#427 Taking wearable biosensors to the next level: Rafaël Michali from Sava

0:00Welcome to the Health Tech Podcast. Here we talk about everything healthcare and technology. and I'm your host James Someru. Hey everybody, this week I'm joined by Raphael, co-founder and co-CEO. We're going to talk about that model definitely of Sarva which is all about biosensing technology science. They've made, I was going to say a wearable, it's far more than that. It sits on the skin, it does a load of cool stuff. Heavy, heavy, heavy R &D, clinical trials and also a really cool consumer-facing brand to it as well. So yeah, looking forward to getting into this, man. How are you? Good, good.

0:41Thanks for having me. You're very welcome, mate. You're very welcome. It'd be good to hear about your journey, man, because you look far too young to be doing this. And I know Zuckerberg started the company at, what, 19 or whatever, but yeah, looking at your background and the research, so Masters of Engineering, Bioengineering, and Biomedical Engineering at Imperial uh got a first no less um that was only in 2017 and now by 2019 you're co-ceo of sarva doing all this cool stuff raised from the latest round balderton capital and like all these sorts of so you've done some awesome stuff so give me give me like your background man like are you are you from a family of entrepreneurs like how on earth did you know this was a thing and that you wanted to do all this and yeah walk me through it yeah for sure um i suppose i always wanted to be a medical doctor as long as i can remember i was like i want to be a medical doctor and specifically i actually wanted to have my own research group oh so i was like i want to push the boundaries of science i want to i don't know sustain human life and the only thing i could think about was medical doctor and technology yeah and so at about like 16 17 i had to make a choice and i was like do I actually want to spend 12 years of my life studying to potentially have access to a research group and the answer was no in the sense that I was like maybe I could have a greater impact by studying less and so I was passionate about technology on one end passionate about like the world of medicine on the other one so I was like well maybe I'll just become a biomedical engineer and so that's how i ended up studying at imperial college and i wanted to also build a company as long as i can remember um because i think that's how you can make the most amount of change is by creating a venture essentially are you someone that had like little companies growing up were you the sort of entrepreneurial person in your class and things like that probably uh all the cliche things that you can talk about like like like reselling stuff on ebay yeah coding from an early age you know yeah all the cliche stuff i've definitely done even some some even more let's say random things where i was trying to get money from my family by uh you know uh with my sister and my cousin creating like mini shows and and no way getting money from my family really the the motto of like do stuff that don't scale we were doing that's amazing that's amazing so taking that energy into bioengineering and biomedical engineering then was that like quite an entrepreneurial course did like a lot of people go on to become entrepreneurs is that was is that like taught within it kind of thing of how to build a device and build a company or were you kind of having that thought process outside of this and uh i think definitely when I came into uni I was like well my single objective here is to build a company oh wow okay fine so I was like I'm not entirely sure where the company is gonna land as in which field I know I'm passionate about medicine passionate about technology but I just want to I want to build a company and so the course wasn't necessarily entrepreneurial i met my co-founder at imperial um we met in second year actually and he had like this idea booklet i had an idea booklet and over the years we were like essentially brainstorming on like what we could build we met we met as friends then as lab mates and eventually as co-founders so there was kind of like um a a journey to it as well and so when we're at imperial we were starting essentially we started building this thesis around health and health monitoring and how you know the health care system is not the way we want it to be it's a in our view it's a curative system so you go to a doctor if you have symptoms and we're like well it actually should be a reactive it should be a preventative healthcare system instead of a reactive system i'm obviously from medicine clinical like you know doctor practicing doctor and so i'm very much indoctrinated by that system of only come in when you've got symptoms only investigate when there's something to investigate potentially like i am from that and of course especially the nhs well well exactly the things that sit outside of that are then called screening programs and so where there's evidence that a certain type of people get a certain blood test to detect a cancer then a business case is made a whole model is built and then you sort of decide like oh okay at national level we we now realize that we can prevent morbidity and mortality at this like ridiculous level and like all that sort of stuff and therefore and then it becomes a screening program it's just interesting like seeing within my lifetime like screening programs like on the on the public sector end as you rightly say the nhs and then what people are doing in their own lives which is essentially this this experimentation with spending money on blood tests and them determining whether they're getting roi because at the individual level you can price in like what that means to you to know that you're optimized feeling good all of a sudden goes on your individual p &l but does not reach the screening uh the the screening program sort of business case you can't you can't price in like how good people feel and all that sort of stuff it's all sort of action and and spend and and what that leads to and all that sort of stuff which is which is totally different but what i was going to say i had an echo scan the other day for the first time