Book Review: Bad Blood

Theranos was founded in 2003 by Stanford drop-out Elizabeth Holmes. It and its revolutionary blood tests eventually became a Silicon Valley darling, raising $700 million from investors that included Rupert Murdoch and the Walton family. It ultimately achieved a valuation of almost $10 billion on yearly revenues of $100 million. Elizabeth Holmes was hailed as Silicon Valley’s first self-made female billionaire.

In 2015, a series of articles by John Carreyrou published in the Wall Street Journal popped this bubble. Theranos was a fraud. Its blood tests didn’t work and were putting patient lives at risk. Its revenue was one thousand times smaller than reported. It had engaged in a long running campaign of intimidation against employees and whistleblowers. Its board had entirely failed to hold the executives to account – not surprising, since Elizabeth Holmes controlled over 99% of the voting power.

Bad Blood is the story of how this happened. John Carreyrou interviewed more than 140 sources, including 60 former employees to create the clearest possible picture of the company, from its founding to just before it dissolved.

It’s also the story of Carreyrou’s reporting on Theranos, from the first fateful tip he received after winning a Pulitzer for uncovering another medical fraud, to repeated legal threats from Theranos’s lawyers, to the slew of awards his coverage won when it eventually proved correct.

I thought it was one hell of a book and would recommend it to anyone who likes thrillers or anyone who might one day work at a start-up and wants a guide to what sort of company to avoid (pro tip: if your company is faking its demos to investors, leave).

Instead of rehashing the book like I sometimes do in my reviews, I want to discuss three key things I took from it.

Claims that Theranos is “emblematic” of Silicon Valley are overblown

Carreyrou vacillates on this point. He sometimes points out all the ways that Theranos is different from other VC backed companies and sometimes holds it up as a poster child for everything that is wrong with the Valley.

I’m much more in the first camp. For Theranos to be a posterchild of the Valley, you’d want to see it raise money from the same sources as other venture-backed companies. This just wasn’t the case.

First of all, Theranos had basically no backing from dedicated biotechnology venture capitalists (VCs). This makes a lot of sense. The big biotech VCs do intense due-diligence. If you can’t explain exactly how your product works to a room full of intensely skeptical PhDs, you’re out of luck. Elizabeth Holmes quickly found herself out of luck.

Next is the list of VCs who did invest. Missing are the big names from the Valley. There’s no Softbank, no Peter Thiel, no Andreessen Horowitz. While these investors may have less ability to judge biotech start-ups than the life sciences focused firms, they are experienced in due diligence and they knew red flags (like Holmes’s refusal to explain how her tech worked, even under NDA) when they saw them. I work at a venture backed company and I can tell you that experienced investors won’t even look at you if you aren’t willing to have a frank discussion about your technology with them.

The people who did invest? Largely dabblers, like Rupert Murdoch and the Walton family, drawn in by a board studded with political luminaries (two former secretaries of state, James friggen’ Mattis, etc.). It perhaps should have been a red flag that Henry Kissinger (who knows nothing about blood testing and would be better placed on Facebook’s board, where his expertise in committing war crimes would come in handy) was on the board, but to the well-connected elites from outside the Valley, this was exactly the opposite.

It is hard to deal with people who just lie

I don’t want to blame these dabblers from outside the Valley too much though, because they were lied to like crazy. As America found out in 2016, many institutions struggle when dealing with people who just make shit up.

There is an accepted level of exaggeration that happens when chasing VC money. You put your best foot forward, shove the skeletons deep into your closet, and you try and be the most charming and likable version of you. One founder once described trying to get money from VCs as “basically like dating” to me and she wasn’t wrong.

Much like dating, you don’t want to exaggerate too far. After all, if the suit is fruitful, you’re kind of stuck with each other. The last thing you want to find out after the fact is that your new partner collects their toenail clippings in a jar or overstates their yearly revenue by more than 1000x.

VCs went into Theranos with the understanding that they were probably seeing rosy forecasts. What they didn’t expect was that the forecasts they saw were 5x the internal forecasts, or that the internal forecasts were made by people who had no idea what the current revenue was. This just doesn’t happen at a normal company. I’m used to internal revenue projections being the exact same as the ones shown to investors. And while I’m sure no one would bat an eye if you went back and re-did the projections with slightly more optimistic assumptions, you can’t get to a 5x increase in revenue just by doing that. Furthermore, the whole exercise of doing projections is moot if you are already lying about your current revenue by 1000x.

There is a good reason that VCs expect companies not to do this. I’m no lawyer, but I’m pretty sure that this is all sorts of fraud. The SEC and US attorney’s office seem to agree. It’s easy to call investors naïve for buying into Theranos’s lies. But I would contend that Holmes and Balwani (her boyfriend and Theranos’s erstwhile president) were the naïve ones if they thought they could get away with it without fines and jail time.

(Carreyrou makes a production about how “over-promise, then buy time to fix it later” is business as usual for the Valley. This is certainly true if you’re talking about, say, customers of a free service. But it is not and never has been accepted practice to do this to your investors. You save the rosy projections for the future! You don’t lie about what is going on right now.)

