Bad Blood

A fascinating book that starts slow, introducing the reader to the host of people involved with Elizabeth Holmes and Theranos as they attempt to get their blood testing machines out into the market, but rapidly becomes a gripping tale as the behind-the-scenes shenanigans eventually cause people to have second thoughts and push for investigations into the company, eventually exposing its technology to be a fraud, but not before causing pain and anguish to people who might have been misled by the false results returned by the Theranos machines.

The story starts with Elizabeth Holmes's childhood ambition to 'change the world' that morphs into a desire to be a billionaire. While working in Singapore, getting blood samples during the SARS epidemic, Holmes would get the 'there must be a better way' urge to show that a whole host of blood tests could be done with small quantities of blood.

After various iterations, the idea would become that of a machine that could sit in people's homes and do all their blood tests, an idea she believes would 'change the world' and make her rich. Thus, was Theranos born. Sadly, this is an idea that others have had and had struggled to achieve.

Holmes may have believed that by doing the machine in a 'Silicon Valley' type startup company, Theranos would succeed where others had failed. Unfortunately, the reality behind health-care's need to do careful studies of new technologies and trying not to hurt patients, appears to have been lost in the 'reality distortion' that a Silicon Valley start-up lives in, especially when Holmes begins to deliberately act like Steve Jobs in the running of Theranos and the treatment of workers and investors.

Time passes: the technology struggles to be made to work, yet Holmes (as do most start-ups) overpromises on what the technology can do. Eventually, it reaches a breaking point when Theranos makes deals to have the machines be used in retail locations. With non-working machines and deals that cannot be delayed, Theranos decides to cheat by using competitors' blood machines to do the tests, but in ways the machines were not designed to. It is at this point that some people at Theranos, locked behind company NDAs, decides that with people's lives at stake due to the inaccurate blood results, this cannot continue and begin to find ways to leak out the details of what was happening. And this is where the story gets gripping.

At this point, that the author gets involved in the story, when he gets a tip-off about shenanigans at Theranos and starts digging. Of course, Theranos reacts with lawsuits and threatening lawyers. Being able to get a 'front row' seat to the confrontations and then the revelations after his first article, and subsequent ones, on Theranos are published was worth it to read it all in one go.

In the end, the technology was revealed to be a sham; Theranos goes bankrupt and Holmes and others are (as this review is being written) now on trial for fraud.

If there is a moral to the tale, perhaps it is that ambitious people can change the world, but perhaps not in the way they intend to if the path they follow is filled with deception and by mistreating people.

The Theranos story is so fascinating. Carreyrou paces the book evenly, slowly building his case. I borrowed this from a clinical chemist who plays (per him) a bit role in the story, appearing in a couple sentences within the book. When I returned his copy, the two of us sat in his office just marveling at how things progressed so far. Within my own little clinical chemistry domain, CLIA looms like a Greek god -- all-powerful and all-knowing. Should we accidentally make a typo in our data, CLIA will send bolts of lightning to destroy us. The idea that a lab somehow became CLIA-certified with such significant variance in their data even before the straight-out fraud is almost unbelievable.

In addition, this seems like any doctor in their right mind would know what to make of Theranos. My best friend who works with silicon valley startups asked me about it several years ago, when I was still in residency, and I told her that the problem with capillary draws was hemolysis (blood cells splitting) and that you could never get some accurate results do that - and that's baked in to the blood draw, before you even get to the machinery. Any doctor worth their salt knows this.

So this is an almost fantastical story about how someone by force of personality alone paraded out technology that everyone knew was impossible, and somehow, without ever really inventing anything became a billionaire running laboratory testing in clinical labs on patients. It's pretty serious and scary stuff.

While reading it, I couldn't help but be amazed by the number of smart, well-educated people who were at least temporarily a party to this, often bullied by fancy lawyers and nondisclosure agreements. I think there's a lot here about how much the assumptions of civil society are really what keep us in check more so than institutions like CLIA or CAP. Once someone starts operating in bad faith, it's pretty scary how far they can get. On the other hand, Theranos was pretty much brought down by Carreyrou assisted by a pair of early-twenty-somethings who felt they had to speak out. So I think there's also a lot here about the importance of protecting whistle-blowers and the media.