oh nice and i've i've always i've hated wearables i've never been like in that kind of world um of the quantified self like i've always hated it because again like but it's from that like medicine thing of like only investigate if there's something to investigate otherwise it's gonna stress you out you're gonna find something then you have to investigate it you have to you might get worse you might get complication anyway had this thing and my cholesterol is like off the charts and she's like what what how on earth do you have this cholesterol for like the size of you like you might have like familial hyper a cholesterolemia and i'm like yeah yeah i think it probably is probably yeah exactly like yeah really like i'm immortal though so how can that be the case like i don't no no no you've got this massively wrong i'm in the health care system therefore i can't have anything health the matter with me and that was my that's my initial reaction they went on the way home i was like thinking about my diet and i'm like yeah i drink whole milk i i have loads of eggs and cheese and like all this sort of stuff i have loads of oils i've lifted i'm like yeah okay this this does actually add up i can actually take some steps to reduce this and test it again in three months but like point is my point being the the neco one i i had because i was about to interview the founder and and and he ended up cancelling last minute and said i'll have a neco scan so i was like oh cool i'll take that um i'll speak to him again later but the point is is like yeah the preventative side in in in one second my view of it flipped my view that flipped completely of like hold on a minute like i i now i now get this a lot more and it sounds like you've sort of got that in inverted commas like from day dot right you you've always been of the opinion that um yeah the more knowledge is power essentially information is power particularly about the human body but yeah yeah for 100 i mean i totally so i suppose one thing um another perspective i suppose is the fact that well first of all healthcare system like the nhs i'm actually french well i was born in the u.s but i grew up in france so kind of like two sides of the coin in the sense that the french system is healthcare french system is incredible in the sense that pretty much anything is reimbursed to the point where now they're having a pretty big problem with um debt inside the healthcare system so let's see it is incredible however i think in most cultures uh if not all doctors essentially they come to you they look at symptoms and diagnose and so in other cultures which i'm not sure if you're familiar with like early chinese medicine greek medicine patients essentially paid their doctors only when they were healthy so and they stopped paying them when they got sick so essentially incentives were fully aligned so doctors invested in their patients like holistic well-being instead of um well pay us when you feel sick yeah yeah this is essentially exactly how we think about health at sava it's like we want to bring a world where staying healthy is a habit and it's not about managing illness once it happens and so um yeah essentially it's like how can you in how can you align incentives between a healthcare system like doctors and uh and patients which in our view patients are in a way consumers because you only become a patient healthcare system once you have a problem once you step into the doctor's office but in the end i think there's a societal shift as well which we can chat about but people are starting to um look into their own health like you said quantified like essentially uh in this world of wearables where you uh you can track everything you do at the moment only at the surface level and then maybe we can chat about like how we how we started Sava but when we started about like seven years ago it was kind of like the rise of all these wearables which were the very in our view the very beginning of preventative health medicine where it's like apple watches or rings I'm actually wearing both right now and it was like well people started being like oh well maybe if I don't have that that uh that glass of wine on a wednesday night maybe i'll sleep a bit better and i'll feel better the following day and so it's not about like okay live a life of restriction it's more about like okay make you aware of like maybe how you could feel a bit better maybe you could live a healthier life which if you live a healthier life you'll probably feel happier you'll probably have better relationships anyway so i guess that's that's how i view it yeah it's really interesting man well so where did the idea for sarva specifically come from because the ambition here in the vision is huge and so i guess for people listening you know a device which um i imagine it's a micro needle or something similar that sits under the skin is going to measure a load of different things um it's going to pull up here glucose lactate ketone sodium histamine urea like all this sort of stuff that you're going to be that that you're measuring um and it's it's bold as well in a world of everyone being obsessed with sass and software to actually think about the hardware um and you're obviously coming from you know biomedical engineering that's probably front of mind for you which is quite interesting um but yeah tell me about the the getting the idea and turning that into an actual thing i think there are two sides to this story there's a very personal side and there's like how we came together as co-founders with with ren maybe else i'll start with this one we ended up so like i was mentioning we both have like idea booklets we want to build the company we wanted to build a company together we joined this biosensing lab at imperial college where it was a lab specialized in can you how can you sample the human body in less invasive ways so we worked on sensors uh all sorts of all sorts of sensors measuring molecules in saliva and urine in interstitial fluid um you name it like we built sensors for pretty much everything um or pretty much every every matrix in um in the body and so at the time it was like So you had these wearables on one end, you had like deep health.

