Anne Wojcicki: There’s No Such Thing as the Perfect Dataset

Anne Wojcicki: By having a large amount of data, we are starting to understand… what does the human genome mean?

Alexandra Eitel: Welcome to View From The Top, The Podcast. That was Anne Wojcicki, Cofounder and CEO of 23andMe. Anne visited Stanford Graduate School of Business as part of View From the Top, a speaker series where students, like me, sit down to interview business leaders from around the world.

I’m Alexandra Eitel, an MBA student of the class of 2022. I sat down with Anne where she discussed breaking down inequality through genetics, and how digital healthcare is being revolutionized. You’re listening to View From The Top, the podcast.

Alexandra Eitel: Anne, welcome to the GSB. We are so excited to have you here for View From The Top.

Anne Wojcicki: So excited.

Alexandra Eitel: Great. Well, before we start, I want to do a quick poll. So, please raise your hand if you have done a 23andMe test before. Wow. Okay, you have a strong market base here at the GSB.

Anne Wojcicki: But there’s a lot more that could be — No, I see opportunity. We’ll have to survey at the end to see how many people are going to get it now.

Alexandra Eitel: So, I have done 23andMe as well, and I just wanted to ask you one question about my test results.

Anne Wojcicki: Okay. I do a lot of customer care support.

Alexandra Eitel: So, should I be concerned that my result said that I have more than 92 percent — or I have 92 percent more Neanderthal DNA than the average customer. What is that about?

Anne Wojcicki: That is a fun fact that you should share at all parties.

Alexandra Eitel: Okay.

Anne Wojcicki: Actually, the Neanderthal report is an example of some of the things that we’ve done where we try to make genetics — and frankly, try to make all of science — relatable, make it something that’s fun for people.

So, honestly, one of the first things — I was at a TED dinner once, and we were talking about — there was Craig Venter, all these famous genetics people, and they were talking to a bunch of tech leaders. And they were talking about the latest results in one area or another. And then I brought up something about asparagus and how you can smell it in your pee. And 45 minutes later, people were still talking about the asparagus and the pee question. And I realized, people want scientific information that’s kind of fun, kind of the cocktail party conversation, and something that’s interesting.

So, Neanderthals was absolutely one of the interesting parts. It teaches people about science, and then it does become one of those things that people are always comparing. Like, “I have so much Neanderthal. What does that mean? And what should I do about it?” So, it’s definitely interesting. But no, it’s a proud fact that you should post widely on everything.

Alexandra Eitel: Thank you. Thank you. I hope you can all find your fun facts.

Anne Wojcicki: I think that’s why you got in.

Alexandra Eitel: Yeah. Actually, I think so. Thank you. Well, since we’re already talking about 23andMe, I’d love to dig in a little bit more. So, I, and many of us here, are amongst the 12 million users. And I’d like to take us back to day one, actually. How did you convince that initial set of customers to buy a DNA ancestry kit?

Anne Wojcicki: Well, we didn’t convince very many people. I’d say one of the things that’s great about 23andMe, and that was also a shortcoming in those early days, we’re incredibly strong on the science. And I had two scientific cofounders from Stanford who had just finished their PhDs, and they had joined, and we created essentially the product we dreamed of. Like how can I peruse my chromosomes and look at all the different reports and see what they mean and explore? It was kind of academic fantasies.

And we have a product now called Ancestry Composition. In the early days, we had these PCA plots, and it was relatively technical and hard to see. And we thought it was all great. And so, we didn’t know marketing research at all. So, from a business school perspective, we did not assess market demand. We just made the hypothesis like, of course everyone wants their genome. Of course everyone’s going to want to get it. So, it was academically very interesting, and it was controversial.

So, we were the front cover of — we were above the fold front page of The New York Times when we launched. Amy Harmon wrote the article. It was the only time New York Times has ever written a first-person account of them doing a product. We were the cover of Wired. Thomas Goetz wrote that piece. So, we got tons of coverage, and the first day we sold a thousand kits. And after that, it trickled down to 10 to 15 kits a day.

And we didn’t have any marketing team. We just assumed it would be word of mouth. But it was a thousand dollars, and the value proposition was not clearly there. It was really sort of an academic product. So, that was the first moment in the company we were like, huh, we might have to do a little bit more product market research here to figure out what’s going to drive sales.

But I think the first customers that we got were really people who are the Quantified Self world, the people who just want to test themselves on everything. And I would say there’s a market of 50,000 to 100,000 people who are just like, I want to try it all. And those were the people who were coming our way who happened to also have the spare thousand dollars. But it was pretty brutal the first few years.

Alexandra Eitel: Yeah. That’s very interesting. And so, now you found product market fit, you found all these amazing customers.

Anne Wojcicki: Well, I would say we’re still finding product market value. I mean, I think what’s interesting for me with genetics, and I don’t know — Healthcare. It’s so interesting because GSB, you guys have founded so many amazing companies. And the tech world has really come from here. And there’s all kinds of areas that have been really revolutionized. But healthcare is this last frontier that has not really been evolved.

