Startup Foundations: Interview with Tara Viswanathan

Tara Viswanathan is the co-founder and CEO of Rupa Health, a health startup focused on expanding the access to root cause medicine, and modernizing the process of ordering specialty labwork.

Tara talked to us about what exactly is root cause medicine and why is it central for Rupa Health’s mission. We discuss how the healthcare and pharmaceutical industry has evolved and what are the current challenges for healthcare practitioners.

Tara shares her thoughts regarding chronic illnesses and talks about why they are currently the biggest danger to our health. We also discuss Americans’ nutrition and dietary habits, gut biome issues and novel treatments and why taking a lot of prescription drugs can have adversary effects on people’s health.

Greg: Thanks for joining us on the show, Tara. Tell us what you're working on at Rupa Health

Tara: At Rupa, our mission is to bring root cause medicine to every person on the planet. And what root cause medicine is, instead of going to the doctor and getting your symptoms treated with prescriptions and not actually ever feeling better, it's how do we actually get to and solve the root cause of an illness? And so the way that is manifesting in the world through Rupa and our first product, is actually a platform for physicians where they can order, and get access to, and get educated on over 3000 different advanced and specialty lab tests.

G: So with regards to how you work with physicians, do they know your mission? Or are you just the lab fulfillment provider?

T: Great, great question. They do know our mission. We are so close to our practitioners, we call the practitioners because they can actually be anybody who is licensed to order a lab test. So acupuncturists, chiropractic, naturopathic doctors, and of course, MDs and DOs as well.

And so our practitioners, they text me, they call me, we are very close to them. They know why we're on this mission. We had actually built out a clinic for practitioners and patients before we unbundled the labs piece and launched that as its own product.

G: When people think about side effects from medicines, I mean I know there's a lot of things in the media about side effects from COVID vaccines, but they were way, way safer than some of the treatments that are more commonly prescribed. I know side effects from IUDs, it's something like a 30% incidence rate, not a sub 1% incidence rate. And so if someone's on a lot of medicines, is it possible that taking some combo of five prescription medicines might be creating new symptoms for which they need more prescription medicine?

T: Yeah, we're seeing that all the time. And here's actually been happening, and here's the shift. So in the 19th and early 20th century, the biggest threat to life was bacterial and infectious diseases. Imagine right? It's this invisible thing that is just mysteriously killing your friends and family. And we had no idea what it was, how to solve it, any of that. Then when we discovered, not we, as humanity, discovered penicillin, it was a complete game changer. So penicillin was the start of our pharmaceutical industry. And so what that allowed now is you could take this magic medicine and you didn't have to die anymore. And that revolutionized healthcare. It really did. Our lifespan more than doubled after that. And it's because we weren't dying from these infectious and bacterial diseases.

And so if we think about what was happening, the disease was infectious and bacterial, and the root cause of that was an infection, was a bacteria. And so what penicillin and antibiotics actually did was it went and attacked the root cause of that illness, which was let's go kill this bacteria. And we killed that bacteria. And it truly solved the root cause.

Then the pharmaceutical industry was born and what ended up happening as one of the results of our increasing lifespan, increasing age, and many other factors, but to simplify it, that's one of them. One of the things that happened is, the greatest threat to human life today is not infectious diseases, it's actually chronic illness. And right now every other person in America is dealing with at least one chronic illness, which is absolutely wild. I think, it's something like a third people are dealing with at least two, which is crazy to me.

And if we think about what the root cause of chronic illness is, so when we think about chronic illnesses, it's anything that is prolonged every year. It's like IBS, diabetes, things like that, heart disease. The root cause of chronic illness is not a bacteria or a virus, it's actually many things. It is more lifestyle-based, and it is also genetic. It is many things. And so with a multifactorial input in terms of what causes a chronic illness, it's not as simple to just create a pill to solve the root cause. So what we've started doing is creating pharmaceuticals to alleviate the symptoms, which is very different from solving the root cause and actually eliminating the chronic illness.