13:31And so these wearables, they could only track external metrics like heart rate, sleep, and seps. And if you actually wanted metrics which went deeper than these surface level metrics, you had to go to a lab. Time-consuming, expensive process. And so we're like, would there be a way to combine the ease of use of a wearable with deep health indicators that you would get only from going to a lab? And that's kind of how the idea of Sava came about. And the only devices out there, and I'm not sure if you've encountered them before, but the only devices out there that could measure a molecule below your skin were continuous glucose monitors.

14:11Yeah. for people listening it's like a lot of um a lot of patients with diabetes use it because it was created for patients with diabetes which are these like the the most famous one is like this white pug that you place on the back of your arm which are incredible because they revolutionize the way patients with diabetes um measure and measure their glucose and dose their insulin however we saw it and we're like well this is still not consumer grade it's not the same way you use an o-ring everything from the user experience of the physical product to the app it's just not good enough in in our opinion because there you identify essentially three pain points first one being the user experience you still have to insert a hypodermic needle which leaves a filament behind so the experience for patients with diabetes it's is totally fine because they don't have to fingerprint but for an everyday consumer it's not amazing the second ones they're very expensive so they are fully disposable so not only well for from an environmental point of view we couldn't get behind this but you end up with like a very expensive product and the last one is they can only measure one molecule at a time which is glucose and when we saw these three problems we're like well the only way to solve them is to build our own product and that's how salva came about i'm going to talk about the tech with you because i think i think you're an engineer and i really want to get your perspective on how to even go about building that and also how you then think about a business model around it as well because hardware is not as cool as software at the moment but i imagine things might change um but first i just want to explain briefly why i think that this is incredible timing so i don't know if you saw the other day in the news it didn't make huge news but google research released a paper on i think they called them like ai health assistants or something or other which is basically this complex ai layer that sits between all your wearables and information and you and it contextualizes the information from the wearables so that you're not acting on any individual data point and or you're not reading a continuous read out yourself and you're only receiving the actionable insights and of course but with it being google like fitbit then come out and say they're doing that now like you're now getting like nudges based on you know it's gone through this ai first and and the vision clearly is this ai layer in between all of this information and us and it's funny because you know how i said like i'm not i'm not the quantified self guy i don't i don't want to be bombarded by data and all that sorts of stuff you could actually you know all those things that i listed there and you do more like you could layer in all the fitbit stuff the orange stuff like whatever sleep that you could layer all of that in it's actually no longer intimidating to me as someone who doesn't like that stuff knowing that actually there's a layer contextualizing it before it gets to me and i actually think that is gonna bring the early majority and the late majority and even some of the laggards to the table with this and really i think the market size for this type of thing is about to go bananas because of that ai layer i mean it's a prediction it might not happen in that in a clean way but i don't know if that's something that you ever thought about or the degree of like the insights that you're getting from this and how you present those insights to the individual and what this kind of time means with all of these you know llms and what google research are doing and like all this sort of stuff i don't know if like any of that plays into your thinking here when you're originally setting out to just measure this stuff but timing is so important for companies man and like it seems to it seems to me that as an if there's a huge amount a first mover advantage if you can get a device to market that just measures this stuff effectively because of what big tech can do in terms of aggregating it all i don't know if any of that's played in but like that's stuff i've been reading anyway i totally agree i think the like a product alone like a hardware product alone won't get you far but a software layer alone also wouldn't get you far, especially I'm talking this in the context of like medical devices and understanding.

18:51And this is the trap we've been in with people trying to do each individually. Yes. Exactly. And I suppose that's where we were at. We were all observing all these companies, either pure hardware companies or pure software companies. And we're like, well, clearly there is a lack at the moment. And still today, there is a lack of high quality high quality low level data yes that's what it's pretty well put nickel health as you mentioned before is trying to solve as well yeah and in this in this system or in the healthcare system or interacting with the human body as you know better than me it's so complicated that it won't be like a one size fits all it won't be like with this one solution can solve everything you'll need a combination of product and it's kind of like what is the first element you want to tackle and for neco health they were like well let's start with the physical lab for us it was like we believe in this world of like what a decentralized medicine where we should be able to understand what's happening in your body without being in a physical lab and so So we're like, well, before solving the software layer, we need to build really, really, really good low-level data gathering.

20:12And that's why we really focused on building hardware products and building hardware plus medical devices plus consumer is really hard. The company is still set up as an integrated company because as we mentioned, if it's hardware alone, then it won't get you far. However, the first maybe three years of the company when you had loads of either family members, investors, they were like, well, you should have an app already. You should have, what are your stuff with our guys? Where is your AI strategy? We're like, well, we could do all of these, but we will fail because if we don't de-risk the hardware element, if we don't de-risk, if we don't spend every dollar we have on building hardware, on making sure that the technology is scalable, then the rest won't matter.

21:04And we think that paid off because six years down the line, now we've got about 70 people in the team. And we also have a software team now. So we've got a front-end software team. So we're building everything in-house. But it's more like, it's like imagining a race where you've got like, 12 different people that run at essentially a different speed and you have to in a way everyone has to finish or arrive at the finish line at the same time yeah you're only as fast as the slowest one yeah definitely exactly totally get it totally get it i love this man and i love that focus on we're going to do the hardware right to begin with i i just i just think that's the opportunity because you you put it so well that there's a lack of high quality low level data like it's so true and also there's a lack of knowing what it means because we also haven't researched that next bit as well of like what does like a a low normal potassium actually do because it's normal for the nhs it's normal for we also just don't know does that need correcting is that a good thing that it's low normal is it a bad thing that's low normal like what like what's normal is should we change these parameters like this there's so much that we actually don't know that i know that one of the ways that you've talked about the company is that you've basically been in five or six years of R &D as well.

22:23And I think that's, it was really interesting for me to hear that because when I looked at your website, and I know that we've spoken about this before, but like when I looked at your website, it comes across as a very polished B2C brand. And I'm so used to this man that when I see like, you know, like a hardware or a software or da da da, or it's ambiguous and it's really polished B2C and all that stuff, you know, you dig a little bit underneath it. and like the heart the usual heart sync moment for me is like yeah there's no clinical rigor here whatsoever you guys been five or six years in r &d years that's crazy for a brand that looks so polished like this uh to actually have done that and am i right in thinking that you guys have done a clinical study as well and you've got this like very heavy research component to what you do that's that's totally right and i suppose when we started the company we've we were always so we looked around and as i mentioned medical devices such as like the one i mentioned before which revolutionized the way patients with diabetes interact with their health we looked at the product and we're like this is not a consumer grade product we're like why do we why is it it's either an ordering or an apple watch with can only measure heart rate and sleep or this product which doesn't look good which you don't want to wear which in the end um patients with diabetes were ashamed almost of wearing the product and as a result push these companies to build a smaller and smaller product just because they thought um patients basically just don't want to show the product itself and we're like well there should be a way to build this apple user experience of medical devices and so our mind was always rooted in well it has to be design-led user i suppose user-centric but really design-led well it has to be deeply rooted in science as well it's hard to marry the two though right it's hard to marry the two for sure i think we must be because very few people do it i think we have an unfair advantage because we grew up with iphones and so most medical device companies since it's so hard usually time scales do not match with venture capital uh life cycles and fund cycles just explain that for me for people that are listening because i say this a lot and i don't want to bore people but i'd love you to explain this because i think this is one of the fundamental problems of um of healthcare innovation traditional venture capital funds invest uh well the life cycle of a fund is usually about 10 years this is i would say uh most like 90 percent of venture capital funds so they invest there they raise a fund they invested over three to five years and then the following five years they kind of like trying to get money out of the investment.