And the reality is it’s not just like it’s this frontier. It’s kind of like a different solar system. Healthcare doesn’t operate in the same way. We all use healthcare, but none of us are the customers. You’re just the means for generating revenue, but somebody else is paying the bill. So, it’s really challenging to change, and it’s also incredibly fragmented.

So, in the tech world, when there’s a new technology that comes out, it’s usually rapidly adopted. You look at what’s happened with machine learning and TensorFlow and all these things that Google puts out, it gets adopted relatively fast. And the human genome was sequenced 20 years ago. And I would say how many people have had their doctor recommend that they get their genome and use it outside of pregnancy or outside of cancer? It’s almost none.

And so, part of the issue we have right now is genetics has still not been adopted by the existing system, and there’s all kinds of laws for that reason. So, for instance, there’s no profit motive for people to get this information. So, a doctor does not make money if they give a diagnostic. And so, there’s good things about that, like you don’t want them excessively recommending. But for that reason as well, no one is really motivated to create extra work for themselves.

So, when I think about product market fit, there’s still this huge chasm between — I have lots of consumers who are, frankly, really eager to do more and take more ownership of their health, but the healthcare world’s really not set up in any capacity to help them execute on that. And so, doctors are not trained on genetics. Doctors are not used to people coming in with more information.

And frankly, prevention is not a reimbursed part of medicine. Figuring out how you can exercise or how you should eat better is not something that you get from your doctor. You get that on your own. But frankly, that’s a huge component of all kinds of prevention. So, we’re still working on product market fit and how you actually create a new industry that, frankly, is direct-to-consumer and how you’re inspiring people to take more ownership of their own health, but it’s also an out-of-pocket expense.

Alexandra Eitel: Yes. I think that’s a very humble answer. You have 12 million customers, which is amazing. And I’d like to talk about those 12 million because, obviously, selling kits is one part of the business. But then when you have these 12 million-plus customers, there’s a swath of data, of course, that comes along with that and massive opportunity in the therapeutic space. So, I’m curious as you’re moving to focusing really on that data, what gets you excited about all that data?

Anne Wojcicki:& For me, when I think about starting the company, that was a huge part of my incentive and my dreams. I find it fascinating that we all have — all of life comes from a really simple code.

So, for those of you who are engineers or coders, it’s mind-blowing to me how remarkably simple. You have an A, C, G and T, and that accounts for all of life on this planet. And it’s like small variations. You and all of us are 99.5 percent the same. And I always tell my kids, “You’re 50 percent banana, and you’re 90 percent mouse.” So, you’re very similar to everything. It’s remarkable to me that we don’t understand this code.

So, I think about every night you go to bed and your body just — everything works. It’s like you live in this incredibly complex system, and we have no idea how it works. To me, this is the ultimate puzzle. As a kid it used to just keep me up at night, like how does it all happen? And even things like all of your cells can differentiate and how they turn out, it’s mind-blowing to me. So, by having a large amount of data, we’re starting to understand what does the human genome mean. And you have some really simple examples.

So, for instance, one mutation causes whether or not you have dry earwax or wet earwax. Another really fun medical example. But the reason why we put out the dry earwax and the wet earwax report is because it teaches people that you can have one simple genetic variation, and that can cause a different phenotype, a different trait.

And so, what’s really interesting for me is by having almost 13 million people and billions of data points is that we’re starting to make sense of the human genome. And frankly, this should translate one day. When you have billions and billions, it should translate one day as like how you actually really understand the code of life. And that’s really, for me, the ultimate goal here is you want to understand it.

And when I think about drug discovery, my background when I was investing on Wall Street was in biotech. And biotech’s are really — it’s amazing because the science is so interesting. But from an investing perspective — There’s one well known investor. He was like, “Anne, I love biotech.” He’s like, “90 percent of everything fails. I just short it all.”

And that’s true. From an investment perspective, there’s some reality to that. Statistically most of it’s going to fail. But for me, it’s like I want to create things that are going to work. I want to create things that are actually going to have an impact on people. So, if you start with human genetics, you are more than twice as likely to be successful. So, one of my hopes here was to bring structure and a new kind of approach to drug discovery so more of those drugs would actually succeed.

And again, I think about — My dad’s a physicist. We mentioned my dad’s particle physics. My dad used to always complain. He’s like, “Oh, you biologists. It’s so confusing. You’re such a disaster. It’s like all over the place. There’s no structure.” And there’s some truth to it. It’s really complicated. And physics has its laws and its principles.

So, for me, that’s part of the goal. It’s like in some ways once we have enough data, how do you bring enough structure so that then you could really have very rational drug design and actually be able to have a much higher success rate?

Alexandra Eitel: One unique aspect of the data that you have is there is a self-selecting aspect to it. Most of the data that you have is people who have signed up for the kit. So, how do you think about that when you’re making pretty large generalizations, potentially, about the data that you have?

Anne Wojcicki: Well, we get this a lot about what’s our bias. And again, coming from Wall Street and looking at all clinical trials, I was going to say, I’ve never seen a dataset that doesn’t have a bias. So, it’s not bad that we have a bias. The important thing is to know what it is and to be able to identify it, and then you account for it.

