Sunday, 1 July 2018

Review: Bad Blood: Secrets and Lies in a Silicon Valley Startup by John Carreyrou

This is a book about Theranos, and what the hell happened that they were able to raise hundreds of millions of dollars to become valued at $9 bn, fool Silicon Valley's top investors, government officials, and major companies, 

It was fairly slow to get into, with far too many names to keep track of, like how the founder's mother's friend's husband's old buddy went to college X and high school Y with some other person, so I wasn't really enjoying it until I was about 70 pages in but after that I read the remaining 280 pages in a day. I tried to stop about 50 pages before the end but I was too scared by it to sleep so had to finish it!

My main takeaways: 

1) Elizabeth Holmes has some absolute balls. I literally gasped with outrage many times throughout this book.

2) Said balls can get you shockingly far in Silicon Valley (and possibly elsewhere).
3) The criminality! The irresponsibility!
4) Lawsuits desperately need reform and lawyers need their powers curbed drastically.
5) What a terrible work environment, christ.

1) I truly cannot believe how ballsy she was. How she just ... kept talking shit with absolutely nothing behind it. She styled herself as Steve Jobs so explicitly, with the turtlenecks and calling one of her devices the 4S.

There were so many examples of this but here are a few: 

  • constantly telling investors that the Army was using these devices in Afghanistan (so they must be good, right?) when they were doing no such thing. In fact, she had pitched the military but then when they asked for some kind of proof of what she was saying, she never wrote back and so the army did not use anything of theirs. But this idea got out to investors and they started saying it themselves too. 
  • the board once voted to remove Elizabeth as CEO because she was too young and immature - she refused to step down and convinced them to reinstate her, then became even more draconian to quash dissent.
  • insisted (to the Army) that she didn't need regulatory approval because the FDA regulated medical devices while CMS regulated labs and her new thing was intermediate between those so she didn't have to be regulated by either
  • had her #2 make up earnings projections entirely, saying they were projected a billion dollars the year after next when they got like a few million or something, if even that.
  • Saying Theranos was the most accurate blood-testing company because like 93% of lab mistakes are caused by human error and their stuff was automated so it HAD to be more accurate right? No! Not right! Bold! Never mind that their stuff was extremely inaccurate, just the idea of advertising that your testing is the most accurate because 'it doesn't do a particular error-prone thing' even though it could do all sorts of bad things! Could just be a function that prints random numbers and because it's fully automated she'd say it's more accurate at blood-testing. 
  • Say she wanted to change the world and make sure no one lost a loved one too soon using the example of her dead uncle - when she wasn't actually close to him at all.
  • Saying repeatedly at company meetings: '“The miniLab is the most important thing humanity has ever built. If you don’t believe this is the case, you should leave now,” ' Also 'Still visibly angry, Elizabeth told the gathered employees that she was building a religion. If there were any among them who didn’t believe, they should leave. Sunny put it more bluntly: anyone not prepared to show complete devotion and unmitigated loyalty to the company should “get the fuck out.”' Wat. Even if your thing did work, it's literally just combining a bunch of existing diagnostics tools and miniaturizing them. It's definitely hard engineering-wise (which is why they couldn't make it work), but surely if you're gonna say something is the most important invention it would have to at least be the original diagnostics machines?
  • Putting her name first on all the patents even though she hadn't contributed any scientific knowledge.
  • in a pitch to investors, showing them a scatterplot of the values obtained by 'her machines' vs those obtained by commercial machines to show they were very similar and thus 'her machines' were accurate - only they weren't her machines at all, they were other commerical machines. Of course they matched! They were the same type of machine!
  • When setting up a deal with Walgreens and someone tasked with sussing out the deal asked to see her much talked-up lab, just saying nope.
  • Continuously just saying nope to requests for evidence and people somehow just being like oh well okay then.
  • Just before the Walgreens (or was it Safeway?) rollout, when someone said the Edisons (her machines) still weren't working and couldn't they wait for the next edition (so it might actually work) before rolling out, she said No, when I promise, I deliver. Like ... my dude... you gotta actually deliver something that works though.
  • 'Elizabeth wanted the website and all the various marketing materials to feature bold, affirmative statements. One was that Theranos could run “over 800 tests” on a drop of blood. Another was that its technology was more accurate than traditional lab testing. She also wanted to say that Theranos test results were ready in less than thirty minutes and that its tests were “approved by FDA” and “endorsed by key medical centers” such as the Mayo Clinic and the University of California, San Francisco’s medical school, using the FDA, Mayo Clinic, and UCSF logos. ' She absolutely did not have the endorsement of those places. Just a complete bare-faced lie. What.