25:26Worth noting as well, that's because the people that gave them money, i.e. the LPs, come knocking at the door at the 10-year point and go, cool, now give me my profit. For sure. But if you think about in the context of, let's say, a medical device, on average, it takes, well, for a medical device like ours, it could take, five years to get to market because you've been six years in r &d for a start we've been we've been six years in r &d and that's where the beginning we didn't didn't have it raise venture capital money because it was kind of like oh when am i going to see my my money back or um it's so far in the future and so once you once you raise money um well you've got to go through r &d then clinical trials um then go to market well you have to get it like regulated and even like getting a C mark.

26:22You have to wait for regulators to approve it. At the moment, they have a backlog, for example. So next thing you know, it might take you, I don't know, three to five years just to get the product to market when investors after three to five years after their investment, they want you to be making 100 million in AR, 200 million in AR. So it just doesn't match with how they think about getting money back to their LPs, like you said. We've just completed our first, I would say, official clinical study in partnership with the University of Oxford in Cambridge, where we put our product on patients with diabetes, both type 1 and type 2 diabetes.

27:04And this was to measure and compare the accuracy of our product with state-of-the-art, which is both venous blood measurements so essentially taking measurements from like essentially you extract blood from a patient and you put it inside like a machine which is the gold standard for measuring glucose which is called a YSI and then compares it with our product and we also had like state-of-the-art cgm so um in the study and we compared the two and we looked at the performance and the results look great and we'll publish probably the results officially in a in a couple of weeks but we are really happy with the with the with the results so this is really interesting good to talk about actually because i like chatting to people on this podcast particularly when we're talking about a frontier of medicine when people are breaking new ground and I think one area of that is measuring things through the skin I've had a few people on now that are measuring like hydration and like various bits and bobs but like not in I guess the the full sort of completeness that you've described of measuring under the skin But the point, my point being, it's, again, uncomfortable for people that I think are like me that have learned and been taught that a blood draw is the most accurate way that you can define and determine anything.

28:42And it almost feels like, you know, a microneedle interstitial fluid or just, you know, the dermis or something like that. that even the thought that that could bring about something as accurate is incredibly difficult for us to swallow because of i think just the trait well i'll talk for me i don't talk for everyone else like it it's it like that feels like cheating it feels like well oh man like we've been hurting all these people for so long but this is how medicine advances there are frontiers of medicine there are things that we're learning about the skin the microbiome the gut brain axis like there there are these frontiers of medicine and actually it's it's really important that people like me just get really comfortable this with this stuff really quickly in the face of evidence that you're collecting because the the potential upside i was going to say the potential upside downstream i'm just talking in like management consultancy language now but like that it's it's a good thing that's what i'm getting at it is a really good thing and it's important for us to get comfortable with it so can you talk me through the tech and feel free to geek out on the engineering here because this this i think is fascinating and i would love to hear about the device itself for sure i mean it's it's such a great point that um how do you get comfortable with like well blood draws are state of the art you can get everything from blood obviously because that's what keeps us alive.

30:09And the question when we started the company was, are there other fluids which could also provide really accurate and clinically relevant information? And so our very, I suppose, very initial days of what SAVA is today, we actually were measuring another fluid. We actually measured stuff in saliva, which didn't work out the way we wanted it turns out uh we had to learn the hard way that other although saliva is under studied um it's not as it the correlation between saliva and blood is not incredible uh for most molecules there are exceptions but for most molecules then you've got urine which is another fluid which contains relevant information but it still in a lot of cases far away from blood and so we're like well what are the fluid are there that we could measure in a minimally invasive fashion which is clinically relevant and the other fluid which is actually the most abundant fluid in your body which people which people don't know about And I think when I went to uni, I'm not even sure I knew exactly what it was.

