. Well, you'll get it. Hey, kids. Kids, don't start anything. The sheriff will throw you in jail if you start a trap. No, I'll show you. I told you to stay out of this. No, no. You must, my friend, down. Oh, do you feel slighted? Here's one for you. Oh, I'll fix you. I'll fix you. I'll fix you. I'll fix you. I'll fix you. I'll fix you. Stop the fight. I'll teach you tonight. Are you around? We're on the lesson. You're under arrest for disturbing the peace. The sheriff rushes forward, followed by three deputies. I don't know. Bring it up now. Stop that fight.  That's perfect. I don't know. Oh, dear, I'll break your skull. That man started it, Jeff. That was a stranger. He started it. Quiet.  I'm jailing all three of you for disturbing the peace. Look, kid. Good hand, that's all them boys. We'll lock them up. Do it. The first part of the Lone Rangers' plan had worked out satisfactorily. He had accurately judged that the sheriff would jail all participants in a cafe brawl. With Stephen Skinny, he was taken to the cell at a join the sheriff's office. You ought to blame for this. You started the round of cafe. I admit it. Jail is a good place for you and Skinny. What's that? I went to Boomerang Canyon to see if I could help on the bridge. I learned of two. Well, uh, accidents. What about those accidents? A man known as the Lone Ranger was asking questions. What? The Lone Ranger? Hey, what's he asking questions for? He suspected that you, Skinny, left loose planks on purpose and the hope that Connors would fall. Oh, that's a lie.  Say it here, Mr.... You better let me go on. What else did the Lone Ranger do? He told Connors and Kirk that he intended to talk to you and Skinny and find out whether you two caused those accidents. Well, he needn't think I'll talk to him. Not a chance.  Why is Kirk coming to see us? Well, of course, when that cable broke, a man was killed. If it was intentional on your part, Steve, it wasn't murder. It wasn't.  Now, he wouldn't care to hang from murder. You try to make sure you don't squeal when the Lone Ranger questioned you. And why are you... While you're here in jail, Kirk can't get at you to see that you don't squeal. Why are you so interested in me and Skinny? Because I don't like Rance Kirk. I don't want to see him get away with murder. With murder? What do you mean? Your murder, Steve? What? Yes. Yours and Skinny's. A bullet would be the cheapest and surest way to keep you from telling the Lone Ranger all you know. The Lone Ranger had given Steve and Skinny food for thought. In the meantime, Rance Kirk had reached the town. He soon learned of the arrest of Steve and Skinny. Then went to the hotel where Hale stayed under an assumed name. He told about the Lone Ranger. Then, it was half an hour later when the sheriff entered his office and turned up an oil lamp which had been burning low. He took a key from his pocket and approached the door with the iron bars. I'm letting you out. You're free to go. How's that? Your friend fixed things with a judge. Are the three of us to be released? Yep. Judge said I might as well let you go too. Save the cost of feeding him. I'm indebted to someone. Who is it? You can thank Rance Kirk for being free. Rance Kirk, huh? Well, go on into my office. Where is Kirk? I don't know. You're guns and other properties there in my desk. He wouldn't be hiding between the buildings across the road, would he? How would I know? Now, get out of here so I can close my office. Go ahead, Skinny. You first. You go first. Oh, no, thanks. In the darkness, we look something alike. Steve, you go first. What in tarnation are you critters? You're afraid to walk through that front door? Go on, Skinny. You heard him, Skinny. Go ahead. It's dark outside. You'll be all right if you get through the door. I think someone's between those buildings. What are you scared of? He's not used to having people pay fines for him. Get gone. Hurry up, Skinny. Hey! Who fired? He's there.  Who is? Don't open the door, Sheriff. Don't do it.  That's why he paid our fines. What's that? How long will Kirk shoot me? I'll see him hang for trying to kill me. It's him and Steve that caused him his death.   I won't.  You snapped that table. I just left loose plates.  Steve was wild with rage when he grabbed his gun from the table and swung it towards Skinny. Put down that gun. The Long Ranger leaped forward and got shot out of his fist. Good work. You got him just in time. He'll be unconscious for a few minutes. He was going to shoot me. They all want to kill me. Sheriff, listen to me. I admit leaving those plans. What are you talking about? I didn't have a hand in Tim's death. That was Steve and Kirk paid him. Kirk's waiting to kill me so I can't tell about him and how he paid us. I'll slow down and talk to him. Listen, Sheriff. Listen carefully, Sheriff. When he's through talking, I'll call in a friend who can tell you where to find the men you want. The Long Ranger left the office while Skinny talked at length. A few minutes later, Tonto entered. What do you want, engine fork fast? Now I've got lots to do. May I bring message? Kirk in Hotel Room 25. Him there with Feller named Hale. Oh, God. How do you know I wanted that information? Feller who sent message. Tell me wait outside till Skinny finish. I'll get Deputy and take care of things as soon as I put these two back behind the bars. It was the following morning when the Sheriff called on Connors and told of the arrests he had made. On the strength of what Skinny said in his signed statement, we've got enough to hang, Steve and Kirk. And maybe Hale as well. Good work, Sheriff. Good work. With Hale out of the way, I'll not have to worry too much about finishing the bridge on time. You know, Connors, the curious thing is this. Kirk didn't fire the shot that made Skinny talk. He didn't have any intention of killing Steve and Skinny. No. No. He was waiting in the hotel. He was going to give those critters cash to leave town. And who did fire the shot from across the street? The Indian. He was working with a mask man who started the cafe brawl. It was all a plan to make the truth come out. And who started the cafe brawl? He let me know who he is by leaving a silver bullet on my desk. That fellow is the Lone Ranger. Here, a copyrighted feature of the Lone Ranger Incorporated is produced by Kendall Campbell Muir Incorporated. The part of the Lone Ranger is played by Brace Beamer. Your announcer, Fred Boyd. Listen to the Lone Ranger brought to you by special recording Mondays through Fridays at this same time.


