 Good morning to everybody. We want to welcome you to our last Moran Ice Center Grand Rounds of the academic year. We're really pleased that you're here with us. Those of you that are here in person, as well as our virtual audience. And we're going to cap off the end of the year with a global ophthalmology focus Grand Rounds. This is going to be a little bit different style today. We're going to do some questions and answers. We're going to also do some highlights for our division. I think some of you have some questions about the function of how the Moran Ice Center's global outreach division works. And so I'm going to give you a little bit of detail. And then we're going to talk a little bit about how partnerships are so vital to what we do. And we'll be having a very nice feature with Bilal Khan to talk about how partnerships work and how we partner with industry to make global ophthalmology work. These are my financial disclosures, which are relevant for this topic. And I just wanted to share with you that we, in fact, have a mission and vision statement for our division. And our vision is really the Moran Ice Center's global institutional vision that no person with a blinding condition, eye disease, and our visual impairment should be without hope, understanding, and treatment. But specifically for the Moran Ice Center's global outreach division, our mission is to establish and support sustainable eye care solutions that empower individuals and at-risk communities worldwide. And we do that through a variety of activities. And these are the activities that we primarily focus on. Building collaborative partnerships, those can be with individuals, with academic institutions or entities, teaching and training programs for all eye care professionals, not just surgeons, but including medical students, technicians, nurses, et cetera. Advocacy work is something that we've, I would say, is the area that we've been the least involved in, but an area that we are putting more and more effort into, particularly for global blindness issues. Research and finally delivery of high quality eye care. So we invite you, if you don't know where our space is, we're down here on the first floor and we invite you to come and we know many of you participate in our activities and we're grateful for that. We are nearly 100% donor based in terms of our funding, but we also rely on our volunteers, you're really the backbone of the work that we do here and throughout our community as well as globally. So with that, we're gonna now transition over into our keynote presentation for today. I'd like to invite Bilal Khan to come up here up front. Bilal is the CEO of New World Medical, one of the premier glaucoma companies working in this space and his talk has been on evolving global ophthalmology efforts. Bilal did his undergraduate career at the University of Wisconsin, Go Badgers, right? And we know we have a number of him in the audience and some are heading there soon. Also he completed his MBA at the Board School of Business and one of the interesting things that we're gonna get into a little bit later is that his degree is in actuarial science. I didn't know about actuarial science until probably about 15 years ago and it's a really fascinating area I think for people who wanna see the world through numbers and understanding risk, et cetera. So we'll get a little bit into that and how that shapes his perspective as leading this company. So with that Bilal, we invite you to the podium here to give your talk and then we'll have some time for question and answer. So we invite those of you that are here in the audience, we will have microphones to pass around for our audience and those of you that are joining us on Zoom, we invite you to submit your questions as well. Well, thank you for your time. Well, thanks Dr. Shia and thank all of you for the opportunity to sort of share our story today. You know, I was reconnecting with Lori and we came six years ago, I think in 2017 we came to visit you guys and learn from how you were evolving and basically today is gonna be a transparent talk about what we've done, how our thinking has evolved. We're still finding our way. So we're looking to, I look at today as an opportunity for some thought partnership and feedback. We're looking to improve. So we're not necessarily get affirmations but any opportunities or ideas are welcome. So feel free afterwards to ask questions or give comments, they're also welcome. So my financial disclosures, the primary one that's relevant is I'm CEO of New World Medical. I'm also involved with a couple of startups, one Spyglass Pharma, which is drug delivery IOL and another eye tracking technology to diagnose traumatic brain injury. So those aren't really relevant. So just to give you a snapshot of our organization really briefly, because I think the context matters when you're making decisions and we're lucky with a very unique context. So we're a closely held organization and I'm gonna go into depth about that. But I think that that has empowered us to be mission driven in a little bit of a different way than other organizations. We have a different type of freedom I think and it's a privilege to have that. We also have demonstrated R&D capabilities. I think that also speaks to our ownership structure. And that's allowed us to build out a comprehensive glaucoma surgical portfolio because we started from R&D base and we continue to launch products into that space. And we have about 200 plus employees and we have a direct sales presence in the US and internationally we sell through partners. But to get back to the why we exist because I think this is why I just feel very honored to be part of this organization and I didn't get my job through merit. I was an actuary for nine years. So that's not how you usually become a leader in a medical device company. I got my job through marriage. So 18 years ago, I married my wife who's the founder's