In fairness, one aspect was that she was mostly talking to people who weren't experienced in medicine; instead, they were tech investors. And medicine is not the same as an app. The stakes are pretty different in diagnosis vs. using an app to get your groceries delivered. When she did talk to investors who knew something about medicine, this happened: 

One morning in July 2004, Elizabeth met with MedVenture Associates, a venture capital firm that specialized in medical technology investments. Sitting across a conference room table from the firm’s five partners, she spoke quickly and in grand terms about the potential her technology had to change mankind. But when the MedVenture partners asked for more specifics about her microchip system and how it would differ from one that had already been developed and commercialized by a company called Abaxis, she got visibly flustered and the meeting grew tense. Unable to answer the partners’ probing technical questions, she got up after about an hour and left in a huff.

The big question is whether she drank her own Kool-Aid, and sadly it's not one that's answered in this book. I don't know whether she really believed she was right and was blind to the cheating and lying, whether she intended to cheat and lie all along, or whether it just sort of happened along the way. But wow. 

2) She got so far! Theranos operated for over ten years before it was exposed! That's a hell of a con.

It kinda makes me think about what unwritten rules we all go by just because we assume they're cast in stone, and that some people, like her and Trump, don't give a shit about and thus exploit. Most of us think 'if you're caught in a lie you should be embarrassed' or fess up or something. But not these people. They just let it roll off their backs - and that makes it very difficult to do anything about them.

Walgreens and Safeway believed her and spent millions of dollars setting up their stores and buying her equipment (that didn't work) even in the face of negative evidence because of FOMO, because of her hypnotic presence, and because, well, it sounded so cool how could it not be true?

There was a culture of enablement too; one board member raised his concerns with the leader of the board and was told he should resign. A former employee told his grandpa, George Shultz, that Theranos had inaccurate and faked results and his grandpa chose to believe the company over him. She had an incredible reality distortion field.

On the bright side, there was a funny moment: when that board member who was made resign for raising concerns tried to not be locked out of his shares, his lawyer said to him: knowing what you do, do you really want to own more of that company?  Must have sucked seeing them rise and rise but hopefully he was around to see their comeuppance.

3) So much criminality and lying! Holy shit! How do you live with yourself releasing incorrect medical test results to patients?!