Welcome again. So, in the previous lecture, we had introduced this concept of volume velocity and we had developed the relation for pressure field attributable to a monopole and the relation looked something like this. So, pressure field due to a monopole is the real component of volume velocity divided by 4 pi times j omega rho naught times E minus j omega r over c times E j omega t. And where this volume velocity was defined as complex amplitude times r naught square times 4 pi, where r naught square times 4 pi equal the surface area of sound source emitting radially symmetric sound, sound pressure. So, if I have a sound source and if it is let us say radius is r naught and it is generating this sound which is radially symmetric, then that is the surface area which is emitting sound, I multiply that by velocity and that gives me volume velocity. The other thing we had done as we were developing this relation was that we had assumed that r naught which is the size of the sound source is extremely small compared to lambda over 2 pi and as long as this assumption held valid, this relation would be reasonably accurate. If this particular relation is not valid, then we have to go back to the first principles and modify this particular relation, so that we also include the effect of size. At this stage, I also wanted to introduce two more terms, so one is that if the device is small and I am doing measurements which are very close to the device, so such that my measurement are near the device such that is which is the position where I am taking measurement is 0 to 2 times lambda over 2 pi, then these type of measurements are called near field measurements and if measurement is far away such that r is very large compared to lambda over 2 pi, then I have these measurements are known as far field measurements. So, I have near field measurements when I am extremely close to device which is emitting sound in the sense that the distance between the device and my observation point is less than 0 to 2 times of lambda over 2 pi, then I will be doing near field measurements and if my location is extremely far such that the radius or the distance between observation point and the device is very large compared to lambda over 2 pi, then what I am doing is they are known as far field measurements. So, that is about volume velocity near field measurements and far field measurements. Now, we move one step further and we start exploring what happens if we have more than one monopoles and then how does the sound field get affected and at this stage we will start talking about the concept of interference. The concept of interference in case of sound waves is not in any fundamental way different from light ways when they interfere with each other or for that say any type of ways when they interfere with each other. So, we will use similar mathematical tools to predict the sound pressure field when there are more than one monopoles in the neighborhood of each other and essentially what we will do for purposes of predicting the sound field is that we will compute the sound field attributable to one particular sound source. The same thing will be done for a sound field attributable to another sound source and then if we have two sound sources we just add these two components and then we get the total final consequential sound pressure field at the place which we are interested in. So, we will start talking about interference and specifically in this lecture we will just talk about two sound sources. We will just talk about two sound sources to make the discussion simple and relatively easy to understand and then we will see how these two sound sources interact with each other to produce an interference sound pattern at some distance away in the pressure field. So, let us say I have two sound sources and this sound source is S 1 this is another sound source S 2 and this is a geometric line which connects these two. So, these two sound sources are separated by a distance D such that this is distance D over 2 and this is another distance D over 2. Now, I am interested in finding the sound pressure level at this point and let us say this point is P and the pressure here is lower case P and that is what I am interested in finding. So, this is my origin this point. So, these are two sound sources and this is my origin. So, from with respect to the origin this point P is located and the distance from the origin to point P is R and this angle is theta. So, I will just make it a little larger this angle is theta. So, the pressure at point P is lower case P and that depends on three variables R which is the distance between P and origin theta and of course, time. The distance of sound source S 1 is R 1 and similarly the distance of sound source S 2 is R 2. Finally, I draw some construction lines. So, I drop a normal from S 1 on the vector R and if that is the case then this angle is again theta this angle is again theta and if I extend this line. So, this is 90 degrees and from the origin which is point O to this point let us say this point is B then O B is basically D over 2 times cosine of theta because the angle between line O S 1 and the normal is again theta and O S 1 is the hypotenuse. So, the base of this triangle is nothing which is O B is D over 2 times cosine of theta. Now as so again I have two sound sources S 1 and S 2 I have a point P which is distance R away from origin. I am interested in finding the sound pressure field at point P and see how this pressure varies with respect to R theta and time and that is the basic problem which I am trying to address here. Now for purposes of this discussion we will make a couple of assumptions. So, assumptions so the first assumption is that S 1 and S 2 are monopoles. So, ideally they are point sources of sound, but in reality you cannot generate sound from point sources, but if they are if they still have to be like monopoles or approximate to monopoles then the size of these devices sound these sources has to be extremely small compared to the wavelengths they are emitting. So, S 1 and S 2 are monopoles. The second one is that the volume velocity of S 1 or I will call it V V 1 the magnitude of this volume velocity is same as magnitude of V V volume velocity of the second one. So, this is another assumption. So, essentially I have two monopoles they emitting sound and the strength of these two monopoles is same and their volume velocity is V is equal to V V this is the second assumption and the third assumption is that even though they have similar strengths the phase difference between the sounds being emitted by them is not exactly zero and there is a phase difference between the volume velocities of these two monopoles. So, phase of V V 1 minus phase of V V 2 equals phi and that is phase difference. So, these are the three assumptions. So, once again I will formulate the problem or I will restate the problem I have two sound sources S 1 and S 2 they are in terms of size they approximate monopoles they generate sound waves and because of these sound waves an interference pattern is getting generated at point P which is located at a distance r from the origin and which is also at an angle r theta with respect to the origin and I am interested in finding the sound pressure field in the neighborhood of in this entire area the strengths of these two monopoles are same even though they are off in terms of phase by an angle phi. So, with that statement I now proceed to start solving the problem. So, the first thing is that I will write down expression of V V 2. So, V V 2 is essentially it will have some magnitude and that magnitude we know is V V and it will also have some phase E j phi over 2 and similarly V V 1 is equal to some magnitude component and some phase and we know that because the phase difference between S 1 and S 2 is phi. So, it is magnitude it is phase will be minus j times phi divided by 2. Now, P of r theta t equals pressure due to V 1 plus due to V V 2. So, I will write first complex pressure and complex pressure is complex pressure due to V 1 and plus complex pressure due to V V 2 and then I will add these two up take the real part and then I can get the actual pressure. So, this is essentially V V divided by 4 pi r 1 times E minus j phi over 2 times j omega r 1 rho naught E minus j omega r 1 over C times E j omega t. So, this is my complex pressure due to first source plus now I have complex pressure due to second source. So, instead of r 1 now have r 2 now I am going to simplify this whole thing. So, I have several things common. So, it is V V over 4 pi and then I will also make j omega rho naught is common and so is E j omega t and then I have two terms in parenthesis minus j phi over 2 times E j omega r 1 over C and the entire thing is divided by r 1 plus E j phi over 2 times E minus j omega r 2 over C divided by r 2. Now, if r is extremely large compared to D. So, now, we are making an assumption here that if r which is this distance between the point of observation and origin if this distance is extremely large compared to the distance between these two sources then if r is extremely large compared to D then r 1 is approximately equal to r minus D sin theta over 2 and r 2 is approximately equal to r plus D sin theta over 2.  So, I have this somewhat complex expression and now I will at this stage I will start simplifying it. So, one simplification is that the denominator this is approximately equal to r similarly this denominator is approximately equal to r.  