daughter. And I think Dr. Ahmed waited five years and then he asked me to take over the business. I think he first one to test me out a little bit. So 13 years ago, he asked us where we were living in the UK. I was working there and he asked me to come back and take over the business. And that context is really important because Dr. Ahmed is a unique individual. I always make this joke and I think people at the company are probably sick of it but it's true. He's driving like his sixth red minivan and he's basically gardens all day now that he's mostly retired. But as long as we can afford red minivans and an opportunity to get whatever he needs from the gardening store, we're good with our investors. And I think that's unique. I think that like other organizations not better or worse but just different, they have a different type of cap table that sort of orients them to different types of objectives where Dr. Ahmed's always been very pragmatic, I think in what he wants from us but also not necessarily prescriptive. So when I joined the organization, the first thing he told me was you can't sell my business. So I think he thought this guy's coming from a finance background. So what he's gonna do is he's gonna come take the family's business and just sell it on. So I was like, okay, fair enough. I won't sell your business. And then he's, so I said, what do you want me to do? And he's been very unique as a mentor and that he doesn't give advice. Like, and I struggle with that. He's given me context but he never gives me actually advice about decision-making. And the reason for that he says is he doesn't want me to become dependent. He needs to give me space to make my own mistakes. And that's the only way that we're gonna grow as an organization, which I think is unique for a founder that sacrificed so much of his well-being actually to create the business. So when he founded the business in 1990, he had a couple of partners and there was some context around the regulatory environment and for folks that are older like myself, you'll remember there was a breast implant scare in the early 90s and nobody was investing in silicone implants. So he wasn't able to raise funds. So that was really trying for him to be able to found the company. But he was very, he was very, he was very determined and was able to do it with the help of a number of actually academics across the country, including Dr. Crandall here who ran the trial for our Amit valve with little or no support from the company because we just couldn't afford it at the time. But that unique sort of founding story allowed Dr. Amit to actually buy back the business and it's wholly owned by the family now. And that's what's really empowered us. I think it's a pretty harrowing journey for him but for us it's a privilege. So I asked him, I was like, look, you told me I can't sell the business. So what does that mean? What do you want me to do out of the business? Because you're not looking to get a richer yield out of it. And it sounds a little corny, but I think if you meet Dr. Amit and he'll be at that academy, he doesn't travel as much anymore. It's authentic and he drips with authenticity. And basically what he told me was like, I want you to benefit the people and benefit humanity. And in our organization, that's really the mantra and that's how we tried to orient it. Now the challenge of that and the challenge of not getting advice is what does that mean in reality? And that's been sort of my journey and that's really what we're gonna speak to a little bit as a management team is like how we've had thought through that because what happened initially was we probably aired one way or another too much where people thought maybe we're not being authentic enough to our mission that he sort of charged us with. And sometimes we were impractical in trying to deliver on the mission in a way that wasn't sustainable and wasn't gonna allow us to continue on as an ongoing concern. And even within the company, you have to sort of clarify that because it can cause tension, especially as we've grown. When I started, we had 15 people and now we have, I think we're approaching 220. The debates are now not always inclusive of me because the decision making is now spread out. So you have to be able to convey things in a way that is understandable because otherwise what happens and we saw this in our, as we evolved was people will be in a debate about a business decision and we'll end up with something totally impractical as a solution. The reason is, is someone sort of usurps the authority of the moral high ground, right? And they say like, look, if we're about benefiting humanity, this is what we have to do. And then it leads to a decision where if we do that, we're driving our organization right off a cliff, right? Which is great in the near term because it's fulfilling but it's just not pragmatic in the long term. So we had to define that. So the way we defined that was fivefold. So first and foremost, we empower surgeons like yourselves. I think that we're a technology company and we need to think about how we can contribute, right? We can't actually deliver care like all of you but our contribution is delivering technology. And because we're not just driven by growth, we realized that our specialty is in Guacoma Surgical. We've had a lot of opportunities to go outside of that. I think we have differentiated capabilities in Guacoma Surgical because we've developed more products in that space than any other company we've developed products for more anatomical targets than any other company. Secondly, and I think this is really important to me personally. And I think a lot of folks I was speaking to one of the providers in the community yesterday and she was, and I was asking her because a lot of people, especially now in training, it's different where they may not wanna get involved with managing a practice. And I was asking her about that