  • 'it's okay if we don't do the tests labs are supposed to do because our products are ~so unique~'
  • When showing off the product to investors it never worked so they'd just take the investor's blood, then get the screen on the device to pretend it was working and show a result from someone else from one time it did work. Their Chief Finance Officer said he was uncomfortable with this and felt it crossed a line and was told he's not a team player and fired. 
  • They manipulated the devices so that instead of showing an error they'd just pretend to have slowed down and they'd tell the investors to come back later when it had finished processing, blaming slow wifi or an earthquake in Japan (yes, really).
  • Because their machines didn't work, they did most patient tests on some Siemens machines they'd bought (very fraudulent because their whole thing was that they had their own special machines and that was their product, but now they were just using ordinary commerical machines) and worse, jury-rigged so that they would work with diluted samples because Elizabeth absolutely insisted that the samples be small for her ~vision~. Never mind that diluting them took them below the concentration limit that the Siemens machines could accurately perform tests at and they got super inaccurate results. Also that running tests on small samples and in general getting small samples of blood to behave was an entire branch of bioengineering and people were not close to solving it.
  • Outright faking validation tests like covariance tests, throwing out outliers with a very very liberal definition of outlier that they just gamed, etc. Straight-up unmistakeable scientific fraud, ranging from setting up your parameters like outlier detection to allow you to throw out any incorrect results to literally just making up numbers.
    • 'One type of experiment he and Erika were tasked with doing involved retesting blood samples on the Edisons over and over to measure how much their results varied. The data collected were used to calculate each Edison blood test’s coefficient of variation, or CV. A test is generally considered precise if its CV is less than 10 percent. To Tyler’s dismay, data runs that didn’t achieve low enough CVs were simply discarded and the experiments repeated until the desired number was reached. It was as if you flipped a coin enough times to get ten heads in a row and then declared that the coin always returned heads. Even within the “good” data runs, Tyler and Erika noticed that some values were deemed outliers and deleted. When Erika asked the group’s more senior scientists how they defined an outlier, no one could give her a straight answer'
  • so much more oh boy

4) Horrible lawyers and horrible lawsuit culture

I am honestly so upset about the litigious culture that exists in America, and about what's considered acceptable by lawyers. A lot of them seem to just take on cases regardless of morals, and you can get the best lawyers not because you have the most deserving case, but because you have the most money. 

Theranos hired arguably the top law firm in the country, who had previously argued against California's Prop 8 and Microsoft and for Al Gore, and then used them to viciously pursue, intimidate and spy on (using a P.I.) innocent whistleblowers and the journalist who wrote this book. It makes me so angry honestly - there were people who just capitulated with not whistleblowing after they resigned as employees because Theranos threatened them and even though they were right they'd never win their case against these amazing lawyers who literally threatened to ruin their lives. And so they had to just drop it and agree to whatever Theranos wanted. I don't understand how a system so unfair is allowed to exist. 

5) What a terrible work environment

  • So much pressure on employees and refusing to listen to any concerns - people were either ignored or fired if they raised concerns about the technology not working, and yes-men got ahead quickly.

  • Tim was a yes-man who never leveled with Elizabeth about what was feasible and what wasn’t. For instance, he’d contradicted Justin and assured her they could write the Edison software’s user interface faster in Flash than in JavaScript. The very next morning, Justin had spotted a Learn Flash book on his desk.

  • They had to work crazy long hours and weren't given a choice about it; the #2 reviewed the security tapes frequently and confronted someone over 'only' working 8 hours a day. Dinner was provided but would only be ordered in to arrive around 9 or 10 pm (if I recall correctly) so people had to stay really late or waste the food.

    • 'In the months after Greg left, the revolving door at Theranos continued to swing at a furious pace. One of the more surreal incidents involved a burly software engineer named Del Barnwell. Big Del, as people called him, was a former Marine helicopter pilot. Sunny was on his case about not working long-enough hours. He’d gone as far as to review security footage to track Big Del’s comings and goings and confronted him in a meeting in his office, claiming the tapes showed he worked only eight hours a day. “I’m going to fix you,” Sunny told him, as if Del were a broken toy. But Big Del didn’t want to be fixed. Shortly after the meeting, he emailed his resignation notice to Elizabeth’s assistant. He heard nothing back and dutifully worked the last two weeks of his notice period. Then, at four p.m. on a Friday, Big Del picked up his belongings and walked toward the building’s exit. Sunny and Elizabeth suddenly came running down the stairs behind him. He couldn’t leave without signing a nondisclosure agreement, they said. Big Del refused. He’d already signed a confidentiality agreement when he was hired and, besides, they’d had two weeks to schedule an exit interview with him. Now he was free to go as he pleased and he damn well intended to. As he pulled out of the parking lot in his yellow Toyota FJ Cruiser, Sunny sent a security guard after him to try to stop him. Big Del ignored the guard and drove off. Sunny called the cops. Twenty minutes later, a police cruiser quietly pulled up to the building with its lights off. A highly agitated Sunny told the officer that an employee had quit and departed with company property. When the officer asked what he’d taken, Sunny blurted out in his accented English, “He stole property in his mind.”'
  • She drove chemist Ian Gibbons to suicide! I was so sad at this part, made all the worse by the fact that it's a true story.
    • 'Gibbons was a legitimate scientist and ... like most scientists, he was an honest person' - knew I was going to like him already