So, this is a somewhat simplified expression of the original version. Now, I can make this version further simple by taking E j omega r out of the bracket. So, what I get is I have taken r from outside from here. So, in the parenthesis what I am left with is E minus j phi over 2 times E j omega D sin theta over 2 plus E j phi over 2 times E minus j omega D sin theta over 2. So, this is my further simplified expression where I have taken r outside the parenthesis and I have clubbed it with E j omega t. So, now, what I see in the parenthesis which is this term that the first term is E minus j phi over 2 times E j omega D sin theta divided by 2 and the second term is just the inverse of it E j phi over 2 times E minus j D omega D sin theta over 2. So, this is essentially excuse me. So, we know from complex algebra rules that these two terms they add up if I expand them in terms of cosines and sines then the sin terms will get cancelled because the sin terms will get cancelled and we will be left with only cosine terms. So, that is what I do. So, I make it further simple. So, I get V V over 4 pi r times j omega rho naught E j omega t minus r over c times twice of cosine of omega D sin theta over 2 minus phi over 2. So, this is the simplified expression here. Now, we know that omega I think I am missing a c here. So, there should have been a c here and a c here. So, there is a c here as well. So, now, omega over 2 c equals 2 pi f over 2 c equals pi over lambda. So, I can replace omega over 2 c by pi over lambda. So, my complex pressure relation is further simplified and also I cancel this 2 by 4. So, I am left with only 2 pi r here. So, V V over 2 pi r times j omega rho naught E j omega t minus r over c times what I am left with is cosine of pi D over lambda times sin theta minus phi over 2. So, this is my final expression. So, what this relation shows is that if I know the volume velocity of these two sources and I am aware of the phase difference between the two sources, then I can calculate complex pressure using this relation and once I have the complex pressure, then I can take its real component and that will give me the actual pressure. So, I will rewrite this equation again. So, P and what I will also do is that I will drop the t term because that is just E j omega t. So, I will just take the drop that dependency you know for purposes of convenience. So, P is dependent the complex pressure magnitude is dependent on r and theta and that is V V over 2 pi r j omega rho naught E minus j omega r over c times cosine of pi D over lambda sin theta minus phi over 2. So, what we are seeing here is that the first term depends on r and then this term depends on theta. The second term depends on theta. So, even if the value of r is fixed and if I go around a circle, the value of the pressure at different values of theta will be different. So, what we are going to do is we will assume some value of lambda and theta and then see some value of lambda and some value of D and some value of V and then see how does for a particular set of variables the dependence of theta manifest itself as. So, what we will do is we will do an example and example is such that the phase difference is pi over 2 and D equals lambda by 4 D equals lambda by 4. So, for these two parameters phi equals pi over 2 and D equals lambda over 4, we are going to see what kind of dependence of on theta is there. So, we will develop a table. So, the first column in table is theta, second column in the table will be pi D over lambda times sin theta minus phi over 2 and the third column will be cosine of pi D sin theta over lambda minus phi over 2. So, when theta is 0 degrees or 0 0 radians, when theta is 0 sin theta is 0. So, first term is 0 phi is pi over 2. So, this becomes minus pi over 4 and cosine of minus pi over 4 is 1 over root 2. When theta is pi over 2 then what I get here is pi over 4 minus pi over 4 equals 0 and here I get is 1. When theta is pi then again sin theta is 0. So, the first term is 0 and what I get is minus pi over 4 and here once again I get 1 over root 2 and when this theta is 3 pi over 2 then sin theta is negative 1. So, I get here minus pi over 4 minus pi over 4 is equal to minus pi over 2 and then I get here is 0. So, if I do a polar plot of cosine with respect to theta this is how it is going to look like. So, at 0 it is I am just making some marks. So, at 0 degrees the value is going to be 1 over root 2 which is 0.707. So, this is 1. So, it is going to be little less than 1. So, this is 1 point at pi over 2 when theta is pi over 2 this value is 1. So, this is another point when theta is pi then again I get 1 over root 2. So, this is. So, this is half this is 1. So, at theta equals 0 it is 0.707. So, it is going to be this is 0.75. So, it is going to be somewhere here. So, this is here and then similarly at pi again it is going to be 1 over root 2. So, this is 0.725. So, again it is going to be somewhere here and then at 3 pi over 2 it is going to be at 0. So, these are the 4 points. So, now I develop a curve and I hope I do a an job in developing this curve. So, it is going to look something like this. So, this is the polar plot for term T 2. So, what this polar plot shows is that when theta is 90 degrees I have the maximum amplitude, when theta is minus 90 degrees the amplitude is minimized and I have very interesting polar pattern. So, even if I keep my radius fixed the plot changes the amplitude changes as with respect to theta and this is purely because of interference of sound waves and at different places they add up or they interact in a positive or constructively or destructively and we get variation of sound pressure levels as I move in the theta direction. So, this is the essence of interference of two sound waves. Similarly, we can use similar theory. We can extend this theory very easily to have three sound sources interacting with each other four sound sources and so on and so forth. One there are several significant application areas of when sound waves are interfering and how do we predict these sound waves. For instance, we use this approach to figure out the performance of radars. We also use similar theory to understand how sound propagates when it is being broadcasted over a large area. Also, there are directional microphones and also directional sound sources where the sound pressure field is predicted based on this particular theory. So, I hope this approach of using interference helps you in understanding what happens when more than one monopoles start producing sound in a 3D field and how do they interact with each other to produce constructive and destructive interference pattern in the 3D sound field. So, that closes this particular lecture and thank you very much. Bye.


Good morning, everyone. Good morning. Today we are going to talk about a new paradigm in health care called the value paradigm. And the idea is pretty simple. It just puts the patient at the center of the health care navigation system. And what I mean by that and what our illustrious panel will explain in the next hour or so is why that's so different from what we're doing now. It focuses on outcomes, not on inputs. And that really is a fundamental reworking of the way we do health care globally now. And there are some exceptions to this, and we'll talk about that. But first, though, before we talk about the old paradigm, I mean the new paradigm, I want to talk about the old paradigm. And to do that, before we do anything, I'm going to introduce these extraordinary guests here. My immediate left is Lori Glimcher, who is the president and CEO of the Dana Farber Cancer Institute in Boston. This is next to her is Franz Van Houten, who is the chief executive officer of Royal Phillips. Then we have Omar Ishrak, who is the chairman and CEO of Medtronic. Next to him is Bruce Broussard, who is the president and CEO of Humana. And finally, on the far left is Christoph Weber, who is the president and CEO of Takeda Pharmaceuticals. Thank you all to these incredible guests. This is an amazing group, because what we're going to do, we picked this group because it covers pretty much every aspect of the health care continuum, except of course the patient, although I'm sure we're all patients in some way. But to talk about that, I would love to get this first slide up here, because this is the old paradigm. And what you can see here right over the heads, unfortunately, of some of our panelists, is the health-adjusted life expectancy globally. And what health-adjusted life expectancy means is it's life expectancy when you're healthy. So the last part of this, the years that you're not healthy, is phased out of this particular chart. And we can see that this is graphed against the expenditures and emerging economies versus developed economies, light blue for emerging and dark blue for the dots or developed economies. And you can see we've pretty much topped out. It doesn't matter how much we spend per capita. At this point in the current system, we are really at this place where we're not making much more progress. We're spending more and more for less and less. And in fact, this was shown in the United States, at least, just recently, where the life expectancy dropped for the second straight year, the first time that's happened in more than half a century. So Laurie, as a physician, as an immunologist, as someone who runs one of the most renowned academic medical centers in the world, you see firsthand the challenges from just taking care of people, the health, what are we doing wrong? So let me start out first by doing a reality check. And that is, let's remember that at the turn of the century, 1900, the average lifespan was 40. So there has been a lot of progress over the last hundred and some years. But nevertheless, we are looking forward to a time where life expectancy probably will decrease. And I think, most recently, that has been in part because of the opioid epidemic of substance abuse. But leaving that aside, all of us want to deliver the very best care with the very best treatments to everybody globally. And I think that there are probably four categories where we need to improve in order to reverse the trend. And one of them is in basic research. So we still have not discovered many of the key proteins that we need to target with drugs. So basic research is essential, and hence the health of all academic medical centers is critical, and perhaps we can say a little more about that later, but just remember that academic medical centers are in a perfect storm right now. It's where the majority of basic research and new transformative discoveries take place. It's where at Dana-Farber, for example, the new protein against which the most used immunotherapeutic, the PD1 blockers, arose from a basic discovery. So we're not there in terms of basic research, but at the same time, academic centers are in huge jeopardy. It's a perfect storm, as I said, because healthcare reimbursements are not increasing at the same rate as medical costs. That's not a good balance to have. And secondly, the funding for basic research has declined. From the NIH, 20% decline in real dollars over the last decade. So this is a perfect