31:30And it's this fluid called interstitial fluid, which is very, very poorly studied because it's so difficult to access. Even though it's the most abundant fluid because it's the fluid around your cells, it is really difficult to extract. It is really difficult to sense. It's just difficult to access. and so continuous glucose monitors also measuring the interest of interstitial fluid and they kind of like had to prove that it was a relevant fluid 15 years ago and now the market is just very very big for continuous glucose monitors and when we saw this we're like okay let's dig deeper into this fluid and i think at the time there were loads of studies showing how correlated uh blood in isf and isf being interstitial fluid uh were in the sense that 90 percent of molecules present in blood also present in isf and you also have molecules in isf that are 90 percent of molecules in blood 90 percent of molecules and i didn't even know that that's yeah we can put a a couple of papers if people want to geek out and in the oh please yeah no no send them we'll put them in the show notes that's ideal yeah so we still like even before starting the company we're like well we broke our teeth in measuring saliva we had to learn the hard way that it's actually not that interesting let's not make the same mistake twice and so we probably spent three four months just understanding chatting with expert and seeing well is isf actually clinically relevant and it turns out that patients with diabetes rely on the measurement in the isf to stay alive so we're like well it's definitely yeah it's definitely relevant and so we're like well introducing a hypodermic needle and leaving a filament in our views to invasive so could there be another way to sense inside the isf but being as minimally invasive as possible so we looked into optical methods we're like well we don't think that's going to work because you've got about 10 000 molecules flowing inside uh the isf changing concentration uh in different ways at different times so it's just a nightmare to to get specificity and specificity is like are you um can you detect and can you be um can you detect a single molecule of glucose basically and so So the only way is to build our own technology based on micro sensors and micro sensors in literature.

34:08They're called micro needles and they're essentially so small, these sensors, that they're completely painless when you apply them on your skin. So they penetrate the first layer of your skin. And if we want to geek out a little bit, you end up in the dermal layer of your skin. So you've got a couple of areas in the skin. you've got the first layer which is like the stratum corneum which is like essentially um pretty much like dead cells then you've got another layer which is called the um epidermis and then you've got the dermal layer so the dermis where our microneedles essentially land uh continuous glucose monitor are underneath the derm underneath the dermis which is the hypodermis which is like a fatier compartment and so we land in the in this dermal layer so what what depth is that out of interest in so it's about one millimeter under the skin so to i suppose to put this in context our microneedles are about essentially a tenth of an ent's leg so really really small yes yes and the actual sensing of all these different molecules how is that done in such a small space i guess that's the challenge over the past few years.

35:43But essentially, the way our product works is it's essentially a smart connected patch that you place on your arm, which in real time measures molecules flowing under your skin. And we created these very small sensors, as I was mentioning, which you can functionalize using the chemistry that we also build in the house. So we coat these microsensors with very small amounts of chemistry. And I'll use the word chemistry. It's a sensing element that we've created, which is specific to just a molecule. So in the case of glucose, you will build a sensing element, which is just specific to glucose. and if you want to be specific to another molecule well you have to create that sensing element which is sensitive to glucose but the way our product works is that we don't extract any fluid everything happens at the tip of the micro sensors and if you want to be specific to another molecule well you just change the chemistry so 90 percent of the platform stays the same you just change uh You just change the chemistry.

36:58And what's, I suppose, I want to say beautiful, but that sounds a bit arrogant. But what's really cool about what we've created is that you can have more than one micro-sensors on the same patch, which means that you can measure more than one molecule at a time. Wow. I think there is a beauty to that. I think it's completely fine to say that something you've created has beauty. I think that's completely reasonable. think we're all trying to express ourselves with our companies man and like i think that's true i think if you've got an eye for detail and an eye for design and and an appreciation of all those things then i think in part what you are trying to do is create beauty in the world and i think we see that in you know i think we always as well associate efficiency with beauty i actually heard this this is a real tangent now but i actually heard this one because i play a lot of tennis i was actually here like speaking to a couple of people on a podcast talking about um you know roger federer's tennis game and like why why are we so drawn to it and when you look at the biomechanics of roger federer's tennis game unlike a rafael aldell who's all about brute force and and you know a questionable technique just applied with force actually we like we might like roger federer's game because the biomechanics are probably the most efficient of anyone's biomechanics and actually we see beauty in that efficiency which i thought was just a really interesting play because you know i certainly relate to it you know trying to find efficiencies and just how i did my work as a clinician or you know in the company now all those efficient inefficiencies just weigh on me like a ton of bricks and so I completely appreciate you seeing beauty in the way that you do that because you can associate that to you know meeting the goal that you're trying to meet and all that sort of stuff so I completely get it man what I'm interested in though now is is like turning this into a business because there's loads there's loads of different ways that you could play this you could you could create a micro sensor and try and sell it to Abbott you could or the patch and try and you know go down that route you could build a b2b business you could sell this to consumers you could monetize it in loads of different ways like how how do you now think about turning this medical device company into a functioning business that's a great question and we don't necessarily view us as a medical device company we are rooted in the fact that we want to be as accurate as a medical device and will eventually be regulated as a medical device but we view ourselves as a consumer first type of product and i know that that might uh it's pejorative isn't it i know i i know the feeling that you've got you're wincing because you as soon as you say the word consumer everyone like will forget the hour that you've just spent talking about the clinical rigor everyone goes ah this is this is nonsense and i think that that definitely upsets a lot of doctors because it's like well it's either a medical device or a consumer product we actually view especially the world of like um in the world of diabetes and well in the world 800 million people have diabetes which is an insane number at the moment only 10 million people so about like a bit more than a percent have access to a cgm and so in our view well all these patients with diabetes they interact with their product using a an iphone app an android app so there there's a massive overlap between a patient and a consumer in that sense yeah and so i think there's been a wave of companies that tried building a software layer on top of medical device companies such as like the cgms that i mentioned before and we were always like well we'll always be limited by other people's view of the world and the view of how they build hardware so the fact that they're building a product which is fully disposable we don't get behind and going back to the product we've actually decided for first off um user experience we've decided to separate the electronics and the disposable components and why why did we choose to do this is that well current cgm companies well they have to essentially make their product as cheap as possible and as a result it becomes as dumb as possible and in our view it was like well we can provide if we could provide like a multi-metric platform so let's just not stop at like measuring glucose or measuring lactic acid it's like well can we actually provide this multi-metric uh biosensing platform which instead of just providing stuff happening on their skin you can actually combine this with contextual data such as like sleep or activity and actually provide let's say let's say we started with patients with diabetes there are about like 42 factors which affect uh your blood glucose if you have diabetes and if you don't there are maybe 20 25 metrics that that affect your blood glucose and it's like well if you only can measure blood glucose then how can you tell what affected your blood glucose in the first place so how can you provide it how can you provide exactly insight to the user you're just a measuring tool exactly You're not a preventative tool.