burden and she was saying it's really fulfilling to create fulfilling careers for people. And I feel really much the same way. We have 200 families that we support through our organization. And I think we give them meaningful work and we also provide them hopefully robust ways to support their life endeavors. We also try to expand access to care. So in the U.S. that means people who are uninsured or underinsured and we will give no-charge products internationally. What that translates into is we do give no-charge products. Sometimes that can be problematic and that's not sustainable and it actually can cause issues which we'll get into a little bit. So but in lieu of that, we all the time try to work with our partners to make sure that our pricing internationally is achievable in local markets so that access is not an issue. We also donate 10% of our profits. I'm gonna talk a little bit more about this today. It's interconnected with the rest of the things we do but I think it's representative of how our thinking's evolved. And finally we support employee mission trips. So we've had employees, I think one of our team members joined you with one of the trips to the Navajo Reserve as well but we cover 75% of the cost and 75% of the time. And that's selfishly, we wanna really ingrain people into our mission and really let them feel it. So every single town hall we have, we have quarterly town halls, we have someone present on something they've done just because especially for folks that are not in the field, it's easy to get detached from how real the work that we do is and how great a responsibility we have to do it at a really high level of professionalism. So I'm gonna talk about our initial phase and I don't mean to be dismissive about this but this is like one of the things I always cringe about is that we are a family business and I feel a little guilty about that because a lot of times family businesses become lifestyle businesses. And I think we try to be mission driven and true to that but that's been an evolution too. We have a founder who's a very powerful personality in the sense that he is so giving to the point where we as a family have to restrain him at times because it can cause problems. But that was the origin of our evolution and it really was a mode of giving and it wasn't as systematic as maybe someone who like myself would like as far as scaling but actually it's really special because you have to sort of keep that even as you scale you don't wanna lose that sort of soul of your organization. But what we did initially and this is just a sampling of what Dr. Dama did over the years, it would be a lot of times folks that he knew well. So we supported a mobile vision screening clinic in New York City for different populations that weren't really going to see providers. We supported Ann and I Institute in India in Hyderabad, we were one of the founding donors for that but these were both two individuals that Dr. Ahmed knows, Dr. Al Oswed who was recently at NYU and then Dr. Ramesh Ayala who's the chair at USF and we supported them but it was mostly because Dr. Ahmed had a relationship with them. It wasn't necessarily where we were optimizing our impact. Also we did things personally and this is something that we blended away. So our family is of the Islamic faith. So we funded a masters of divinity program for the Abrahamic faith. So people who are of Jewish background or of Christian background could study together and we also funded a school in South LA that would provide a safe environment for kids there. And over time, we continue to be involved with those things but we've moved those to our personal level because we wanted to connect it better with our organization because we want to coherency. It's a big thing I think about when I think about building our business is the coherency and the reinforcing elements of our business because I think that that's how you create a really powerful organization over time. So we wanted to be more systematic and coherent and what we did is we sort of pivoted away from some of the emotive giving and personal giving for the family and we separated that into, we can do that separately outside the organization and try to align with our customers and actually our employees as far as our giving moving forward. So we launched humanitarian awards and actually Moran was one of the recipients for our project award for your work in Tanzania. And it was a $50,000 award that we gave every year and we also launched a fellowship award for recent Guacoma Fellowship graduates that wanted to go on a mission trip. We would provide them travel support and finally an outcomes research support where we would fund a project that would basically go into ICAMPs and try different techniques to be able to screen people efficiently with more pragmatic technology. These were really, I think impactful in some instances and other instances not so much. And we realized that sometimes this just doing these sort of one-off projects aren't as lasting as impact. But the big benefit of these awards is it allowed us to receive a lot of applications and really educate ourselves on all the work going on in this space. A lot of the work going on in space, not all of it. But that informed our next step of evolution and how we've been thinking. The other thing we did is we funded Orvis's Guacoma platform for CyberSight. And the last thing we did, which I think was incredibly impactful, hopefully, was we worked with Cure Guacoma Foundation, which is the charitable arm out of Guacoma Associates of Texas. And there's a doctor there, Dr. Tosen Smith, who's of Nigerian origin. And she led a program in Nigeria and it's actually been pretty incredible. So we went in 2019. At that point there was one surgeon that could do Guacoma drainage devices in the country and she'd only been doing it for a couple of years. And Dr. Smith created a sort of systematic education and actually