storm. And I think we don't wanna jeopardize the very best academic medical centers because this is where basic research is gonna come from. And frankly, if we're not doing basic research and figuring out how to treat diseases, we still don't know how to treat like obesity, like diabetes, like many kinds of cancer, then healthcare costs are gonna continue to rise. The second category is making sure that all physicians know best practices. And that is, what is the best treatment for this patient? So we have to disseminate that, and we have to provide education. And we're doing that at Dana-Farber, hopefully in collaboration with Phillips, by our clinical pathways, where we have come up with a whole set of this is the best standard of care, because 90% of care is delivered locally in communities. And these patients don't necessarily have access to the very best treatment plans. I think that's second. The third is, of course, cancer prevention, early screening. Well, let's just save the prevention issue for later on. Let's say that for later on. But that is absolutely. We'll definitely come back to it. But those are terrific. Oh, you've got more. The fourth, of course, is value-based reimbursement for expensive drugs. So that's what this, we're gonna talk about for the next hour. Bruce, though, I mean, that was a fantastic framing, and it's a stark framing of our challenges. Bruce, last week, I heard you talk at J.P. Morgan, and one of the issues was whether people who even have insurance and they are employed and they have access to care, they still defer care a lot because of the cost of this. So, again, even when you look at the developed circles and the money we're spending on this, there's still a lot of people who are holding back because they can't afford it.  Well, Cliff, thanks for having us. I would imagine in the US, we are probably the farthest one over to the right in the cost of the bucket there. And part of our, I think there's sort of a good and bad to the progression of science, and that is we are living much longer as a country and as a world as a result of the progression over the years. And that's good, but what also has happened is our lifestyle, as a result of having all the conveniences we have, have allowed us to live a life of luxury, but it's also allowed us to create these chronic conditions. And I know in our population, we're just primarily seniors, we see us four or five chronic conditions. And what we have found is that if prevention isn't attained, those conditions progress. I'm just giving you an example. If someone has a mild or a low severity of diabetes, it usually costs us around $1,000 per member per month. If they progress and they start having foot ulcers, start eyesight is deteriorating even up to amputations or blindness, we start to, our cost expenditures increased to four or $5,000 per member on a per month basis. And that doesn't represent all the casualties in their life. And what we've found is that some of the simple things that make the difference. And what we've also found in our research is that people delay their care. We talk a lot about, especially in the employer side where we have a high deductible plan. There's a lot of people that can't afford that high deductible or they're deductible. And so they're preventing from having the proper drugs. They're not going to the doctor for the proper screenings. They're not getting their in specific conditions like diabetes or other, their particular insulin, for example. And so what we see is delayed care. And we call these things high valued services where prevention, medical prescription adherence really makes a large impact. Just one other thing to that. And the problem we see is in the lower income populations, they are hurt the most. They are the ones that have four times more chronic conditions because of some of the lifestyles that they live and the complexity of their life. And then secondarily, their ability to afford it as much less. And so you have this sort of this spiral that happens that's in a population that is needing help but they can't afford it. So we have a broken system. And again, as great as Lori's and Bruce's comments where you all know from your own experience with various healthcare systems that there are things that are broken. And it's true that we've come a long way since the turn of the last century. But there is a new paradigm. And that's what we're here to talk about in the World Economic Forum has spent two years working on a project that will help define this and actually put it into a proof of principle which they've been doing now. We'll talk about that later. But first, what is it? So you see all this cost that Bruce talked about before and $8 trillion at a global spend this year. Across the globe, we're gonna spend $8 trillion on healthcare. That is projected to go up to $18 trillion. $18 trillion by 2040. Now that's an unthinkable number. And yet we're not, as we've seen, getting these sort of outcomes we want. So how do you change that so that instead of a patients navigating an increasingly complex bizarre healthcare labyrinth, that now that labyrinth kind of rotates around the patient. And so we're gonna talk a little bit about that. And in fact, Omar, since you worked, you're the executive board on this program as well as Bruce and Kristoff as well. Omar, why don't you talk a little bit about why this is such a different paradigm? Well, first, let me backtrack a little bit. The concept of value-based care, which is improving outcomes as a lowest possible cost is something that you can't really argue with. How can that be bad for anyone? And all of us who are in healthcare in the end our sense of purpose has led us to work in this field for that very reason. So the alignment, the philosophical alignment around this topic is really not that difficult. I think one of the biggest issues is that our system has been built over decades in a way in which payment mechanisms and accountability has not been structured in a way that you're actually paid for value, instead you're paid for a service. With the expectation and the promise that value would be delivered. But when you just make promises at scale in a complex environment, there are many things that fall through the crack because no one's really accountable for the result. And so the challenge here is to shift the entire system and all the stakeholders with accountability for care. And that's a big challenge. Now once that's done, I think it's good for everybody. I mean, we fund programs, people come to us, people who work for us come to me and sort of present programs for which they want money. And every program has some kind of value at the end of it, otherwise it won't come. Now how can it be bad to get paid for that? And so, but the system as such with so many stakeholders is not supported today. And that's why that's a challenge. But it's extremely important that we get on that because I think that's the root cause for the cost issue and some of the data that you showed. So we've got different kinds of stakeholders here and Franz, I wanna come back to you in just a minute. But Kristoff, your whole business is based on selling drugs, selling medicines to people. And you could argue that there's a tremendous amount of value in those drugs and I'm sure you will argue that and I hope you will argue that. But the challenge is how do we measure that and how do you make sure that people are getting the kind of value from a medicine? How do you tie that to an outcome? Talk a little bit about that if you- Yes, I mean, first, it looks very simple. So it's a very simple formula. I mean, nobody can argue against it, but it's highly disruptive because what we need to acknowledge if we follow this path is that there are different outcome based on which hospital we go, you go based on which medicine you choose and that the medicine has not been designed with that type of mindset. Doctors were not buying to outcome, they were buying to, my job is to do the best for you. And so it's a very disruptive model. But of course, in order to get there first, you need to measure. And actually, this is a value of that model is that today we spend eight trillion, we don't measure a lot outcome. If you look at the type of measurement we do today in the healthcare system, it's very little. You can do that only if you measure outcome and you set up systems to measure outcome. And I think this is a real value that you gain from such a system is that you end up doing partnership with healthcare provider, with insurance company, with patients, with medicine company, pharmaceutical companies to generate data so that you can measure outcome. And then the level of discussion is totally different and it's not transactional anymore. It's really a partnership to understand this data. So that's a perfect transition to Franz because really at the heart of a lot of this is measuring its informatics. If we had called this session bioinformatics, none of you would have come. So we call it the value of healthcare paradigm. But Franz, your company now, the appliances are gone, the lighting's gone, all the old Phillips that people knew for 120-some odd years has gone. This is a health company now. And a huge part of what you do is informatics. And measuring at a biological scale, to some extent a molecular scale, what is actually happening when there are these interventions? I'll take a slightly wider context and then I'll come and answer your question. So many of the panelists have spoken about the need for a system change and I agree with that. But the danger of saying we need a systems change is that we all wait until the systems change happens and that is kind of a game chicken. Who moves first? Who blinks? And so that's a slow process. Now, I'm hopeful because in the meantime, we can do a lot. Dr. Noseworth, if the Mayo Clinic yesterday in Wall Street Journal had an article, he said the best medicine is teamwork. You just said one of the things we need to do is best practice, right? And then Crystal says we need to measure. All of these things, teamwork, best practice, measurement can be done today by organizing ourselves better. So the equation of value-based care, outcomes over cost, we can measure both, right? We can start measuring outcomes, we can start measuring cost. But it has to be done