So, I would also say now that we are so large, we have pretty amazing representation and diversity of all types within the dataset. And that was part of the push we had for 10 million is like at 10 million, you get a lot of statistical power to do analysis on most disease areas.

So, there’s absolutely always a bias because we are self-selecting as people who are paying. Lowest entry point is a hundred dollars. But we do attract people for very different reasons. And I would say the ancestry customers, which also do consent for research, coming in at a lower price point and are also interested in a different type of product than my health customers.

So, I would say again, my main thing with data is it’s important in some ways just to go for size. Size really is the number one thing that matters, and secondly is really understanding your limitations. But there’s no such thing as the perfect dataset.

Alexandra Eitel: Right. Well, your intention around women and other disadvantaged groups in getting data around them is so important because there are not enough medical studies done on women and people in other groups. And so, is that something that you think about as well as [crosstalk]?

Anne Wojcicki: We do. We think a lot about — I mean, most genetic studies have been done in European populations.

Alexandra Eitel: Right.

Anne Wojcicki: So, that’s one of the other things. We are still majority European within 23andMe. But the fact that 20, 30 percent of 23andMe is non-European, that makes us the largest in the world of non-European genetic studies.

So, there’s things that we can do that absolutely will attract and encourage certain populations to come in. And I think that’s something that’s more and more of a priority for 23andMe is to make sure that we’re attracting not just a European population, but a very broad population.

And just to emphasize, I think people don’t realize. In some ways, studying Africa is one of the most important and exciting opportunities in genetics, because there’s more diversity in Africa than there is in the rest of the world. And so, there’s going to be a tremendous number of really interesting genetic insights that come from there.

So, we’re reaching a point — There’s been all kinds of challenges before with the complexity of studying different populations. But we’re getting to a point where we actually really have that opportunity to do a lot more in every population. And we think about ourselves even as we put out a report, how do we hold ourselves to a bar that we’re not just putting out content for a European population, but putting out content for all different communities?

Alexandra Eitel: I’d like to go back to what you were saying about marketing and how it wasn’t initially a huge focus. And in 2013, you unexpectedly got a note from the FDA to discontinue marketing of the tests. We do a lot of crisis management case studies here at the GSB. And I’m curious, if you did, who was your first call, and what advice did they have for you?

Anne Wojcicki: Good question. So, it’s definitely one of the parts — When I speak at Rob Siegel’s class, it’s one of the key things. I love him asking the students, “Was it Silicon Valley arrogance or ineptitude?” And I love always hearing people talk about us. And I just did another talk, the innovator’s dilemma, where also there’s really this sense is like, “Oh, you were so inept.” And so, what people don’t realize on 23andMe, we did get a warning letter I’m almost proud to say. It was one of the most well-read warning letters ever. And partly, it was an unusual warning letter because it was so angry.

What’s interesting is when 23andMe was started, like I said, we were very academic. Because we were academic, we hired Joanna Mountain who came from Stanford. She was an assistant professor here. We had an IRB. We thought through a lot. We engaged with ethics like Hank Greely who still doesn’t really love us, but we engaged with him. I come from an academic background. I love debate. Tell more what can I do, where am I wrong. So, we totally engaged.

And one of the first people we had called was David Kessler, who was the former commissioner of the FDA. So, he’s clearly very experienced. He was a professor at UCSF. And he pulled together his whole team, his senior advisors from when he was in the administration. And we sat down and we’re like, are we a medical device? And we really debated this. It was a whole debate with his team, like what are we? And concluded, we’re not a medical device.

And in those early days, it was kind of a question. You have a right to own your genome. It’s your data. Like the same way you have a right to look in a mirror. That’s your image. You have the right to have it. So, you have the right to have your genome. And in my mind, all I was doing was connecting you to publicly available literature. That seemed totally reasonable.

So, in those early days, we concluded we’re not a medical device. And then we even met with people like von Eschenbach, who was actually the FDA commissioner at the time, and he was super clear, “You are not a medical device, and we will not be touching you and regulating you.”

And one thing that was a political wake up call and just a company wake up call is that when Obama came into office, that changes everything. And the leadership of the FDA changed, and they said, “No, you are not outside of our rein of regulation. We are going to regulate you.” And so, it was an overnight kind of shift. We had just been told for years that we were not going to be regulated. And then it became very clear, “You’re not just going to be regulated, but we’re coming now.”

So, I got the letter on a Friday, and then I had the weekend to think about it. And my typical stance, it was like, oh, it’s not such a big deal. And then they made the letter public. And Kessler called me. And he called me, and he said, “Anne, I know you, and I know you’re not paying attention. And I’m telling you now that it’s a big deal.” The company really had to pivot.

And I had no shortage of people — There was a article Fortune wrote called 23andStupid. I had no shortage of people, like well-known geneticists, who were like, “It’s time for you to step back and let us clean up your mess.” No shortage of people who loved to come and be like, the woman with no degree is really screwing up the industry.

And I had one really great mentor, and it was a regulator, also a woman, who said, “Anne, you have two choices. Do you want to sell the company?” I was like, “No.” She’s like, “Well then, you put your head down and you just do the work. Get the work done.” She’s like, “But I’m telling you now, it’s going to take you 5 to 10 years.” And we were lucky because we had cash, we had that ability. I found an amazing leader to do it. And frankly, it was the best thing for the company because I think one of the most important things 23andMe has proven out is that consumers actually can get genetic information.