an identification first of the right partners and then an education program and then a model where we help people accountable for passing on their knowledge that's expanded the number of surgeons capable of doing these refractive surgeries to 50 in just a couple of years. And she's looking to expand that. But and we also, one thing we did there too to help incentivize that was we provide a financial support. We went there to learn from what they were doing. We provided access to our training systems to help them create a curriculum to do remote training and also onsite wet lab training. And lastly, we also have worked with the locals to provide product at basically cost for us so that they have ongoing supply because Dr. Smith told me at the beginning, she's like, I'm not doing any of this with you unless these people have access to the technology longterm because otherwise it's all for none. But with all of that and all those learnings one thing we thought is we don't think we're optimizing what we're doing yet. So in 2019, we established a donor advice fund and the reason we did that is we had this 10% profits that we were giving away every year. We felt pressure to sort of just find an opportunity to give them but we didn't think it was as strategic as it needed to be. So what donor advice fund allowed us to do was segregate that money so no one can accuse us of just not giving anymore. So that money can't come back in the company. It has to go to a 501C3. But what it allows us to do is because those funds are now outside of the company we allow us to sort of make a little bit more results oriented investments basically milestone based grants where we can say like, look we'll give you this initial funding and we can escalate it if you hit these targets. And that allows us to be a more consistent partner because like our business is not guaranteed forever we're in a technology industry maybe we get out and invaded maybe something happens. But if we have sort of these segregated funds it allows us to at least ensure that our commitments are met to the partners that are dependent on us. And again, that just speaks we were looking for one or two locations where we could really indigenize care. That's another thing we saw with the learnings from all of you and what you've done in Tanzania but also with Dr. Smith's success in Nigeria is that the real challenge is not necessary or the real opportunity is not necessarily folks from here going abroad but really cultivating the capabilities locally. And we were looking for one or two locations. So we had a series of trips lined up in the spring of 2020. Actually the first was gonna be right after the AGS slash MAGA convention in DC. And we were gonna go the next week to Ethiopia and then we were gonna go to Guatemala and we were gonna try to look at different sites that we had worked with over the years to find who the right partner was but obviously that all got delayed because of the pandemic. So in the interim what we did was we made some less like not as thorough contributions but something that still were aligned. We open sourced one of our key collaborators books online. We made a Wiki platform with a textbook about Guacoma procedures. We also worked with Dr. Petty. We were so privileged that he reached out and then we were able to contribute to there to the first global outreach meeting you guys did. Supported some international fellowships for folks coming here to further their training and also run an Orbis study in Africa where again similar to our outcomes research study they were using non-medical staff to screen for Guacoma. And finally, and this is the organization right now that we're looking to go deeper in and we're continuing to talk to you. We just did a site visit earlier this year. It's Hospital Adela Familia. We provided them staffing support to develop their organization. And I'm gonna speak to why we're looking to go deeper with them. So that area, and I wasn't aware of this but Southern Mexico and Western Guatemala and I know you guys have done work there before but then I think there might not have been reliability of the local partner, but they, you know it's one of the most impoverished areas in our hemisphere and 70% of the kids are malnourished and you know, there's just tremendous need but one of the unique things is it's historically accessible. There hasn't been the social unrest that some of the other areas like Haiti is and I know that's been a challenge for some of your projects. And other thing is it's actually we had an established partner there where they have 80 plus full-time employees. They have four programs. One is a medical center which has 20,000 patient visits a year. They also have a child nutrition center where kids are admitted if they're severely malnourished to recover for four to eight months and they have some educational programs but they have an eye center and the eye center is really well run but the challenge was always getting providers, right? And that's the thing like you don't wanna go in somewhere at least from our perspective where there's no ecosystem and here are the unique thing was there was actually an ecosystem in a culture to actually deliver care. The challenge was providing, getting providers to move to Western Guatemala or to be there given that a lot of these people are highly educated like yourselves and for personal reasons it's just not sustainable for them to be in a remote area to raise their family or further their lives and or find fulfillment outside of work. So it's always hard but for us we thought that there's an opportunity because there is an ecosystem that's reliable that can be sort of leveraged to expand care. And this year they are on pace to do 4,400 procedures at that clinic. So which I think is just tremendously they operate seven days a week but the biggest thing is again not to belabor the point is that they're indigenizing care delivery. So