patient-centric because otherwise it becomes very abstract, right? We start saying, well, population health, but I always say that's one patient at a time, right? And there's a lot of people that work very hard to get better outcomes. So we need to tear down the silos in healthcare within the hospital, first of all, right? And then hopefully between primary care and the hospital and the skilled nursing facility, make sure that that whole flow of the patient is starting to be optimized. So patient-centric care means you need to measure everything around the care pathway of that patient. You need to start correlating information from radiology image to a pathology data source to genomics and bring that together. So many mistakes are made in all those professional silos that we can reduce cost by just optimizing healthcare delivery by adopting best practice. Now, we have put a big investment on health informatics because it's a great way to tear down silos to make information flow with the patient so that the whole dossier can be integrally evaluated. We can correlate pathology and radiology and genomics data, get to a precision diagnosis, and then come to predictive care pathways as what is the most effective for these patients given their genome and then put it in the hands of doctors. We call that clinical decision support systems, right? Where, by the way, artificial intelligence will support the doctor, not replace, but support the doctor in understanding what is the matter and how do we help this patient? So technology can actually help tearing down the silos, become more patient-centric, and optimize, let's say, the chance for a better outcome at lower cost. So I think that's very important. I want to drill down on what's different. Yeah, go ahead. So may I just add to that by providing perhaps an example because I completely agree with Franz here. What Franz is talking about, of course, is precision medicine, precision prevention, et cetera. So how do you do that? Because let's take immunotherapy for an example, right? There are two drugs out there right now, but there are many, many more in the pipeline, and we all know that the treatment of cancer is gonna require combination therapy. That's how we turned HIV into a manageable disease from a lethal disease was putting drugs together. Same thing's gonna be true for cancer, but how on earth are we gonna do the huge numbers of clinical trials? There's over a thousand now in a way that's affordable. We have to be able to predict ahead of time which patient needs which drug ahead of time before you treat them. Because drug costs are still only about 14 to 17% of all healthcare. They are expensive, and I know we need to do something about that, but still remember it's a minority of healthcare costs. So what we really need to do is to develop algorithms from a combination of patient records which measure outcomes. So the patient first comes in, you get their genomics, you get their imaging, you get their pathology, and you then continue doing that when they're treated with a drug. And you say, okay, what was the outcome? What was the pathology? What was the radiology? Can we now predict before we treat that patient if we have enough patients? And Dana-Farber, we have 25,000 patient records and 25,000 patients whose genome has been sequenced. We're gonna be sequencing their immunoprofile as well. We have pathology that's being digitized. We have radiologists being digitized. We need to develop the algorithms so that we can in fact do neural net learning. We can do machine learning because right now the algorithms aren't good enough to do that. But that to me, five years from now, or less, maybe 10 years from now, we're gonna be able to look at a patient and say this is the drug you need. And that's gonna save a heck of a lot of money if we treat the right patient with the right drug. So, in terms of informatics, do we know what it is that we need to collect in terms of data? Because you mentioned genomics, transcriptomics, the microbiome, do we need to know the epigenetics? Do we need to know the microenvironment signaling there? What sort of other proteins are active? There's so much happening. Are they? All of that. All of that, but. Even today. Yeah.  Really bringing everything together, patient centric. And in an academic hospital in Europe, we found that 30% of the cancer patients were either over or under diagnosed, over or under treated. And that's an academic institution. So by just putting the data together across the various silos of the hospital, you can get to a massive improvement of cost versus outcome. And so again, I plead not only to look at, you know, what's out there for 10 years because it put people into a complacent mode, not withstanding your need for your budgets on R&D. I agree with that. But we can do so much to improve effectiveness today. So because a lot of the challenges we don't really know, we didn't know 10 years ago what's important today in terms of information. I mean, again, immunotherapy, that 100 year old science was still at infancy, at least in terms of the excitement factor, the buzz factor of seeing real responses like we have. And so looking at whether we wanted to collect a different kind of measure on that. But Omar, one of the challenges is standards, right? So we've got all, part of the huge thing, this fundamental thing you need in this new paradigm is some way, some baseline to measure. Because if you don't understand what the baseline is, you can't know who's doing better or who's doing worse or how much you're spending versus what you're getting. And the challenge with standards is, we love stairs. My friend Dave Agus says, we love standards so much that we have so many of them. So how do you focus on what you need to create this system-wide change? Well, actually the fact that you have many standards, depending on the types of outcomes you're talking about is probably a good thing. Because you've got lots of diseases, you've got lots of conditions, you've got lots of cohorts, risk. You can't expect all of them to meet the same standards. So I think I'm a little bit in sort of building on what Franz mentioned as to what, you know, there's already problems. And I think picking out specific cohorts of patients, defining outcomes, which are standardized for that disease state and that risk stratified patient is the way to do this. Now maybe you have a methodology through which we set those outcomes, but the outcomes aren't all gonna be the same. In fact, they're gonna be different, even for a specific disease, depending on the risk stratification of the patient. The age, the comorbid conditions and so on might lead to a different outcome than someone with a different condition to start with. So I think the process is what needs to be standardized. The data itself is gonna be different depending on the patient, but let's not underestimate what it's going to take to actually define these outcomes because today they don't exist. And if you cannot define the outcomes in a measurable way, to your point, you cannot baseline. And if you cannot baseline, you cannot improve. Or maybe you think you improved, but you cannot prove that you've improved. Right, as we've seen, we saw that first scary chart. We think we're improving, but we're not, yeah, Lori. So let's bring up a subject that is a difficult subject and that is end-of-life care and what is appropriate. Because we're talking about- I thought it was gonna be a different difficult subject. Health care costs, right? But let me give you a little example here. My older son is a thoracic surgeon and a patient was admitted to a hospital which will remain nameless. A 96-year-old woman who had advanced Alzheimer's disease because she had very tight aortic stenosis. And he assumed that, of course, she would be treated with compassionate care and have a peaceful end of her life, which was only gonna be a few weeks. But instead, the surgeon took her in and replaced her aortic valve. She spent three weeks in the ICU at great cost and then she died anyway. So I do think in the United States is, I think, the biggest problem here. We, I think, believe that if a technology exists, you should use it no matter whether it is appropriate or not and compassionate for that person. We're gonna be seeing an epidemic of Alzheimer's disease. One out of three people over the age of 85 is gonna have Alzheimer's disease. We have no treatment for that. If we had a treatment, if we could even delay that by five years, it would be an enormous- We're already spending $250 billion in the US taking care of Alzheimer's patients. It's predicted to be over a trillion in 2040. And yet, how much money are we putting into biomedical research to try to figure out how to treat Alzheimer's disease? Now, and the many in the private sector will say, okay, well, if we don't try out some of these new techniques and some of these new products and the new devices and new drugs, our innovation pipelines will dry up. We won't be able to do the kinds of reinventions that we've seen in recent years in some cases. Kristoff, I mean, part of the fear of this, anytime you start to talk about clamping down on something, is that the innovation pipeline will dry up. I mean, this is something that I know drug makers and others have talked about quite a bit.  It's interesting that every country is not responding in the same way and it's actually interesting to see differences depending on the culture. But the reason, I think, is a necessity to look at that. I think the research for innovation is slightly adjacent to that. You take Alzheimer, I mean, for example, Takella is very much dedicated to neuroscience and searching still in treatment for Alzheimer disease. I think that, I think we'll continue to research and the key actually for Alzheimer is, can we find, can we generate data which allow early intervention, earlier intervention? So can we better detect, potentially, find some marker to detect who is more at risk of Alzheimer and there is a lot of science generating in this area and then eventually find a treatment but for more early intervention rather than late? I think that's how the system will evolve. So Bruce, I mean, every time somebody mentions some new device or treatment or other, you've got to take out your wallet and pay for it.  