And most healthcare providers, I would say, tend to assume that you’re not capable of changing your behavior or understanding complicated information. And we have now successfully really proven out that you can understand really complex concepts. And we had to prove to the FDA that at a certain grade level, over 90 percent could pass, actually, tests. And we had to prove that with our reports they can do that, and we did.

And we now have 6, 7 FDA authorizations. We’re the only ones who have gone down this whole path. And I feel like we — when I think about us as advocates, like 23andMe as an activist brand, we’re advocates for consumers and proving out that you are far more capable of taking care of yourself than the healthcare system today believes.

Alexandra Eitel: And as you’ve just described, healthcare is obviously a heavily regulated industry. And many of us will be going into other heavily regulated industries, whether it’s healthcare or fintech or what have you. I’m curious. Obviously, you had some great conversations and some great points of contact, but what was the best and maybe worst advice that you got around regulation?

Anne Wojcicki: Well, it’s interesting. The night before I got my FDA warning letter, I was actually at a healthcare political dinner. I won’t say which group. But it was like a group, and they were like, “Anne, you’re getting so stale. You should do something more crazy.” And I just want to say, that was a group of healthcare regulators, et cetera, who were like, “You got to keep pushing boundaries.” And then the next day I got my warning letter. So, clearly that team was pushing in the wrong direction.

I mean, look, I think the number one thing that — The best advice we got when we had our letter was you know you’re on the right side of history. And so, it’s just a matter of time. So, one thing I remind people in the company is that when we started 23andMe, gay marriage was illegal. So, the world does change, and it changes because of advocacy, because of people rising up, and also because of data. So, when people ask, “How did 23andMe convince the FDA?” We convinced them with data. We went head-to-head with their arguments and we’re like, we’re going to prove out that we are accurate, that people can get it.

So, I think the most important advice for people is knowing that whatever the laws are now or whatever the regulations are, things can change. And society is constantly changing, but you have to put together the right kind of package and the right data and the right support to drive that change. But it’s totally mutable.

Alexandra Eitel: One obvious big societal change in the past three years has been the pandemic. And I’m curious how COVID-19 has informed your strategy for how 23andMe can engage in potentially future health crises.

Anne Wojcicki: Well, I think what was interesting during the pandemic is because we have millions of people who are consented for research who are part of it, very rapidly we were able to put out a questionnaire to customers and collect hundreds of thousands, and now I think we have 1.5 million people who’ve taken our COVID survey. So, very quickly we were able to actually do research on why are some people getting so sick, why are some people not getting sick.

Even now I’m fascinated. There must be genetics about why some people — some people must be genetically resistant. And you see that with things like HIV. HIV, there’s actually a mutation where people are resistant to getting it. So, we have the ability to very quickly survey millions of people and get information about them. So, in this day and age, it’s remarkable that there’s no nationwide surveillance system for public health, and we have that ability now to really do that.

Alexandra Eitel: Another aspect of COVID that changed how leaders interact was — I heard a lot of CEOs having text chats or email exchanges with other business leaders. And I’m curious how you potentially leaned on other business leaders and what kind of maybe business community that you formed.

Anne Wojcicki: I mean, in some ways it’s been nice. I never had really the CEO business community before. But I feel like there’s now where I do see more CEOs and we all have that same pain point of like, it’s really hard. And specifically, right now it’s really hard. It’s a really tight job market, so people all want a lot more money. Return to office is super complicated. Is it hybrid? Is it in person? Everyone wants something different. And then the stock market has really collapsed.

And so, there’s just a tremendous amount of uncertainty. And also, how do you develop culture in a Zoom environment? You can’t. You all saw what it was like going to school in a Zoom environment. It’s not fun. And so, having your office be a Zoom environment is also not fun. So, I think it’s super complicated.

So, right now, it’s actually really — it is fun. It’s kind of relieving with other — So, you know how it used to be like none of us really know what to do. And so, there’s comfort when you know we all have that pain of it’s hard, and all the market dynamic. Everything is about being redefined. Work environments are never going to be the same. And so, how do you really have a hybrid environment? So, that’s been the number one, I think, for me.

And even at different policies, talking to companies about what are you doing for return to office, or are people coming in. How do you manage vaccinations? Everything has been nonstop of helping manage. And then also we’ve had all kinds of social unrest. So, also then how do you manage George Floyd, and now you have Roe v. Wade. All of political issues are also now really rising up to really occupy people’s minds. So, how do you actually also have a company and in the background have such political issues? So, I do think that has the world’s gotten more complicated, there’s been more bonding over — It’s complicated.

Alexandra Eitel: Yeah. So much of what we learn at the GSB is around collaboration and doing projects together and everything, so I think that’s really nice to hear that that continues even when you’re at the top.

Anne Wojcicki: Yeah. I mean, I think it’s important to always reach out. I mean, I think that’s one thing I just always — And I have to say, LinkedIn is amazing in this capacity. It’s so easy to connect with people now and it’s so lovely to go cross industry. So, I do think that people are particularly interested. It’s so dynamic right now. People are particularly interested in hearing different viewpoints. So, I do think it’s a particularly receptive time.