So this shift that we're seeing happen towards personalized root cause care, is people feeling like they're not truly getting solutions for their illnesses and they're living with their chronic illnesses. And so this movement that's happening that we are powering at Rupa is helping physicians and practitioners get to that root cause by using advanced lab testing. So things like genetic profiles, epigenetic profiles, advanced hormone tests, nutritional panels, things like that. And so that's what's happening. Right now, the average American is on 12 prescriptions a year. That's the average American.

The idea that mental health is separate from physical health, it is archaic now. Hopefully we are starting to enter this phase where what we're seeing is that mental health is very, very much connected to physical health. And it's wild that we for so long have separated the two and go to a psychiatrist. And the standard today is there's no communication about your microbiome or your nutrition or any of these other factors.

And so I want to make it clear that personalized root cause medicine is absolutely not against pharmaceuticals by any means. It's a tool in the toolkit. But we now have many, many more tools. We now understand the human body so much better than we did even 10 years ago. And we have to realize that this stuff is new. The Human Microbiome Project was only completed in, I think, 2018. And we take it for granted that everybody knows what a microbiome is now. But five years ago that absolutely wasn't the case and was actually very controversial.

And so what's happening is medicine is changing. We now understand so much more of what happens inside the body, but what has been stagnating is the actual time it takes for medical learning and knowledge and science to get to patients. It takes on average, 14 years for that cycle to happen. And I think what people are saying now is that's too long. We want shorter cycles. And so now I think there's a book called The Patient Will See You Now, and it's a tongue in cheek comment on how medicine is really driven by the patient now and their care coordination and owning their health. And so a lot of this movement, this personalized root cause medicine movement is driven by patients.

G: So let's go back to the beginning of Rupa Health. How did you meet your founding team? How'd you get the idea? How'd you decide to go all in and quit your job and do this?

T: Oh my gosh, so much to unpack here, right? It's a massive life decision. I think the short answer, and I've talked about this a bit on other podcasts even on our Rupa of blog, is that I experienced what it was firsthand to be sick and not get results through the conventional system, and realized there needed to be a change. And as did my mom. And it was really when my mom got sick. And my dad, who was the most incredible western medicine doctor, conventional medicine doctor, he was a surgeon in India and he came to the US and ran the pediatric ICU for over a million people single handedly, working 24/7 on call for 20 years. Just absolutely wild. I was the sickest I could be, I'd go see my dad. And he, and no other physician in her hometown, could help my mom.

And what ended up happening, and this is the longer story, but I had been working at a root cause medicine company, it was a clinic, a digital health clinic. And through what I'd learned there and talking to patients, reading their charts, things like that, I was working on product, I started seeing patterns, and I understood what might be going on with my mom. Huge fight with my dad. He said that he didn't believe in good bacteria or microbiome. I did some tests on my mom, my dad wouldn't order the tests. Many of those tests we have on Rupa now. And ultimately, we got her better using a root cause personalized approach.

And to me, it was so clear that this was the future. And again, this was in 2016, I believe, this was a while ago. But that was the moment where I realized we need to bring this to everybody. And the way to bring this to everybody is through infrastructure. And so that's what I said out to do, is I'm going to build the company that helps every person on the planet achieve a higher standard of living. And by that, I mean what it means truly be alive. And we're going to give everyone the opportunity that my mom had, because what if I hadn't been there? I don't know what would've happened to my mom.

And so to make a long story super short, I ended up quitting my job because I had conviction in this space, although it was very, very tiny at that point, it was a drop in the bucket. No one had heard of it. I knew how long it takes to really get a startup off the ground. It's not easy. And I wanted to be there when the market hit. And I wanted to be there with the right product. And so I had no money, I had no idea of the product, I just had strong conviction in the market. So I quit my job and started Rupa and I said, "You know what? If I find a co-founder, great. If I don't, I got to do this." So that's how I started.