So, you know, the concern, obviously, is that when we talk about all the testing we need and the new, you know, informatics and things like that and the new sophisticated machinery and even some of the, you know, new, newfangled drugs, that's coming out so you have to pay for that.  Well, similar to what Omar was talking about is that if we look at it over a, not a particular treatment but you look at it over a condition, you look at it over treating someone over a period of time and for us, we are average customer stage with us for seven to 10 years. And so if there are interventions early on in that relationship or during that relationship that we can impact that condition whether the condition is cancer to diabetes to, to, you know, COPD or, then we are all in, we're all in. And so we're less about the utilization of a particular treatment. We're more focused on how does that extend life and how does that extend the health of somebody and prevent the disease from progressing. So, you know, so you said your average patient stays with you or a customer stays with you. How long? Seven to 10. Seven to 10 years. The problem with, so cancer is a multi-decades in progression, cardiovascular disease, multi-decades in progression, dementia, Alzheimer's, could be many decades in progression. A lot of the things we're thinking about, if we're really thinking about moving to a prevention paradigm, how do we figure out in this model or another model, how to pay for that if you're only, you know, I mean, if you're gonna pay for somebody for seven years and you're not gonna see the benefit of the reduced burden of disease, it's pretty hard to get you and others. Yeah, Franz. Well, we need to make a distinction between primary prevention and secondary prevention, right? So if you have a primary prevention issue, make sure the person doesn't get sick in the first place. You need to think about education, food habits, environment, pollution. But secondary prevention is where the big cost savings can be made near-term, right? And there I would argue seven to nine years is long enough. Because in that time, you can optimize a whole lot. And there, I think, better collaboration between the various industries can help, right? The care providers, the payers, technology companies. And now we need to demonstrate that innovation has clinical outcomes. And Crystal, you mentioned, you know, medication compliance, right? All of that. And here is where I think the IoT and the cloud really is going to help us to create new models of engagement with patients, to help them, first of all, in lower cost settings. But secondly, tying the data together to make sure that somebody, for example, you mentioned COPD, you know, that has support to breathe, that they are compliant to that treatment, that we can give them coaching every morning, you know, how did it go? That we can demonstrate to the payer and to the doctor, you know, how is this patient doing? That I think is already a big breakthrough. So I agree that primary prevention is absolutely critical. 80% of lung cancers are due to smoking. 30% of all cancers are due to smoking. And we and many other cancer centers and institutions, of course, have programs out there in the community. But we have another huge epidemic, which is obesity. And it is incredibly hard to change people's behavior. I'm not saying we shouldn't be trying to do it. And I think some of these new smartphone apps will help so that you're always in contact with the person. But ultimately, we need a pill that will reduce appetite or that will prevent, that will induce satiety. I mean, I don't mean to be negative about the impact of behavioral changes. I'm positive about that. But I think ultimately this is gonna require, again, more basic research and the generation of, we don't have enough drugs. The drugs that we have available target only 600 proteins. We have 20,000 proteins. We got a huge amount left to discover in terms of new pathways and new drugs. So Cliff, I think there's probably different timelines we're looking at. I think when we look at our costs today, we are with a population that has a high degree of chronic conditions. We have to deal with those. I think there's, through science and other mechanisms, maybe our education system and other investments, we can deal with some of the earlier prevention programs. But in today's world, and I think this is a little bit what was talked about a few minutes ago, there's a lot of things we can do as a system that can improve. And let me give you a story. We ran a predictive model a number of months ago to identify patients that were highly likely to have foot ulcers. We identified, and I'll use the name Jimmy, this is in the southeastern part of the States, as an individual that was going to have that. We reached out to Jimmy and we have these consumer personas that identify how they engage. So Jimmy was a control seeker. He hasn't listened to people. He doesn't take people's advice. He doesn't know it all, so to speak. And so you really have to come and build trust with him. He doesn't trust him. So we had a wonderful nurse that reached out to Jimmy and asked a little bit about his lifestyle and really was trying to dig into, did he have foot ulcers? And he did, he had a very large foot ulcer about the size of a coin. And he weighed about 250 pounds. He was on 25 medications. And we began to understand how he pursued through the healthcare system. He hadn't been to a podiatrist in six months. His primary care doctor really treated the foot ulcer one time, but he didn't have the ability to go back to that primary care doctor because of the ductability and because of transportation. He was had a bar tab down the street with a pharmacist and he was deciding what drugs he could take. And through the collaboration between us having a relationship with him for a long period of time with a proper primary care doctor, a home health nurse and some preventions, we were able to take care of the foot ulcer that didn't progress to an amputation. We were able to get medical adherence in the proper level and be able to get him on his 25 drugs. He lost 50 pounds as a result of giving him a nutritionist. And at the same time, he's living a better lifestyle. But that's to me where I think about this two stages we're in. One stage we have to deal with the population we have today and the collaboration and understanding of how to engage with a member or a patient and then be able to take these primary delivery capabilities and help them while developing science to prevent the next wave of population to not have the same chronic conditions or behavioral change or whatever it may be. So that's a great example of what a single company can do with new technology and smart thinking. But in terms of systemic transformation, I mean, so the World Economic Forum and this value project has created a pilot program in Atlanta to see if they can improve outcomes in a dramatic way on congestive heart failure. So this is a big city trying to work across 40 different organizations systemically. Omar, I know you're involved in this, Bruce, as well. Omar, why don't you just tell people about that because I think it's a fascinating, you know, test project. Well, yeah, see, one of the underlying themes of that is what's already been discussed that you've got to pick a certain condition. In this situation, that's clearly chronic and it's fairly advanced and there's probably a lot of money being spent on it. And, you know, that has got its own story of the sort that Bruce just related in a different condition. And I'm sure if you did a survey there, you'd find all kinds of patients in different stages of heart failure being treated in different ways. So that project focused on a certain condition. And one of the first things you do is try to stratify what are the different sub-conditions within that. Define what the expected outcomes are for each of those conditions. A lot of this is already known. It's what the expectation should be. And then what are the variables that are required to impact, to connect the outcome and the cohort together? And I think a study like that with a population in a certain specific area with multiple stakeholders from pairs to providers to technology companies to drug companies, all, not all trying to compete with each other, but all working together, working in the appropriate space where they can help each other get that outcome. And as you do that, you not only have a clinical value, you also have economic value at the same time because you stop a lot of wastage. Let me just make one more point there. One of the things that's become apparent as well, and Bruce kind of alluded to it, is that in all these studies, especially when you look at any population of any size, the social factors and the behavioral characteristics of individuals actually are extremely important criteria and sometimes more important than their disease because you can treat them, but they're not compliant. One patient is compliant, another is not compliant and you have to manage them differently. So that angle, I think in studies like this, come out to the top. Bruce mentioned the transportation problem because maybe an economic situation of an individual patient and you can get groups like that. And although the clinical pathway and principle should be the same, you've got an overriding social and economic management as well that has to be integrated with this, otherwise you won't see the results. So some of the learnings you get from a study like that. I know Franz and Lori both wanted to jump in. I just want to let the audience know in a minute I would love to get some questions from you or just some quick questions for the audience. So, but just think about that perhaps. Yeah, well, a few, I mean, so we all, I think, seem to agree that there is a lot possible, right? And in the beginning I said, let's not talk too much about system change because we can do so much. But this discussion around secondary prevention does require some kind of a systems change. The first systems change needs to relate to the same data that is the promise, right? We all entrust our financial health to the cloud. We have our social life in the cloud, but many countries in this world are schizophrenic when it comes to health data, right? And in Europe, especially, in