Alexandra Eitel: You mentioned company culture, briefly. And every single guest that we’ve had on stage has talked about company culture. It’s obviously very important. And how are you intentional about setting the culture at 23andMe?

Anne Wojcicki: Well, I had, coming from Wall Street — And again, I lived in Wall Street during the craziest era: ’99, 2000. Most of you probably don’t remember this, but it was really-

Alexandra Eitel: Wolf of Wall Street.

Anne Wojcicki: Oh yeah, for sure. I mean, there’s experiences when I see that, or even when I watch Billions, I was like — So, parts of Billions are based on real experiences. There was one episode I was watching. I was like, “I remember when that happened.” And they got down to the specifics of specific trades, like trades and information. It was a totally crazy time. So, in some ways, having that experience, I learned a lot of things of what not to do. And I have one boss who is in jail.

Alexandra Eitel: That’s a good start. Okay.

Anne Wojcicki: So, I always say. I was like, well, there’s no better way to experience what not to do than living that. And I had another boss who would get so angry and would slam phones into the wall. And so, it was also an interesting time watching Google start and Google being really fun. It was super supportive. It was really quirky. They hired my sister when she was pregnant. People wore whatever they wanted. They were always rollerblading. Sergey and Larry were always rollerblading into meetings.

So, it opened up the door. I do credit them. They opened up the door for having different types of cultures. And I’ve never been a person who like veneers. I have this issue. I really hate things that are fake. And I don’t like commercials for that reason, and I don’t like a plastic office place where everyone’s dressed up nicely. I feel like it’s a veneer. So, having a culture that was authentic was really important to me. And having a culture where people felt really comfortable, and you had diversity. We’re a genetics company. We support diversity. The world is amazing because of diversity. So, we want to support diversity.

I have always said, and I realize this with myself, is like you hire extraordinary people, but extraordinary people are not extraordinary every day. And so, we’re a team. And so, for that reason, if you get sick, someone can cover for you. Or if you’re just having a bad month, it doesn’t sink everything. Then people don’t get mad at you. We are a true team.

And so, I’ve always wanted to have a culture where we have extraordinary people, but it’s truly supportive, and we have this diversity. And kind of like an academic environment, you’re always learning. You have this humility of like, I know nothing. I still to this day feel like I know nothing. I’m always just trying to learn. And I look at my scientists and others. That humility is just so important.

So, when I think about culture, it was really about authenticity and truly supportive. If I want to hire people and have them with me for 10 or 15 years, you have to be flexible with work life balance, you have to be flexible as people have other issues, so a real balanced environment. And one that was really — hire humble people who are super eager to learn from each other. And for that reason, I have really great marketing people who knew nothing about therapeutics, and therapeutics people who know nothing about CAC to LTV. It’s so interesting to learn.

And so, I always tell people, “Join 23andMe, and you should take advantage of the fact that you’re constantly learning really interesting different things.” So, culture for me I think has to be really intentional. And I think it’s really important for me to have a positive culture where it’s supportive. And I’m really proud of the number of people who have left 23andMe and gone off to start companies, especially a huge number of women who’ve done it. And they, again, also are really focused on creating a positive culture. So, it spreads.

Alexandra Eitel: Is there maybe a little specific norm or practice that you think represents the culture well, something you guys do?

Anne Wojcicki: We’re very focused on exercise. So, I never dress like this. It was like a big debate for me, like do I wear my shorts? So, I wear shorts, t-shirts, and my running shoes every day. And I totally terrorize people who take the elevator. And I wanted to put up the sign — So, there was a study that came out about, hey, you’re sitting in the elevator. But if you had just walked up those stairs, it would’ve added 30 seconds to your life.

So, I just think, for me, exercise and health, for me it’s like walk the walk. We have good food. It’s healthy. We don’t have soda. We have lots of fitness classes. I have a huge number of people — We have a very intense workout culture. So, we have intro to working out and then more of the advanced. We have lots of yoga. I do lots of yoga meetings. We’ll put the notes on the floor and then you downward dog and you read your notes. Hold one hand, you’re in plank. I mean, I think you can-

Alexandra Eitel: [I think balancing] —

Anne Wojcicki: Yeah, you can be super creative with that. But I would say I think a hallmark of our culture is the authenticity. You can be you, and you don’t have to — there’s no veneer that you’re trying to put on. And the best thing about being authentic, too, is you make mistakes all the time, and then people, frankly, I think trust you more when you make mistakes.

Alexandra Eitel: Yeah, absolutely. Well, so, many of us here are in healthcare, but many of us are not. So, I’m curious from your perspective, what is a trend in healthcare today that we should all be aware of?

Anne Wojcicki: Well, I think the trend that’s hard to ignore is the rise of virtual. So, when I first went to Health 2.0, it was a scary set of companies. I mean, this is probably 12, 13 years ago. It just was not starting it. It was just not starting it. And even pre-pandemic, we used to meet with all kinds of companies that were virtual pharmacy or virtual telemedicine, and it was such a niche. And 23andMe had talked about should we get involved in these areas. And I was like, the last thing we need to do is pioneer another whole path.