How I found my co-founders, very different. I went to grad school at Stanford, and one of the classes that changed the trajectory of my life was this class called Designing for Better Health, where we worked with chronically ill patients and their physicians, to try to build lifestyle based solutions to their pre- diabetes and things like that. So it's how do we help them not become fully diabetic and have to lose a toe or whatever outcome was going to happen. And it really showed me the power of supporting patients through their lifestyle, behavior change and nutrition and things like that.

And I had graduated at that point, and I had come back to give a talk to the class, because I'd also TA'd that class and helped it get started. And it was so funny because the professor asked three people to come back and give a talk to the class. And one was someone at Verta Health, someone was someone at Omada Health, and then it was me, who I had no money, I had nothing. I just had an idea and I made a slide. And I remember driving down to Stanford being like, "What am I going to say? And I'm going to speak next to these really incredible digital health companies and who am I?"

And I gave this talk that was just about what I'd experienced working with different patients and seeing the results that they had that were truly life changing and the emotional experience of that. And I was so shocked. I was totally joking because I've a pretty ridiculous sense of humor. The person at Omada, [inaudible 00:24:51] were like, "Oh, and we're hiring, come chat with me afterwards." So I also was like, "Oh, and by the way, I'm hiring, come chat with me afterwards." And I was totally joking, but it was shocking when after the class ended, every single person in the class came up to me and said, "This is the company that we want to work for. I'm so inspired by this mission." And it just so happened that one of the people who came up to me, she followed up with me, ended up becoming my first employee, and then now is my co-founder.

I feel so indebted to her. At that point, she had already accepted an offer from a healthcare consulting job and I told her, "Hey Rosa, I don't know how we're going to make this work cause I have no money right now. I haven't raised any funding, but just trust me and let's figure this out." And I said, "I'll figure out a way to pay you when you come back from..." She was also doing an internship and also presenting her medical research around the world that summer. This was in May. I was like, "I'll figure out a way to pay you by August when you're back."

August comes, I don't have any money to pay her. I end up paying for her first rent check in San Francisco with my personal bank account. And that is just one of my favorite moments to look back on, because I should have known right then that this was someone special, someone willing to be in it with me and to be a true co-founder. For her to take that risk, turn down the job with no promise of anything other than I'll take care of you, with someone she'd met a week prior. She did it. And she's still here today, which is amazing.

Our other co-founder came on a bit later as our technical co-founder. We had actually met him at a root cause medicine conference a year prior. And then when we discovered our labs product, we needed someone to build it and we got reconnected with him. It was perfect timing. And he came on and he is been with us ever since.

G: How did you decide what to focus on early, and did you go through any pivots from your original product to what you actually have in market today?

T: Yeah, I don't know a single person who's not pivoted their way to product market fit. You know what I mean? You have to. You have to listen to your customers. And so I wouldn't say we had any strong pivots, it's not like we moved from one industry to another, but it was always growth in learning. So the first product we built was, and this is the product that I had in my mind when I first started, was a marketplace for root cause medicine providers. So it was how do you find people who actually treat you in a more holistic way, in a more whole person way? And there is so much patient demand for this, but people don't know where to go. And so the first product was Zocdoc for alternative holistic medicine providers. And that's what we ended up raising our precede off of.

Then for a variety of obvious reasons, that is a very difficult product to get off the ground. And I had no conviction that I was going to get product market fit. So we iterated into actually being a full service clinic. The idea behind the full service clinic was, hey, if we actually build the infrastructure for a clinic and run that and get practitioners on board, we are going to see what the problems are. Why is this so difficult to scale? How do we get it out to more people? And so the second product was actually our way of understanding the market a bit more. And through that second product, we realized the process of ordering lab tests, and reviewing the results, and explaining instructions to patients, because by the way, these aren't just go to Quest, get your blood drawn. This is I need a poop in a stool kit for three days, right? Or it's I need to pee five times a day on this card, and not eat bananas for two days prior or coconut or any of these other things. It's very complicated.