what they did initially was California Pacific was the partner that would fly down and they would fly in fly out do some procedures and fly back but then over time the individual in the back in the picture Dr. Sorenson he decided that like look it needs to be sort of localized to care. And so they tried to figure out how can they get someone to move to that region of the country? And what they did is they created sort of a pseudo fellowship where somebody would be incentivized to move there they would be compensated for their training but then they also would have access to some of the leading ophthalmologists from the US that would come down there quarterly and spend two weeks there and go over procedures there and then do some distance learning. So over those couple of years they had access to sort of some of the highest level trainers in the world. And this is something that they've continued to leverage and now they have eight local Guatemalans all women actually who go there and they have facilities where you can stay so they go there for 10 days at a time and they rotate in and that provides coverage for the whole month. And because this model we think is very promising we're looking to help them continue to build it out and really figure out a way to make sure that it lasts beyond Dr. Sorenson who puts his blood, sweat and tears into it but how can we help him with our support and contributions to maybe institutionalize this? Something that's impactful and also it's also impactful in the region because the people coming out of the training there's huge variations in training in a lot of countries and in Guatemala it's no different. There's a couple of very good training programs but even in those programs the surgical volume is not very high. So a lot of trainees come here and they get a tremendous amount of surgical volume and they also get exposure technology that they don't have access to in Guatemala City. So I also think it escalates or elevates the level of care within the country and actually neighboring countries as well because some of the people that work there are from the neighboring nations. So just a couple of thoughts about approaching industry. Now I only have worked at New World Medical within this space so this is very biased to that but I'll give you some thoughts and just some advice about when you approach industry, some considerations. So first and foremost, I encourage everyone hold industry accountable. Everyone in industry loves to talk about how they're your partner and that they're in it with you for the patient. Well, hold us accountable for all the things that you're trying to do because you're investing your time and you're trying to fight the good fight. I think it's very fair to hold industry accountable for making sure that they're working alongside you. Also, you need to understand your target. So a couple of things about approaching industry and this is just my perspective and Dr. Chai and Dr. Petty and Lori, they know a lot more about some of this interactions but when you look historically at industry, the projects they'll fund, a lot of times they're projects, they're not gonna fund brick and mortar. So you have to know what your ask is and if it's the right ask to ask for that party, right? A lot of times what we've seen for international ophthalmology is the brick and mortar is from like patient donations from a large patient donor. It's not necessarily from industry. Also, different companies have different approaches to it. Allergan has a foundation. They'll give a lot of monetary contributions from what we've seen. Alcon, for example, is the most, I think, generous giver of actual product. I think they're just open arms as far as providing supplies for surgery but they don't necessarily give monetary grants in the same level. So you need to see a understanding of what's a practical ask for that organization historically in how they're structured. Also identify the right internal advocate. You know, you're in our field, there's a lot of overlap with industry and providers. But, you know, a lot of times it's hard to navigate from the outside who the right person is to motivate it within an organization to get your ask across the finish line. And the way I would advise that is, A, obviously someone who's more senior as always could, but I think also someone who's motivated is a big thing, because they will find the right person internally. And even if you don't have a connection within a certain company that where you need something for your patients, industry is really well-networked. So if you know someone at another company, just ask them. And they can, even if they don't know someone directly, they'll be able to find someone. And then if you find the right advocate, a lot of times you can get the right answer. But industry can at times be a dead end. And it's not because people are not motivated or well-intended all the time. It's because they don't really feel empowered and they actually don't even know where to start within their organization. Also, realize you're providing an opportunity. When you're pushing folks, it's actually good because they'll be reticent, be sometimes a little insecure about whether they can deliver on whatever they promise for you. But it will be fulfilling. And I've seen this, like we've pushed different individuals and, but then when you see them at the show next time, they're so proud that they were able to contribute in a way. Because it's an opportunity for us and it is fulfilling. And I think all of us want to have that sort of self-actualization that we are contributing to something better in society. Now, a couple of considerations from the industry's perspective, we were talking about this regulatory requirements. And we've had uncomfortable conversations because we'll have a person going on a mission trip and they'll ask for product to be shipped to certain place and we'll say, well, we can't