    • 'Ian refused to give an inch and became furious when he felt he was being asked to lower his standards. Paul spent numerous evenings on the phone with him trying to calm him down. During these discussions, Ian told Paul to stand by his convictions and never to lose sight of his concern for the patient. “Paul, it has to be done right,” Ian would say' - you go Ian! If only you weren't dead :(
  • Employees were in siloed departments; the chemists couldn't take to the engineers (on a bioengineering project!) so they couldn't tell which side the error was on, and this was done on purpose so that no one would have the full picture of the product except Elizabeth and her #2.
  • The bosses, especially her #2 Balwani, were straight up abusive even on top of all the firings and long hours. 
  • That Chief Finance Officer who'd been fired for voicing his discomfort with lying to investors? Rumours were spread that he'd been embezzling money. Theranos didn't in general allow people to say goodbye to anyone after they were fired or even collect their stuff - they had to leave immediately so that the bosses could control the narrative of their departure. And wow there sure were a lot of firings. 

Look how horrible she is:

One aspect of Matt’s job had become increasingly distasteful to him. Elizabeth demanded absolute loyalty from her employees and if she sensed that she no longer had it from someone, she could turn on them in a flash. In Matt’s two and a half years at Theranos, he had seen her fire some thirty people, not counting the twenty or so employees who lost their jobs at the same time as Ed Ku when the microfluidic platform was abandoned. Every time Elizabeth fired someone, Matt had to assist with terminating the employee. Sometimes, that meant more than just revoking the departing employee’s access to the corporate network and escorting him or her out of the building. In some instances, she asked him to build a dossier on the person that she could use for leverage. There was one case in particular that Matt regretted helping her with: that of Henry Mosley, the former chief financial officer. After Elizabeth fired Mosley, Matt had stumbled across inappropriate sexual material on his work laptop as he was transferring its files to a central server for safekeeping. When Elizabeth found out about it, she used it to claim it was the cause of Mosley’s termination and to deny him stock options.

Man am I glad to see her get her comeuppance.


Something particularly creepy about it is the similarities between myself and Holmes. My big research was into diagnostics. I wanted to make diagnostics easier and better and less invasive, and have multiplexed sensors. I was also a #womaninSTEM and a smart kid. Could that have been me? I highly doubt it, as one of the biggest differences between us is that I actually have a serious respect for truth and a sense of shame, and many many other differences in our philosophies, approaches to life, you name it.  Also, she apparently once said 'I’m not interested in getting a Ph.D., I want to make money.” ' which is very not me. But it was a weird realisation that we shared some interests. 

I was pleasantly surprised by some disliked people in the book. General Mattis, who is now (or has he been fired/resigned yet?) in Trump's administration, who believed his army subordinates when they said don't use Theranos tech in the army, and Rupert Murdoch who refused to pressure the WSJ (which he owns) not to publish the expose of Theranos. Unfortunately Mattis still joined the board and very much misjudged her but y'know: 'Mattis went out of his way to praise her integrity. “She has probably one of the most mature and well-honed sense of ethics—personal ethics, managerial ethics, business ethics, medical ethics that I’ve ever heard articulated,” the retired general gushed.'

In summary: Bit boring for the first quarter or so but after that reads like a thriller (one that'll make your blood boil). 4 stars.

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