But the reality is, pandemic made virtual a requirement. Overnight you had to start using virtual care. And pharmacies and laws changed. So, I mean, there was an incredible opportunity. This is an example where regulation really changed and it opened up a huge sector. So, virtual is really interesting.

The thing I point on is almost all of these virtual companies are focused on employer and health plan-based care. And that, to me, always feel odd. If you go and you join Amazon for two years and you’re prediabetic and you have a program, why do you lose access to that program if you change jobs? Why your healthcare is with your employer really doesn’t make sense to me. So, part of what we’ve always tried to do is create a world that you control that’s outside of the system.

And I would another trend is that more and more is truly going towards your own empowerment. There’s an act called 21st Century Cures that empowers you to be able to get access to all of your health records and move them around. And they’re not making fully easy yet, but it’s coming where you should be able to own all of your records. But there’s also now price transparency. There are really interesting companies now surfacing that you can actually know, if you need to and get a mammogram, what does it cost.

So, in the past, I would call around and try to get direct-to-consumer pricing for something, and it was impossible. And now it’s actually like these laws are in place to actually force it.

So, I’m a huge proponent. I think there are really exciting direct-to-consumer worlds. And most companies are still focused on employer and I would say or like the Medicare populations. But I would say that there’s a huge opportunity on direct-to-consumer. It’s just harder, because I think there is a real shift that people have to get educated on.

And I think one thing, again, just to emphasize on healthcare. And again, privacy is top of mind for lots of people. People don’t realize that if your insurance company pays for you to do a procedure or something, they then know that, and they own that information. So, if you don’t want your physician or your insurance company to know something, then you should self-pay.

And so, again, 23andMe I would say is proudly not HIPAA compliant because it actually forces us to get your real consent versus HIPAA now. Frankly even, I’m always criticizing Stanford for this, you don’t have a way of opting out of their HIPAA form. So, that means they can take — I just went to a doctor the other day, and they mandate taking your picture, and you have to sign a consent for that they can do anything they want with it. Really? Could you imagine that if Facebook’s like, I’m going to take your picture, and then I have the ability to do anything I want with it, and you have to consent for that? That’s outrage.

So, I do think privacy in healthcare, people don’t fully understand it. And you have GDPR and the California Privacy Act that’s happened for the tech companies. But I think there’s going to be a change at some point in healthcare. People just haven’t woken up to it yet. But there’s a really terrifying world of how everything, all your health information is shared that you just don’t know about.

Alexandra Eitel: That’s very helpful advice. And speaking of advice, half of us in this auditorium are actually graduating in three weeks, including myself.

Anne Wojcicki: Wow.

Alexandra Eitel: And many of us have been considering or are going to be pivoting their careers. You’ve pivoted a few times, and I’m curious what lessons you have to share with us.

Anne Wojcicki: I think pivoting is the best thing ever. I mean, it’s so interesting to learn different areas. I don’t know if you knew Larry Lessig who used to be at Stanford who ran Internet law. And then he was just like one day, “I want to learn about corruption.” And he moved to Harvard and he’s like, “I’m going to become an expert in corruption.” It’s so great. To do the same thing all the time is just boring. So, to do totally different things — The world is so interesting. You should absolutely keep pushing yourself to pivot and do interesting things.

I mean, I try to keep most people at 23andMe. But when someone’s actually been there for a while and they want to try something else, I’m like, “Yeah, you should quit and do something new.” The world is so interesting. Never shortchange yourself on going and exploring. You guys are all super — I mean, an amazing talent pool. Everyone can go and interesting jobs. You owe it to yourself to go and have that exploration of totally different types of careers.

And frankly, I feel grateful to my parents who when we graduated college, there was no push to go and get a single job. I worked as a nanny. I temped. I worked in all kinds of different random areas. And all of those experiences were super helpful of knowing what you really want.

And even obviously Wall Street was just a short term for me, and I think I’ll be at 23andMe for a while. But I have this luxury of I’m always doing different things with 23andMe. I’m now in drug discovery more. And then personally, I do all these real estate projects at home in Los Altos. That’s super interesting. So, I totally encourage, keep pivoting. And every experience adds up. And you never know when an experience is going to be valuable. And if it’s not interesting, then quit.

Alexandra Eitel: Great. Well, that was definitely an answer I needed to hear, so thank you.

Anne Wojcicki: Definitely.

Alexandra Eitel: Well, thank you, Anne. I deeply admire the conviction that you’ve had throughout your entire career. And I know all of us here are excited to see how you and 23andMe will continue to change the world. And I have more questions. But I know we have some questions in the audience, so I’d like to turn it over to them.

Anne Wojcicki: Great.

Neil Rens: Hi. My name’s Neil Rens. I’m a medical student and business student here. And I’m curious how you think about balancing data privacy, patient privacy, with sharing information in a way that advances scientific progress.

Anne Wojcicki: I love the privacy questions. Because, again, I think that what I found is that most people actually want to participate in research. So, when we started the company, it was hypothesized people don’t actually want to participate in research. It was almost this mindset of a clinical trial, like get them to come in and consent for everything because you never know if you’ll be able to really get anything else.