do that. And they'll get really upset because they look at us and I get it from their perspective that we're sort of stopping them from delivering care. But sometimes it actually jeopardize the rest of our organization because we have regulatory requirements that we have to comply with. And if we're not actually authorized to ship something into a region, even if we trust the provider, we could lose our certification in the EU or the US. Like those audits are real, right? And some, even though the countries are not interrelated, if our quality system and our controls aren't being adhered to, we can get penalized for that. Local partnerships. And this is something that again is a push and a pull. There's different models for delivering products and services. But a lot of times you do need a local partner even if they do take a cost because that makes having a local partner allows you to deal with customs, allows you to deal a lot of times with registration. A lot of these, there's localized issues that you need to be able to deal with. And without a local partner, you don't have a sustainable access to product. And it's just not a sustainable model. In the short-term, maybe you can cut costs by cutting them out. But a lot of times it won't be sustainable long-term. And it's something that you have to be pragmatic. Even if you're trying to make the price point achievable in the local market, sometimes that trade-off is just not, it might be good in the short-term but it's just not sustainable in the long-term. Also you can distort local markets. So a lot of times you think you find a really good partner locally and sometimes they're well-intended. And sometimes they are well-intended but they're also pragmatic with their practice, right? So you'll be giving product at a discounted or a no charge and we've done this before. And all of a sudden you'll see someone charging for a premium like glaucoma surgery and they're doing it with no cost and they're benefiting from that. And it's actually penalizing some of their peers. And that also causes a lot of pressure on the system and you're really sort of destroying the ecosystem, not really moving it forward if you're not sort of thoughtful about that. And a lot of times it's hard to look and judge that from the outside. You have to have a thought partner locally that really can understand the dynamics within the market. And last two points is you need to look at the right technology for the right context. You know, when we went to Nigeria, one of the things I offered Dr. Smith was I said, like, look, we can go with our whole portfolio. And she was like, no, let's start with the Ahmed valve. And the reason for that is these are the most acute patients and these are patients that don't have alternatives where if we go with the Cahok deal blade or we go with some other products that are earlier intervention, there are substitute treatments. So she wanted to go with that. And that was learning for me. And the last thing, and this is something that gets sensitive and we actually are a little shy to push people on this is avoid reframing your standards when you go abroad. And this happens and it happens in a way that isn't poorly intended. But we see people trying to use some of our new products the first time on a mission trip. We don't wanna add that variable. You're already going into the OR that you're not used to operating in and now you're trying to use new products or they use actually a different technology but then it maybe it's more bureaucratic to go to that organization to get a donation. So they ask us and we're not necessarily 100% comfortable with doing that either because they're not used to using that technology on a day-to-day basis. And then they're going internationally. And you know, it's just a little bit of a slippery slope when you don't control a lot of the variables. So hopefully this was useful. It's our individual sort of experiences and organization but I welcome any questions or comments. So I have a microphone to bring around the audience for those of you that have questions. I think this is a really unique opportunity for us to understand the key role that industry partnerships are in our work that we're doing. And so thank you for pulling the curtain back and giving us an eye into New World Medicals operations. And one of the questions I have for you is how you guys balance mission and profitability. You are ultimately a business and while your shareholders are maybe smaller than an actual publicly traded company, is it more driven by certain metrics or is it more driven by value? You know, you talked about your mission statement of benefiting humanity but is that really a metric that you're using more versus actually profitability metrics? So yeah, and that's a great question. It's a challenge we have. So you can't have multiple priorities. You have to have an order of priorities, right? So we are a business first and for us to be an ongoing entity you have to recognize that and you have to realize that if there's a trade-off you have to do what's pragmatic for you to be an ongoing entity if you wanna contribute because we have responsibilities to our employees. We also have responsibilities to the family and the shareholders as well. So the way we try to do that is we recognize those priorities but when we set metrics internally like so our vision for 2025 is to reach more patients than any other glaucoma surgical company. That works on a business perspective that it also works on hopefully a mission perspective. We also had one of our goals that we had to walk back was we wanted to increase our product donations by fivefold but then we realized that we can try to give product but unless there's actually a capability on the ground to be able to deliver that care appropriately it's that's not the right limiting factor. So that's how we think about it. It's an ongoing balance but I think we contribute in a lot