Germany, it's not even possible to take your data across a state border, let alone the country border, right? Let alone that you can start mining it to do this kind of preventative actions that Bruce talks about. So I do think we need to come and get to a breakthrough around connecting databases so that we can do the analytics. And start understanding the patterns and the cohorts and the individual patients that need to be touched. Second, if we don't want these expensive patients to come too late to the emergency room, but rather get them to get more preventative care, then we need to reimburse that. And even though the example suggests that that is possible, not at a large scale, right? Phillips partners with several large IDNs in the United States around telehealth, and telehealth has been a promise for a long time, but it's cost avoidance at best for the hospital. It is not a reimbursed kind of line item. So it's not bringing the patient in enough and incentivizing it. At best cost avoidance, right? It's not reimbursing the healthcare centers. So a hospital that may do something just to avoid the patient coming back within the next 30 days, but for a long-term, let's say, congestive heart failure patient, you need to start reimbursing that provider for doing the care at a distance. And I would imagine for cancer that will not be different than for COPD patients. So I would hope that we can also get breakthroughs on these systems. I just wanted to bring up another huge risk factor. So along with what all of you have said, I mean, we know that about 40%, roughly 40% of healthcare dollars goes to the 5% of sickest patients, and those are patients who have multiple chronic diseases, diabetes, obesity, heart disease, but it turns out that the biggest risk factor for readmission to hospitals is mental health. And what are we doing about supporting and paying for mental health? I think we mustn't forget that that is actually the biggest risk. It makes patients non-compliant with their medications, makes them not return to get... In the community, right? In the community, yeah. So we've got to think about that. Well, I encourage you all to go to this session. We're going to have on mental health tomorrow, and it's in your program, about incorporating that into the value health system. Do we have a question or comment from a quick, right here in the first row. Could you just identify yourself? Yeah. My name is... We have a microphone for you. My name is Zaid Mandamar from Saudi Arabia. I'm in the healthcare business. I find the biggest challenge will be in the client until we have technology that will allow us to reach to the patient and carry out preventive medicine or preventive healthcare provision at home. We're going to have a lot of resistance. Today, our country is facing a large transformation, and part of the vision 2030, which is brilliant, is to transform the healthcare facilities from diabetes, the old radiology, and so on. The point is that the client doesn't know the deliverables they want, and that's very risky. Even with education and RFPs, we're facing a big challenge, and I think that resistance will continue until we can surpass the client or override the client and go straight to the patient where we can extend our preventive healthcare. So I think that's a good question. So we want to talk about the fact that we've... All this new technology that is going to put the patient more in the center of her care. Does somebody want to address that? Well, you know, one thing, though, in all of this, the patient is at the center because you're measuring the patient's outcome and what it costs. In the end, the patient, in some way, either through their taxes or through direct payment in some countries. But in the end, the value is outcomes over cost. But I do want to make the point that in all of this, we want money, we want to be reimbursed, but we'll go down the same path unless the reimbursement is tied to an outcome. You have to have that. And so the definition of the outcome, the baselining of the outcome, relevant to patients is the task that we're on and that has to be a granular task. This is like disease by disease, condition by condition. And you just got to do this brick by brick. There's no magic solution. I mean, the etiology of disease is multifactorial and we know that we described this long process of the progression of so many chronic diseases. So how do we identify specific outcomes? I mean, maybe something is helping in some little way or how do we identify that? Well, I think it's easy to identify outcomes in cancer, which is what we focus on. Does somebody's tumor regress or does it progress? And we keep very careful records of that, but here's a perfect example of tying reimbursement to outcome and that is the CAR T-cells, right? So we have two, there are two products on the market now. One is for your acute lymphocytic leukemia in kids and adults and the other is from lymphoma. That's Novartis and Gileadkite. And what they have said is, here, the product costs $475,000 or $375,000 and we will only charge you for it if the patient responds. The patient doesn't respond and these are desperately ill patients for whom no other treatments have worked. They are on death's door. And there is an amazing response in a great number of patients, although there is some toxicity associated, but that is exactly what they're saying, Omar. But that's a challenge though, because particularly in the case of cancer, you could have a partial response for 30 days. Yeah, but how do you... Well, there are clinical trials that people do. So all of us, certainly pharmaceutical companies and device companies and equipment manufacturers, we do clinical trials. Clinical trials are science-based, but clinical trials are done under protected conditions where cohorts are clearly defined. Outcomes are measured with discipline. All the variables are managed. Translating that to the real world, those fundamental features have to be translated. Otherwise, if you just throw it into the real world, you'll treat the wrong people. You need many more smaller, more efficient clinical trials. You need more phase one trials, more basket trials. Adaptive trials. Identify the genomics of a patient. You're able to predict what they might respond to. And then you can do a very small trial, get the readout very quickly. And then you don't treat the other 95% of patients who don't have that genetic... Right, and then translate that to a payment mechanism. Exactly. Rapidly. All right. We have a bunch of questions. I want to make sure we get one on this side and then we'll come back. So how about right here in the first room? Hi, my name is Andre Robert. I'm practicing oncology in charge of a network citywide in New Jersey. I have two questions. One of them is that clearly we are the inflection point in many aspects in medicine. And we talked about value-based care today. I'd like the panel to comment on new models of reimbursement and how we go away from fee-form service and global reimbursement and how we apply this in the real world. And the second question is that what we are learning from the Western world trying to fix healthcare on how we can prophylactically, if you want to call it, expand this globally so that we don't have to re-learn this in other emerging countries. OK, we only have 10 minutes. So we'll just try to take it. I think what we found in providers that are trying to move from a fee-for-service dependent to a more value-based is you have to take steps and we caught path to risk. And so you'll have a base payment that would be more on fee-for-service orientation where there's a volume-based model to it. And then there are cost and quality indicators within that payment mechanism that then allows you to receive bonuses to that. So you know what in our industry the slang is, you don't take downside risk. You only take upside benefit there. That's the beginning step. And then you just sort of adjust that over time as you make your changes in your infrastructure, your process flows, and your outcomes to take more and more risk. And you participate in more of the upside and downside of the program. What we find is it's a big change from fee-for-service. And a little bit, I think, of a quiff in the panel was talking about because you're used to billing and collecting. And you're used to maximizing the treatment during that period of time. And that's sort of what your systems are built up. That's what your workflow is built around. That's what your informatics is built around, is how am I going to get paid for this? And how do I get it through the system? And it's a lot of volume. What we find is when you get to the other side of the payment model where it's more around value, whether it's an oncology and it's a bundled payment, or it's population health and a more primary care oriented engine, it is much more around slower, more time with the patient where so volume isn't there. It's more around quality indicators and downstream costs. And so you have to see beyond your walls and you have to see farther down. And you see, you have to see sort of the engagement of your patient. And that engagement is that if you send them to a specialist or a subspecialist, you need to make sure they get the appointment and they go to it. And there are, they can afford the copay. If you give them medicine and a prescription, you make sure they get the prescription and they stay on it. And that downstream effect and that volume versus quality of time with the patient is what we have found is the biggest change in the workflow and the data and the technology to make that as opposed to the payment. Everyone talks about the payment, but I got to tell you what I see is not the payment model that's driving it. It's the informatics, it's the measurement of the quality, it's the workflow in the model, and it's the risk you take of running from a volume-based model to more of a quality orientation to the engagement of the member or the patient. Okay, let's get, go ahead, Lori. No, go ahead. Okay, that works, that's good, but what you're saying is spending more time with the patient. And that's the problem. Our physicians are burning out because they don't have enough time to spend with the patient, but if they don't see more patients, we can't keep the hospital alive. So