42:25And that has been my problem with so many of the wearable feedback loops claiming and the claims that are made and the assumption that just because I look at one thing and I change a variable and that thing changes, that there's a causal relationship between what I've just checked. Like, that is literally it. And so that's why we decided to do this. And then obviously there's a cost element because the aim is to be able to manufacture our product at one-tenth of the cost of current devices. Wow, that's bold. That's ambitious. That's ambitious and we've got high ambition because if we want people which currently and probably will never have access to CGM in countries like India, in South America, if we actually want everyone to be able to have access to a CGM, well, the cost has to go down.

43:18and if you've got a fully disposable piece of electronic which after every 15 days you put in the bin where there's a battery there's a bluetooth module how will they ever have access to a product like this absolutely so we were like well we will not start this company we ren and i sat in a room six seven years ago and we're like the only way we're gonna start this company is if we have a plan to scale the company. It's like to scale the product. And if you don't think we can do it, then we might as well spend six years building something else. Totally. Three bit of comms advice for you. I think you should own this consumer.

44:03Doesn't mean non-clinical narrative. And you should do a load of content around that because consumers deserve clinical. There's a content stream for you. Consumers deserve clinical. that's great there's a there's a content stream for you um yeah get in touch if you want to build that out for you anyway um i heard you say earlier you're a team of 70 7-0 um super interesting uh you raised 19 million was it so you've raised about 30 mil like roughly um in total it's a lot of money man um it's a big team and also this element of you guys being co-ceos is like super interesting so can you talk to me about building the team for this and how you thought about it and yeah maybe we'll touch on the fundraising afterwards but let's let's talk about team first of all definitely something we've at least myself maybe and that's the beauty of uh again the beauty of something but the beauty of being co-ceos is the fact that maybe if i underestimate something well probably my co-founder in this case a co-ceo is not gonna underestimate it so i definitely learned from him in the power of like and the difficulty of building the best team ever i was always like it's fine people will come to us or it's fine uh it'll pretty it'll be easy to recruit high quality talent it turns out that not at all none of the above especially in london and in the world of biotech and the world of medical devices, it's actually really hard to recruit talent across.

45:42Right now, we've got about 12 different teams spanning from like chemistry, material science, embedded engineering, firmware engineering. We've got loads of different engineering and scientific fields. And so building the team, especially in the first, two three years was really difficult because we really need to build the pillars of of the company and so we had to convince uh people all around europe we convinced people from the west coast of the u.s to join us in london i guess that the london is mostly i would say pretty good for fintechs but i would say for biotech is not really good the advantage is that actually people it's a hub so people actually want to come to london um it's english speaking so you've got a lot of advantages but building the team has definitely been especially when you're in a stealth startup it's like how are people going to find you like obviously they're not going to find you so that was kind of a at least for myself a bit of a reality check but i mean that's a really good thing that we were co-ceos because if i had i don't know if i had been if you could down the path where i was the only ceo maybe i would have been like well we'll we'll figure this out and then you scramble to recruit a couple of people and they're not the right people so it was kind of like we individually obsessed on on different things so i was obsessing on technology and getting it right getting it scalable he was obsessing on like uh at the time like recruiting the best people ever to meet our technological needs because obviously a company is just a sum of like intelligent people and the sum of the parts are greater than the parts themselves.

47:34So the first couple of years were definitely hard. Now we've got a, I would say, a pretty good system in place. We've got a, I would say, now we're not in stealth anymore. So people definitely want to work in companies that aim to change the world. um and i would say we're we're in that category yeah 100 man and your co-founder the co-ceo relationship is interesting i i i ask this actually with a lot of um with with somewhat of an empathy and an understanding of how you must get asked this question quite a lot because i'm co-founders with my wife jessica and the mother of my son and we live together and all that sort of stuff and so next level yeah well yeah perhaps on some levels but sharing quite a lot of similarities you know co-ceo with your friend i think i think there's quite a lot there's a lot baked in there and always when people ask the question they're asking it in in i say always like quite a lot they're asking it in this way of like hmm that must cause you problems or something like i don't know whether you get that with the co-ceo thing whether it's just a genuine interest but I'm interested in what that dynamic is and how does it work and I will say the reason I'm asking is because there will be people listening that either have never heard of that as an option have heard of it right now and think that might be an option or like have been considering it and don't really know what the positives and negatives are but or what would lead them to that decision so talk me through that decision and what led to it first of all it was pretty natural but I would say about the co-CEO thing if you had to pick the three elements where we had the most amount of pushback over the past six seven years co-CEO is top three maybe at some point it was definitely top one it was like wow it was like what's this co-CEO thing it is bold of you to do that and and and stay strong on that through two investment rounds that are quite large because where the pushback happens is probably there in a lot in a lot of ways right so for you guys to actually go no no this is the model like it's it's a bold move it must come across very confident and actually you must have to build a decent narrative around it no for sure and it's it's even more complicated because well in some cases and maybe i'm projecting but it's kind of like maybe they don't ask the question anymore but you can feel that they're like so this co-co thing yeah what's that about how do you divide responsibilities and then you kind of like it came so naturally with my co-founder because we started as friends first and foremost so there was never no matter what people say i suppose in all companies if there is a ceo there's always that even if people are co-founders there's a tiny bit of power dynamics because the CEO definitely at the end has the last word.