And I looked at things like Susan G. Komen and Livestrong and all this enthusiasm to do walks. People really actually want to make a difference. And even bone marrow drives and such. And I go again to some of these human subject consent forms where they don’t return information back to individuals, and frankly, I find them super insulting. Like it’s the paternalistic side. You think I’m not capable of getting this information? And just to level set with people, there’s a JAMA study from I think 1960 where they asked physicians whether or not they would tell a patient that they had cancer, and 90 percent of physicians said they would not tell their patient.

So, the world has really evolved, and it’s come a long ways. And I think it’s kudos to the medical world for evolving. But I think that we can absolutely do more with looking at individuals as a responsible individual who can handle their information in more as a partnership. And so, right now a lot of healthcare providers and insurance companies and Epic, they all use HIPAA as a way to not let a consumer share their information.

There’s always these concerns like, oh, a consumer might get their medical records and then accidentally share it in the wrong way, do the wrong things with it, or it might be too much information for them. There’s a very paternalistic take on it. And I’ve just always felt like you should be entitled to your information, and then put it on the individual. If you want to share it in your ways, allow you to share it.

So, to answer your question specifically, I think that there should be transparency and I think there should be choice. That’s the hallmark of everything 23andMe does is I’m fiercely independent, and I never want someone telling me what to do. And the last thing I want someone tell — my healthcare provider should not be telling me what to do. Give me the information and I will make my own decisions.

80 percent of our customers opt into research. It’s not even like they have to click out of it. They’re electing to opt into research. So, I would argue that even more people would opt into research if it was given a choice. And that was my point with Stanford. Why aren’t I giving a choice of actually opting in or opting out? Why do I have to be part of it? And so, I do think that choice and transparency is actually how you build trust, and I think a lot of consumers actually really want to be part of it. But also, one more thing I would put on you is people should have the right to know the results. So, if you participated in a study, tell people what came out of that study. Most people participate in a clinical trial, and they have no idea what happened. Isn’t that crazy? Again, I find it totally insulting. Don’t treat me like a human subject; treat me like a partner.

Harshit: Hi, I’m Harshit and I’m from India. I’m studying business here. I want to understand how you have used or maybe how you have insights from genetics on racial inequality.

Anne Wojcicki: Yeah. I mean, looking at diversity — There’s lots of complexity to your question. I would say a couple things. One, when we started 23andMe, we never expected that we were going to be in the dialogue about race. We got into it for research and all these things, and suddenly we’re about redefining race.

We had one really interesting publication where we asked people the definition of African-American. And you can see how people in the South might have ten percent African DNA and they do not identify as African-American, and you have people in Seattle who have zero percentage African DNA and they identify as African-American. So, even defining what you are and your environment, it’s super complicated. So, there’s absolutely aspects that I think 23andMe can have an impact on by helping understand genetic ancestry and likelihood to respond to medication or likelihood to have an issue.

So, for instance, there’s someone named Carlos Bustamante at UCSF, and he does phenomenal research in the Latino population in asthma. And he has seen, there’s certain medications that people should never take in the Latino population. But why are they prescribed? And you have another example where in Hawaii, the state of Hawaii does not allow the sale of Plavix. Plavix, again, it’s well known. It’s an anticlotting drug. And it’s because so many people in the state don’t respond to the medication.

Again, racial and health inequity is a huge issue. But I think one thing that you can actually start to do is really understand, not racial profiling people, but really understand your genetic ancestry and what the mutations are that you have, and then whether or not you have a predisposition for a condition and should you be managed in a different way, or whether or not you have a predisposition to not respond or likely to respond to a medication.

So, I do think there’s a ton of opportunity to have improvement. And again, racial profiling is the only — the last area where it’s acceptable is in healthcare. It’s the first line of every medical record. 45-year-old white male comes in. That’s something I think that we actually really have the opportunity of changing.

Male Voice: Hi, how’s it going? My name is [Unintelligible] so, I’m the MBA student.

Anne Wojcicki: Ohh, I love it.

Male Voice: I worked in a Huntington’s disease clinic for a year before medical school. And a lot of times the genetic results [that they would get was] some of the most devastating news they could ever hear in their entire life. And how would you respond to people who believe 23andMe should have a more thorough informed consent process before releasing information about BRCA1 mutations, for instance? And then do you foresee a future where people might push to have patients act on some of the information they receive, and how are you preparing for that once those treatments are available?

Anne Wojcicki: Yeah. So again, it goes to some of the paternalistic questions. I think that you can absolutely have a great informed consent online. And I think that’s the kind of thing it’s like it should not be a debate. It’s about data. Generate data where you ask people to fill out the outline consent, and then you ask them to go through counseling, and then you have them answer those questions, like can you understand it? So, we’ve done a lot of work about are people understanding what they are getting. So, I would argue that having an online consent and making sure is potentially even better.