either one has to increase the amount of reimbursement so that it at least equals medical cost to allow physicians to see. And you know, Dana-Farber, I have to say, we spend a lot of time with each patient, but our margin is razor thin because of that, and it's because of healthcare reimbursements in Massachusetts not keeping pace with costs. So there have to be a profit and loss change in the whole system, right? Because also within hospitals, sometimes there are profit centers, right? And if you want to optimize the resource allocation along the health continuum of an individual patient, you may want to redirect resources to the prevention or to, let's say, the counseling or the mental health, but that is not how the system works today. So we'll have to see a change in the P&L management. Now your second question with regard to emerging countries, very important, right? And already we see a risk there because emerging countries build hospitals, whereas they should build capacity for primary care in the community, right? Where we see a multidisciplinary approach to all the NCDs that are coming up and to nip it in the bud, right? But money for primary care in most emerging countries is not available. Phillips has pioneered community life centers that actually will drive the economy of a village, but still the initial financing of such a community life center is not resolved. We work together with the United Nations. Now, and the World Bank to try to get the funding because it will be an economic stimulants as well as a life enhancer. The risk, the mistake would be to just build tech-sharing hospitals in big cities. We have time for one last question. Let's, any, right here in the first row. We get a mic here. Just please identify yourself. My name is Katja Iverson and I work for an organization called Women Deliver. We work to drive investment in the girls and women's health and rights and well-being. I've worked with several other people on the panel. My question is, can you apply a gender lens to what you have just said? If we look at the care system, we have a feminization of the health workforce. We have the care in the families and it's often taken care of by women. I know that the work that you have done in Kenya in the community health also has a very strong gender angle, but I would love to hear the gender angle on some of the other points. Also on the research. Well, let me talk briefly about the gender issue, which I see no gender bias in terms of taking care of women, certainly not at the institutions I've been at. So I don't see any gender bias there. Where there is gender bias, of course, is in senior leadership. There are still a scarcity of women in senior leadership positions and that's unfortunate because we need to be role models for all the new physicians and the new scientists that are coming online. And that, you know, here we have 21% women at this meeting. All of our co-chairs are women and I applaud that. I think that's great, but we have a long ways to go and I was at the Mercer breakfast this morning and that was a topic of discussion. So yes, you're absolutely right and we need to do something about it. And that in part means putting our money where our mouth is in terms of supporting the careers of young women. So it's so important that so many caregivers are women and that burden falls unduly on them. We just have one minute left. I want to alert you all to this fantastic report that is just being released today. If you go on top link, you can actually download a copy of this report, Value in Healthcare. It's the second year report and it's just hot off the press. I wanna thank my extraordinary panelists, Laurie, Franz, Omar, Bruce and Kristoff. Thank you all so much. Thank you.


Every week day after doing my homework, I would rush over to my TV, eagerly anticipating the moment I could switch the channel to Nickelodeon and Indulge in the delightful world of SpongeBob SquarePants. At the tender age of nine, this beloved cartoon brought immense joy and laughter to my life. The whimsical underwater adventures and lovable characters wore like a magical escape from the mundane routines of childhood. But then, on that fateful day of June 6, 2006, everything changed. Little did I know that my innocent excitement to watch a rerun of the episode, Something Smells, would turn into a haunting experience I would never forget. As the episode unfolded, I was as captivated as ever, reveling in the humor and camaraderie of the characters. However, when it reached the scene where SpongeBob asked Patrick if he was ugly, a neary chain of events began to unfold. The screen suddenly froze, plunging my room into darkness for what felt like an eternity. Confusion and fear washed over me as I tried to make sense of the unexpected turn of events. When the visuals returned, my heart sank at the sight before me, a haunting image of SpongeBob, seemingly burnt and tormented, as if engulfed in flames. The eerie spectacle persisted for about eight seconds before the screen once again turned black. The innocent cartoon I had known and loved was now entangled with something dark and inexplicable. A seemingly unrelated image of a serene river appeared next, followed by a commercial 14-dick, hosted by Nick Cannon. Still reeling from the unsettling experience, I struggled to grasp the meaning behind these strange occurrences. To my dismay, cryptic text emerged on the left side of the screen, addressing the creator, Steven Hillenberg, in an accusatory tone. Steven, why would you murder me? I thought we were husband and wife. Your behavior was normal at the time when we were together. Why did you kill me? Please tell me why. The enigmatic message sent shivers down my spine, and a sense of foreboding enveloped me. It was as if I had stumbled upon something I was not meant to witness, and the unsettling words left me deeply disturbed. As if to deepen the trauma, the screen flashed the word, in capital letters, why, its intensity enough to unsettle even the bravest of hearts. The flashing ceased, and a chilling drawing of SpongeBob against a foreboding red-backed drop appeared, accompanied by the ominous text, also in capital letters.  The disturbing images played on a loop in my mind, leaving an indelible mark on my young psyche. The sequence finally culminated with the Nickelodeon logo against an empty background, but to my surprise, none of the splats that make up for the logo were shown, it only showed the text. Followed by the familiar technical difficulties screen. I couldn't bear the eerie experience any longer, and with trembling hands, I switched off the TV, seeking solace in the safety of the real world. That unforgettable day left me traumatized, and it forever altered the way I viewed SpongeBob SquarePants. The innocence and joy I once associated with the show were overshadowed by a lingering sense of an ease and confusion. I tried to move past the unsettling encounter, but its impact on my young mind wasn't denyable. Despite my best efforts to enjoy SpongeBob's adventures like before, the haunting memory persisted, always lurking in the back of my mind. The show that had once been my source of happiness now evoked an unsettling mix of emotions. Over the years, I questioned whether others had experienced the same eerie sequence, or if it was an isolated incident meant solely for me. Regardless, that fateful episode became a part of my personal history, forever intertwined with my perception of SpongeBob SquarePants. Though the world continued to adore the lovable Sponge, my feelings toward the show were forever changed. The once blissful relationship I had with SpongeBob now held a haunting undertone, a dichotomy of love and fear that followed me throughout my life. Years after, I thought nobody knew about the incident, but to my surprise, someone knew about it and uploaded footage to it on YouTube. I managed to find the video.


Hey, it's Flare. Let's talk about those percent-based commands that people have all the time on their Twitch channels. In other people's chats, I've had these commands tell me how much of a gremlin I am, what percent stinky I am, how horny, how worthy, etc. The idea is that users type the command and then Stream Elements generates a random number and uses that as a percentage in part of the output. It's very simple and very fun, and it's a great little engagement tool to give people something to do in chat during lulls and conversation. Let's get started setting it up. I'll assume you're already logged into Stream Elements and have connected your Twitch account. If you haven't already done that, go check out this video about how to set up Stream Elements chatbot, and I'll meet you back on the dashboard. In the left navigation, choose chatbot and then chat commands. Choose the Custom Commands tab. Click the Add New Command button. On this page, set the command you want to use. For this example, we'll use exclamation lucky. Keep the user level at everyone, unless you have a particular need to lock your command down to VIP User Moderate. For the response, use a variation of this string. Dullesign username is Dullesign Random 0-100% Lucky. Those things in brackets are variables, and they will dynamically set the username of the person that used the command and generate a random percentage for the output. You want to keep the username and random 0-100 bits alone and just change the text around them to suit your liking. If you need help formatting this the way you want, let me know in the comments. Now, make sure the command is enabled and click Activate Command, and you should be good to go. To test, let's go over to the chat and type exclamation lucky. If it works, you should see the message from Stream Elements pop up with a random percentage and your message. While you think about what kind of word you want to use for this command, go watch this other tutorial on Stream Elements commands.


This study has identified key genes involved in the development and maturation of skeletal muscle fibers. The researchers have created a comprehensive map of gene expression patterns in developing and maturing muscle cells, which will help us better understand how muscle cells function and how they can be manipulated for therapeutic purposes. This article was offered by Matudos Santos, Akonsha M. Shah, Itchy John, and others.