50:36This was the one that goes to investors. And I understand why maybe investors want to see one CEO because in the end they want one face for the company in case, well, who's going to evangelize the company? And more importantly, well, if the company doesn't do well, who do I call? And in this case, if there's a problem them and who do who do they call who do the investors oh but it came really naturally for us um and in a traditional and i think the model of ceos in in like traditional companies make sense because they're pretty simple it's like whatever a software company you do one thing uh you've got one type of engineer for a company like ours where you have so many different areas you you have to be at the cutting edge so you have to be at the bleeding edge of so many different fields that essentially is like many companies in one so it's the and and also you have the hardware element which means that the cost of making a mistake is most probably deadly so you've got i mean the jeff bezos chats about it a lot it's like one-way door two-way door decisions in the world of hardware you've got insane amount of two-way door decisions so for example if you commit to a piece of equipment like let's say a piece of automation equipment currently we're we're scaling up our production line so we're automating our production line and so a cost a piece of equipment might cost us let's say i don't know 500 600k if we get it wrong not only what delay timelines because it's about like six months to build the piece of equipment but we also only have one shot at target so we had to create a model so the concept of co-seos is like we have to both be aligned and we have to get behind that decision in order to make that decision and i think it works super well and then we had to put stuff in place it came naturally but we still had to put stuff in place where both of us we've got this essentially grading um grading scheme where if we're above like let's say 75 80 percent well it's probably a yes well it is a yes if one of us is above 80 the other one is like towards like the 40 50 well the other person has to pitch to the other co-ceo and if essentially you can't sell the idea well enough it means that yeah you probably the idea was probably not good enough or you didn't believe in the idea enough yeah yeah and then the last one is like well one of us can really have that i don't know i think it's such a bad decision and can just view the decision yeah and you have a few successful company like a lot of successful companies like atlassian had co-ceos for many many years uh waymo has co-ceos at the moment wow netflix has co-ceos so they're yeah wow that's really interesting have you had many instances of needing to go to that framework we go to the framework pretty much every day interesting i wouldn't have thought without without putting it on paper so no no sure sure sure but we go to the framework every day interesting so because one ceo would not be able to do everything that has to be done at this company in the sense that on top of building products and we're really involved and really technical, really involved in product, which I believe is very important, I would say, towards the type of running a company closer to maybe an Elon Musk or Mark Zuckerberg, like very technical founders.