of different things. That's why we codified it with those five different categories because us to be able to reinvest into technology and to be able to bring new products to market is also impactful as well and that drives forward all things. So it's a balance at all times and at times it actually frustrates people too because this year we took a price increase for our AmitVal and we did that in the US and the reason we did that and it did make some of our customers very upset because there's still a lot of margin on the facility fee but we took the price increase so we could continue to reinvest in the organization. For us that's a balanced decision. We wanna make sure that we're being a pragmatic partner to all of our partners in the US but we also realize it's an insured population. So if we can drive revenue here it allows us to do more in other parts of our organization. So it's not a linear answer but it's something that we're constantly trying to balance. You alluded to the idea of distorting local markets. Can you talk a little bit more about your approach? Maybe you can use a case example from Nigeria or anywhere you guys have been working and how you establish what a market rate is for your product and how you plan long-term to make that product available in an emerging market. So we haven't always been good about this. Nigeria has been really, really easy because Dr. Smith goes quite a bit and then there was three doctors that led that. Dr. Tosin Smith who I mentioned is of Nigerian origin, Dr. Lola Daou who is at University of Maryland who is also of Nigerian origin and then Dr. Manjul Shah. So because Dr. Daou and Dr. Smith are from Nigeria they were able to navigate that and they were also able to navigate the politics because they both went to medical school there so they have enough connections. So they allowed us to do that. We went back forth in different pricing. Initially we priced at like even lower and then she brought it up because if you price at zero people will just stock up and they won't even utilize it too. So, and then sometimes you'll see the bleed into other countries. So we'll see this a lot of times people will there's a lot of fraud in certain regions and they'll say like, look, I'm gonna distribute in this specific region of South Africa but then all of a sudden we see them winning tenders in Saudi Arabia, right? So you see that, right? So you need to make sure that you have some costs associated with it. It also gives that local partner a real sense of partnership because they're actually paying for something. So it's a little bit of a, like we haven't found a direct formula but in Nigeria we're differential to the doctors that were local, right? And if you find a local partner that is a balanced advocate and it's unique because Dr. Smith is based in Dallas. Dr. Dau is based in Maryland. So they don't have any sort of biases to distort the market but they were able to guide us on that. And in other regions, if you find the right distributor and a lot of times that's not the easiest thing because there's only so many ophthalmic distributors you have to be relying on them as a partner and sometimes you have to be a little skeptical of their advice that you have to sort of at least be informed with the doctors as well. Questions from our audience? Thank you again, Bilal. This is really lovely. And thank you for your support to Moran and to global ophthalmic community. You've been around long enough in this space to see again, these kind of unintended consequences, surprises as people with best intentions enter into this space. And if you could give one piece of advice to residents, fellows who are really interested in engaging, what would that be? So this is a little bit sensitive. I don't know how to frame it 100% but one thing about, I didn't know Dr. Prandtl well but every time I met him, you could see the sincerity the way he looked at you, he like validates you as a person and that's very rare, right? That's very rare of an individual especially someone who's been very successful and Dr. Ammon's got that too. But I think the thing about them and that I've learned and a lot of people here is it can't be about you. It can't be about only your fulfillment. Like all of us do stuff. Everything we do in our life is about our fulfillment too, right? But it has to have an intellectual sincerity of what you're doing work, right? And I think that even in outreach, I think we see this there's a lot of, for lack of a better term, egos. And that sometimes that drives to people not wanting to learn best practices from each other not trying to reinvent the wheel all by themselves. And I think if you can sort of balance that desire to maximize your contribution with that sort of intellectual sincerity to finding the best path forward, I think that's the balance that I would look for. Another question for you. I alluded a little bit to your background as an actuarian. Maybe tell us what an actuarian is at a nutshell. And then I have a question in terms of how that actually shapes your role as CEO of a company. Okay, so I guess the easiest way to think about what an actuary does is it's like, so what an accountant does is they value stuff in the past and the present. What an actuary does is they value stuff in the future. So if you think about insurance, like health insurance, I specialize in pensionism investments. Those are things where you're using like datasets to sort of predict in a large population, like what's gonna happen and how you can price that accordingly. So at least the decision-making financially. So as an actuarian or an CEO of a company, are you tending to more drift towards data to help in your decision-making or are you more driven by the mission of your company? Because I think they're sometimes competing in terms of raw numbers that can drive you and understanding risk. But as a CEO sometimes you're called upon to take some risk to drive