So, for instance, 23andMe has a — you go through a number of consents. You can’t sign up accidentally. It’s a hard process. Reports like the Alzheimer’s, BRCA for breast cancer, are behind an additional layer of consent. So, you have to click through. And there’s a video that talks about what potentially happens. There are all kinds of resources about like, hey, here’s the information you might learn. This is what to expect. And we see, people pause on health. And not everyone wants to know health.

And to your point on Huntington’s, the information is real. It’s meaningful for people. But Huntington’s is a slightly different story because you can’t do anything about it. Versus in BRCA, at a certain age you can. You can find out that you are high risk and get a prophylactic mastectomy and varicotomy. And we’ve seen people. We have thousands of customers who have now gotten this. And we can see that 20 to 30 percent of our customers never would’ve qualified under existing insurance guidelines.

So, I would argue that healthcare has huge limitations because we have not enabled broad access. And so, saying that you can’t get this information until you have a one-to-one in person interaction only puts up barriers to access. For me, also, the fundamental premise — and I actually learned this. I would spend a lot of time investing in India. Healthcare will never be accessible to all if it’s dependent upon a one-to-one interaction. That right there should be a good concept for all of you to run on. You can’t really improve care for people unless we find ways to automate it more and more. And so, that has to happen.

And the first company I ever invested in — talk about things that were too early — it was a pap smear company called Neuromedical. And it was one of the first AI companies that I’d ever seen. This is back in 1996. And they would take pap smears, the majority of which are normal, and they’d run them through the machine, and then they would isolate, here’s the top 20 percent that we need a pathologist to look at. And the company got taken down by the pathologists, like how dare you automate our job? But the reality is, you can’t have scalable solutions in healthcare if you don’t have automation in some ways.

I ask my kids sometimes. All of you here, you probably don’t remember. When I was little and I wanted to book a hotel in Paris, I had to set my alarm and wake up and call and talk to a human. That’s how it worked. And now we’re all totally spoiled. You go online; you can just book. It’s all automated. We never talk to people. And so, healthcare has to go more and more in that direction, and then save the really expensive precious resources for people who really, really need care.

Alexandra Eitel: We have time for one more.

Brianna: Hi, I’m Brianna. I’m a geneticist and actually a law student here. And so, talking about privacy and consent, the thing that’s different about genetic information, it’s not just about you; it’s about your family. So, how do you think about your responsibility for community consent or familial consent and community and familial understanding of the data that you collect?

Anne Wojcicki: Yeah. That’s a great question, and it’s a huge complexity here. So, we have gone with the hypothesis like it’s your DNA, it’s your right to learn about yourself, but there are absolutely consequences. And so, for instance, your mother might not want to learn if she’s a carrier for BRCA. And you could get tested and find out that you have two copies. And therefore, it’s a hundred percent [determined] your mother has it. And we’ve seen that instance.

And we see this — I would say what’s interesting — again, I love all the MDs in here. And it would be super fun; we should chat more later. We don’t get lots of consternation and concern about health reports. Our customers we find are mostly — they’re okay. A BRCA report is not fun to get, but they can handle all this information, and we’ve proven that now in spades. The part that no one anticipates is that their parent is not their parent, or their sibling is not their sibling. If you have access to your genetic information, you’re going to learn things about your entire family.

And so, I don’t think that there’s a realistic world of group consent. I think the reality is you own the right to your own body, but we absolutely try to educate people that your information has consequences. But I would say no one ever thinks it’s them that is not related to a family member. And we have an additional consent form. That is just always a surprise for people.

But it’s a very real and very tricky aspect of 23andMe is that you’re not just related to your immediate family. This whole room is genetically connected. You could probably take some percentage of this room and connect everybody. In some ways, there’s the inspiring part for research in that we really are all in this together.

So, if you want to solve the mystery of the human genome and you want to solve the genetics of various disease and what does it really mean to be well, it is within the power of all of us coming together. But there absolutely has to be some of the ethics and the consent of how are we actually all getting together. And that’s where I said, there’s — And Stanford is a lot like Hank who is, again, engaged with us quite a bit. But there’s really interesting questions around this, around ethics.

And that’s why, again, I’m eternally grateful to Joanna Mountain. When she came from Stanford, she was absolutely a thought leader in ethics. And when I always think about the difference between 23andMe and other companies, Facebook didn’t start with a consent form. I know they have a research team and other things, but there’s no consent that’s part of it. 23andMe from day one had consent and engaged with ethicists and really thought through and recognized there’s consequences.

The guiding principle for 23andMe is transparency and choice. And whether it’s like transparency in yourself, it’s like choice whether you want to get your genetic information, choice if you want to participate in research, choice if you don’t want to do all these things. And I think that’s one of the issues I have in healthcare. It’s like most times you’re not provided choice and you’re not provided transparency.

Alexandra Eitel: Well, thank you, Anne, for your leadership and your wisdom, and thank you all for coming. That concludes View From The Top.

You’ve been listening to View From The Top, The Podcast, a production of Stanford Graduate School of Business. This interview was conducted by me, Alexandra Eitel of the MBA Class of 2022. Lily Sloane composed our theme music. Michael Reilly and Jenny Luna produced this episode. You can find more episodes of this podcast at our website www.gsb.stanford.edu. Follow us on social media @stanfordgsb.