The existence of a crime called “fraud” is really useful for our markets. When lies of the sort that Theranos made are criminalized, business transactions become easier. You expect that people who are scammers will go do their scams somewhere where lies aren’t so criminalized and they mostly do, because investors are very prone to sue or run to the SEC when lied to. Since this mostly works, it’s understandable that a sense of complacency might set in. When everyone habitually tells more or less the truth, everyone forgets to check for lies.

The biotech companies didn’t invest in Theranos because their sweep for general incompetence made it clear that something fishy was going on. The rest of the VCs were less lucky, but I would argue that when the books are as cooked as Theranos’s were, a lack of understanding of biology was not the primary problem with these investors. The primary problem was that they thought they were buying a company that was making $100 million a year when in fact it was making $100,000.

Most VCs (and probably most of the dabblers, who after all made their money in business of some sort) may not understand the nuances of biotech, but they do understand that revenue that low more than a decade into operation represent a serious problem. Conversely, revenues of $100 million are pretty darn good for a decade-old medical device company. With that lie out of the way, the future growth projections looked reasonable; they were just continuing a trend. Had any investors been told the truth, they could have used their long experience as business people or VCs to realize that Theranos was a bad deal. Holmes’s lies prevented that.

I sure wish there was a way to make lies less powerful in areas where people mostly stick near the truth (and that we’d found one before 2016), but absent that, I want to give Theranos’s investors a bit of a break.

Theranos was hardest on ethical people

Did you know that Theranos didn’t have a chief financial officer for most of its existence? Their first CFO confronted Holmes about her blatant lies to investors (she was entirely faking the blood tests that they “took”) and she fired him, then used compromising material on his computer to blackmail him into silence. He was one of the lucky ones.

Bad Blood is replete with stories of idealistic young people who joined Theranos because it seemed to be one of the few start-ups that was actually making a positive difference in normal people’s lives. These people would then collide with Theranos’s horrible management culture and begin to get disillusioned. Seeing the fraud that took place all around them would complete the process. Once cynicism set in, employees would often forward some emails to themselves so they’d have proof that they only participated in the fraud when unaware and immediately handed in their notice.

If they emailed themselves, they’d get a visit from a lawyer. The lawyer would tell them that forwarding emails to themselves was stealing Theranos’s trade secrets (everything was a trade secret with Theranos, especially the fact that they were lying about practically everything). The lawyer would present the employee with an option: delete the emails and sign a new NDA that included a non-disparagement clause that prevented them from criticising Theranos, or be sued by the fiercely talented and amoral lawyer David Boies (who was paid in Theranos stock and had a material interest in keeping the company afloat) until they were bankrupted by the legal fees.

Most people signed the paper.

If employees left without proof, they’d either be painted as deranged and angered by being fired, or they be silenced with the threat of lawsuits.

Theranos was a fly trap of a company. Its bait was a chance to work on something meaningful. But then it was set up to be maximally offensive and demoralizing for the very people who would jump at that opportunity. Kept from speaking out, guilt at helping perpetuate the fraud could eat them alive.

One employee, Ian Gibbons, committed suicide when caught between Theranos’s impossible demands for loyalty and an upcoming deposition in a lawsuit against the company.

To me, this makes Theranos much worse than seemingly similar corporate frauds like Enron. Enron didn’t attract bright-eyed idealists, crush them between an impossible situation and their morals, then throw them away to start the process over again. Enron was a few directors enriching themselves at the expense of their investors. It was wrong, but it wasn’t monstrous.

Theranos was monstrous.

Elizabeth Holmes never really made any money from her fraud. She was paid a modest (by Valley standards) salary of $200,000 per year – about what a senior engineer could expect to make. It’s probably about what she could have earned a few years after finishing her Stanford degree, if she hadn’t dropped out. Her compensation was mostly in stock and when the SEC forced her to give up most of it and the company went bankrupt, its value plummeted from $4.5 billion to $0. She never cashed out. She believed in Theranos until the bitter end.

If she’d been in it for the money, I could have understood it, almost. I can see how people would do – and have done – horrible things to get their hands on $4.5 billion. But instead of being motivated by money, she was motivated by some vision. Perhaps of saving the world, perhaps of being admired. In either case, she was willing to grind up and use up anyone and everyone around her in pursuit of that vision. Lying was on the table. Ruining people’s lives was on the table. Callously dismissing a suicide that was probably caused by her actions was on the table. As far as anyone knows, she has never shown remorse for any of these. Never viewed her actions as anything but moral and upright.

And someone who can do that scares me. People who are in it for the money don’t go to bed thinking they’re squeaky clean. They know they’ve made a deal with the devil. Elizabeth Holmes doesn’t know and doesn’t understand.

I think it’s probably for the best that no one will trust Elizabeth Holmes with a fish and chips stand, let alone a billion-dollar company, ever again. Because I tremble to think of what she could do if given another chance to “change the world”.