your company forward and innovate. So I was not a great actuary. So I did get fully qualified and stuff like that. So, but I was a skeptical actuary. And I think that what it led to was you can't trust numbers. I think people, the only thing you know about your projections as an actuary is that they're wrong. Like they can be directionally right, but they can be wrong. So I think there's a lot of fallacies in decision-making and I think that that's something that it did raise awareness for. And the way we think about a lot of decisions, people ask us and a lot of times, especially in my role, they wanna see a vision that's like, we're gonna go A, B, C, D and this is the direction we're going forward. And my answers are always a little bit more circuitous because I think you have to look at things through frameworks. And I think that that's the right way saying like, look, here's our order of priorities or here's how we think about these different types of different issues. And even the way we build out our organization, we're pretty dogmatic about that. We think about activity systems and that's how we think about how we develop as an organization. So I think starting my career as an actuary just made me a little bit skeptical while people being overconfident with analytics. So maybe it actually went the opposite direction in a way. Awesome, any other final questions for Abloh? Thank you so much for the talk. I just had a quick question about local partnerships again and you mentioned a lack of sustainability if you don't partner. I specifically mentioned customs and the difficulty that can present. I was wondering if you had any other examples or maybe experiences that you can share on how to be not sustainable over time. Oh, it cannot be sustainable. So I'll give you an example of what is sustainable. You can find loopholes around it, right? So sometimes you import into a country and there can be exemptions and we were just talking about that. So in Nigeria, what happened is there's an iFoundation which is a major hospital there. So they and they're a pretty good partner but they also have an exemption where they can get importation of devices that are not necessarily approved through the government through their foundation and they can distribute them through there. So you can find end arounds but as far as sustainability that isn't, we've partnered with physicians, no offense to physicians but we've partnered with physicians in certain markets and as our distributor and that's turned out poorly for us historically because what we see is that there's always politics and that is leveraged there or somebody got an argument with somebody at some point and all of a sudden they have a special pricing that may be three times the price of everyone else. So we do see that that you have to have a local partner. We've even seen one of the countries we struggle with and I think every country struggles with every company struggles with is Brazil because Brazil has a hundred percent import tax. So when you go there, like so when we go with the Amit Valve in Brazil, we're selling it to into Brazil at $250. The receipt for our distributor is $500. At one point our distributor is starting $1,600 for an Amit Valve there and we sort of had to have a conversation saying like, look, you can't make more money than we do as an organization. We actually produce a product and that can be that can get out of control too. So you have to you have to be savvy, but there's a lot of politics so you get feedback within a country and sometimes it's hard to discern what's actually substantiated and objective and what's not. Again, more art than science, unfortunately. Thank you so much for your time. We appreciate it. We're going to transition now just some brief highlights. Laurie McCoy is our director of global outreach here and I think many of you know about the work that we're doing, but we're just going to give you some context, give you some numbers for the impact that we've had this year. Okay, so thank you. I'm grateful for the opportunity to talk and it's just kind of a recap of the last year of the things that we have done as far as outreach. So to start off, I have a QR code for everyone to download because we're going to play a game. We'll see how knowledgeable you are with the game. You can make up whatever you want. That's the fun part about it. Okay, waiting for everyone to join. There you go. Even those who are online can also join the game if you were able to scan the QR code. Okay, so we have 17 players, 19 players, 20 players. Fine, okay. The names, Corner Bakery, yeah. Okay, 21 players, I think we're, anybody else who needs to still join? Oh, there we go. Okay, I'm going to start the quiz so we can get moving. I think we have 20 or 21 getting there. Okay, so start the quiz. Question number one, how many total clinics do you think that outreach has held in the past this year of 21, 22? You're on a timer too, so you only have a certain amount of questions that you get to ask. Okay, so 65 to 70, and there you go. There's your leaderboard. Those are all correct. Next question, question number two, how many physicians have been involved in our work? And there's Dr. Crandall, when he brought that up to me, I'm like, oh, he's up, right, very good. I do, it's in the lead. Next question, how many patients have we seen in our clinics? This is locally and internationally. Here we go. Next question, number four, how many patients have had surgeries that outreach has helped set up? Goodbye, how many international trips has been ran at adjunct faculty done in fiscal year 22, 23? I've always been able to read. How many total hours of outreach volunteers have given in 22, 23? How many different types of surgeries have outreach patients received? Okay, eyeballs, who's eyeballs has won the game? Who's eyeballs? Are they somebody who is here in the room? Rachel, yay, the winner is Rachel. Okay, so thank you.