And so that process was horrible for practitioners. So we took that product out, we unbundled it from the clinic, wrapped it up in its own little packaging, and it took off. And I say product market fit is a lot being in love or meeting your person, it's like if you have to ask if you have it, if you have to say, "Hey, I wonder if we have product market fit?" Or if you say, "I wonder if this is my person." It's not your person, and you don't have product market fit. You just know.

G: It's an interesting way of putting it. Well tell us what's next. You raise the series A, what's next on the agenda and on your roadmap?

T: Oh my gosh, so much exciting stuff. I can't wait to share with the world. So to be totally honest, I can't share with the world yet, but our mission is to bring root cause medicine to every person on the planet. Today, to go see some of these doctors, it truly costs thousands of dollars. And so our goal is how do we provide tooling and infrastructure to basically produce the cost that it takes to experience this? And we are working with our practitioners to do that. Because right now, they do a detailed health intake form asking questions, everything from, were you a C-section or vaginal birth baby? Because that'll determine your microbiome as an adult. All the way to how are your sleep and stress over the last week, and what is your diet? And so they do an hour and a half long, generally speaking, intake visit where they're collecting all these data points and then processing that in their brain. And our goal is, how do we make that simpler? How do we make lab testing simpler? How do we all this?

So our goal over the next year, year and a half is to really meet this massive consumer demand that's happening. And it's pent up consumer demand for more holistic healthcare, because most of the options right now are unaffordable. So our goal is to build infrastructure to make it more affordable.

G: Going back to your co-founders, how did you decide how you split up equity and your roles on the company? I mean, I guess it was obvious for the technical CTO you brought on board, but...

T: Yeah, so the way we define equity was interesting, right? Because I started the company on my own, I put in my own personal money, I forego a salary for a couple years, and then one of our other co- founders took a very little salary, took a huge risk, was there for a couple years prior to other co- founders. So it was definitely not an equal, I don't know, I was going to say 50 50, but in this case there were three of us. So it was not an equal split, but it was a very well respectable split. And I think we felt really good about it. The process of splitting up equity will tell you a lot about your co-founders and how they handle it.

The way we did it was literally, we got a spreadsheet and we wrote a list of all of the factors that people consider when thinking about equity. So length of time there, experience, money in the company, experience in doing X, y, Z in the future, type of work that we can take on, all of that. And we had a list of our names and then we wrote what the reality was for each person, and it became very clear what the split should be after that. And there's so many emotions also, because when you do an equity grant, like sure vice versa, certain number of years, but people definitely feel like they have it upfront. And so it's an interesting exercise to go through, and I suggest people who are in early days of co-founding with somebody, have that discussion upfront rather than saving it for after you think about a product or after you incorporate the company, because it'll tell you a lot about who your co-founders really are and what motivates them.

G: What's something that you've learned that you wish you had known when you were first starting out? And if you can't limit it into just one thing, you can pick a few.

T: Oh man. Okay, let me try to limit it to one thing. Because I joke at the company that there's dog years of startups, where every hour feels like a day, every day feels like a week, every week feels like a month, every month feels like a year. And you just learn and grow so much. And so it's hard to put it into one.

I think if there's one thing that I wish I'd done more of is trust myself and listen to myself. I'm a first time founder, and I think I underestimated my own ability to know what was right for the company. And I look back and a lot of the pain, a lot of the stress, a lot of the anxiety would have gone away if I had just done what I believed was right for the company. Because while I might be a first time founder, I'm actually the only CEO in this position, in this company, in this market with these investors. There's only one of me, and I know all the inputs in a way that no one else does. And so trusting myself could save a lot of that back and forth and sleepless nights and heartache and things like that.

Greg Miaskiewicz: Right. Well thanks for joining us in the show and sharing what you're working on.

Tara Viswanathan: Thanks, Greg