54:48So we're very technical, but you have product. Within product, you've got mechanical engineering, you've got chemistry, you've got software engineering, you've got electronics so you've got a lot of different technical fields you've got commercial elements then you've got regulatory elements you've got clinical trials which we chatted about and so one single person wouldn't be able to do this at very high quality on its own so if for example i truly believe in let's say well i think we should launch uh this initiative in clinical trials or i think we should really push and i should spend my time let's say my co-founder is like i should spend my time thinking about a commercial deal with this partner but it's gonna take 80 of my time he comes to he comes to me and he's like i think we should focus on this and i'm like really i don't really believe that's the way to go and he's like no i truly believe so and he starts pitching it and let's say he builds an incredible case and he was like and i'm like well i'm convinced let's go for it that's how it usually i love i love this um when when your co-founder is your wife you don't have that framework written down but the things that well it's quite simple the things that i am over i i ask her anyway i make sure they sign off anyway the things that she is over she will ask me anyway we will talk about all of this stuff because the company is our life and we have more time allocation for this stuff because we don't need to put meetings in each other's diaries because in part we love this stuff and so we talk about it a lot in our free time of course we firewall friday at six until monday at 9 a.m like we we we you know firewall that sort of stuff but like so you don't chat about work in bed no no not unless it's been a really good day um there's yeah there are some things the work chat stays out of um but yeah as i say unless it's been a particularly good day so yeah i think it is that man i think for us like it it it sounds like the same as you in that that phrase because i would say we have the same framework and actually we just haven't got it written down i think what it's done for us is two things i think it's i think it's extended our upside and i think it's protected our downside i think there are some big decisions that i would have made as ceo that i didn't think were big decisions or were i don't know just plain wrong that actually i've just had a quick sense check on and it's like hold on a minute you can't like whoa and then all of a sudden I've learned all this new information of like whoa okay right I'm so glad that we did this so like I yeah I get the one-way and two-door thing as well and when there are a lot of one-way doors and only one person in charge of making that decision ultimately I think that people do end up going through more of them and you won't you won't go through many of them in your framework so I get it I definitely get it from the situation that we've got as to why especially when you said actually at the very beginning it came naturally to us immediately now in my mind potentially you know if you'd came to us for an angel investment like way back when and you'd said that not only would we'd have got it from our situation but when you said it comes naturally to us i'm sort of already bought in because i'm like all of a sudden now it's more effort for you guys to now have a conversation about who's more important than the other one and is going to be able to lord it over the other one in terms of ceo and cto or ceo and cpo or whatever because like i get it like it makes loads of sense i couldn't agree more about the downside protection and upside optimization i was the only devil's advocate and it'd be great to hear your take it's like speed of decision making does it slow down speed of decision making i think it does in areas that probably benefit from slightly slower decision making and you might do 90 of what you were going to do anyway but it was the 10 that actually protects quite a lot of downside and makes the whole thing worth it in inverted commas now that's an algorithm but i think if you were to analyze it in our company i think that's what you would find i think you'd find that yeah they probably each individually would have done 90 of the same stuff but the 10 they didn't do was where there was outsized upside and protection against downside i've got a really really concrete example of this by the way um that i can't actually say too much on other than to say there was an entirely new you would call it like business within a business that i was like it's a distraction and jessica was like it's absolutely not and i was just saying it from a point of view of as a ceo you know focus like let's all focus we've got a product line that works we've got a business that works it's a comms agency we spend less than we earn each month we deliver everything under the marketing umbrella which means we do all that for individual companies the rest of it and then this other opportunity came to us and i was like no focus simple decision and and and i got really challenged so in your framework that's the person b is disproportionately wanting this what seems like an outsized reaction therefore i have to at least listen to it and we'll probably do it which is where i got to right and then we did it very very profitable very highly revenue generating and we will be doing it for a we will be expanding it in uh 2026 and being a lot more public with it and so that's a real concrete example of that that actually you know that decision came to me i would have been completely within my rights to not even present it internally because it was just you know something that happened through the podcast and blah blah blah but like yeah a real a real real real concrete example of that that like fundamentally changes the not only the direction of company but actually like frankly just how profitable you are and what your upside is potentially you know five ten years down the line you're talking really big differences in multiple so like yeah it's it's super it's it's super interesting man i know we're running out of time dude so i i want to just finish by figuring out where you guys are as a company right now five or six years in r &d 30 mil raised in the last couple of years you've got a waiting list on your website you've got goodness knows how many jobs you're looking for on your careers page on your website um so like you're in a fast growth part of what you guys are doing so where's the tech where's the where's commercialization on your journey when are you going to start selling this um and i guess what are you excited about what's next i mean at the moment we've got three main areas of focus for 26 and i would say the overarching element is our eyes on our eyes are on launching a product so we can work we can only think about is like let's launch a product within the calendar year well it's probably going to happen since we want this product to be regulated it's probably going to happen beginning of 27 yeah just because of the timeline that are involved with getting a product regulated and getting it C marked and eventually FDA cleared.

1:02:36If it weren't for this, then we could definitely launch in 26. The product is, we've got a, I would say, a product of the, a version of the product, which is almost ready to be launched. And so in 26, the aim is to be automating our manufacturing line. So one element of one other challenge of building a medical device is the fact that the product that you launch has to, well, the elements of the product that you are launching have to essentially be frozen. So once you get your product regulated and launch well, the way you're manufacturing it can't really change. And so that's another challenge because it means that you essentially have to start scaling it a lot in advance of a launch date.

1:03:31And so in 26, the aim is to, and we've already started, is to automate our production line on the final version of the product, so the product that we're going to launch. And at the same time as, and this happens in, traditionally, this does not happen in parallel. So big pharma companies usually do this in a sequential fashion. So they build a product, they freeze the design, they automate, they go through a clinical trial and then they launch. and so what we're doing we're doing things slightly differently and this is trying to align the traditional venture capital model with the medical device world is that we have to take a bit more risk and we have to do things in parallel so we're automating the manufacturing line at the same time as uh we're performing clinical trials so you freeze the way you manufacture your product you automate your line and you do a let's call it last clinical trial which will be the the data that you collect in order to submit regulators love it what are you most excited about the thing i'm most excited about is the reason why i personally started the company in the first place which is um delivering a product that can change someone's life whether it's someone with diabetes and enabling that person to measure their glucose dose their insulin and provide actionable insights in their life or someone that just wants to take control of their health because they feel like life is overwhelming at this given point in time and while you you don't understand what's happening you always feel tired you always feel hungry and And so having that level of data in your pocket, essentially, I think is incredible.

1:05:22And that's one of the reasons why I wake up in the morning is to be able to provide multimetrics in the palm of your hand. So measuring more than one molecule. And so I'm so excited about finally delivering this first version of the product to our users. If people want to get in touch with you, Sava.health, you guys can head on there, have a look at the jobs if you think you're joining. And Raphael, I imagine people can message you on LinkedIn if they've got any questions for you. LinkedIn, send me an email as well. It's my first name at Sava.health. Love it. Appreciate you coming on, man. Yeah, thank you.

1:06:01Thank you for having me.

1:06:10And