Eren Bali of Carbon Health on public health, Covid vaccinations, and working as a unified society to problem solve

Hi, I'm Eric Ries. This is Out of the Crisis. It's been a long 18 months, hasn't it? And during that time, we have seen it again and again— unlikely people thrust into the spotlight for their work fighting the pandemic, and even more tirelessly working away out of the limelight. One such person is Eren Bali. However, if you went back in time and told Eren a few years ago that he would one day be at the center of one of the largest public health responses in history, I don't I don't think he would've believed you. Eren came to the US from Turkey to work at a Silicon Valley tech startup, which is actually where I first met him a few years ago. But now, as CEO and founder of Carbon Health, Eren is leading one of the fastest-growing healthcare startups. Carbon Health is a provider of low-cost health clinics across the country. As you'll hear, COVID arrived unexpectedly and directly on their doorstep. They had to decide whether and how to respond. What happened next was entirely unexpected, Even by those of us who've admired Eren for a long time. Carbon Health is now running some of the largest vaccination sites in California, most famously at Dodger Stadium in partnership with the city of Los Angeles. During the pandemic, Carbon Health fully reinvented themselves from an affordable care provider into a full-stack public health company. This raises the question, how did Eren go from building apps on top of Facebook to ensuring that hundreds of thousands of Americans got their vaccines? We've seen this story before, even on this podcast with stories like Curative. Why did a private company, a startup, wind up playing a vital role in the vaccination rollout? And what was it about Carbon Health that made them ready and able to step into this vital civic responsibility? What can this tell us about the future of public health, about public-private partnerships, and about the civic fabric that we all inhabit? In this conversation, Eren and I talked about his journey from a small town in Turkey to founding the education startup Udemy, also quite successful, to Carbon Health and eventually Carbon Health's vaccination efforts. Eren spoke openly about his growth as a founder and leader, as well as gave candid advice for future founders. His number one takeaway is one we have heard again and again: put the mission first, think long-term, and everything else will fall into place. Here's my conversation with Eren Bali.

My name is Eren Bali. I'm the founder and CEO of Carbon Health. We are a technology-enabled healthcare provider, and most recently we have been helping the vaccine rollout, and we run some of the largest mass vaccination sites in the country, including Dodger Stadium in Los Angeles. And before Carbon Health, I was the founder and CEO of Udemy, which is now the largest online education platform in the world.

Eren, thank you so much for coming on. How have you been? How's your family? How's your team? How have you been weathering the storm?

I think I have been doing fine because at Carbon, we have been really in the front lines of the pandemic. When you're very busy with something, it actually helps you stay strong. And I have 3 small toddlers, so I'm enjoying working from home quite a bit.

I know the feeling. So, share a little bit about your background. You've done some really, really interesting things in the tech industry, including going back to when we first met. But I also think, you know, it's not the usual path people would imagine to running a healthcare company. So, talk a little bit about your background. How did you first get into tech and come to Silicon Valley?

So, if we go really back, I was born in a small village in southeast part of Turkey. That's the kind of lowest income part of the country, which had a lot of accessibility issues. So I grew up where we had only one teacher for the entire school rotating between classes. Both healthcare and education access was really limited. So that was kind of, that was the '80s. And I was able to break out of it because I was very interested in mathematics and to everyone's surprise, ended up winning silver medal in International Math Olympiads, which was one of the first times somebody from the eastern part of Turkey had really participated and won a medal. But the main reason this happened in my mind was that access to internet really kind of made a big change in my life because even when you're in the place with lowest access to education, having access to other people online, mathematic problems, it allowed me to kind of self-study this in a way that would not be possible probably 10 years before. So, I studied computer science and mathematics in Turkey and then decided to create— start a platform which would allow everyone to be able to teach online. I was really inspired with platforms like YouTube and Blogger, and I thought somebody should have— should do the same thing for online education. And I started the company in Turkey first. That didn't work. I shut it down. We had to move to Silicon Valley. So it was a really long story. I guess it took 3, 4 years to get Udemy off the ground. But yes, I migrated from Turkey to Silicon Valley in 2010 and started Udemy. But before that, actually, there was this couple of years break where when Udemy did not work in Turkey, I met this Silicon Valley entrepreneur who wanted to build an online, like, speed dating, video-based speed dating application. So, we actually took the original live classroom application to convert into a live video dating application. So, that's how I came to Silicon Valley in the first place.

I remember SpeedDate. That's one of the very, very early companies that I was talking to Lean Startup about. What was that, 2009, 2010?

Yeah, I think it was 2009 and '10.

Yeah. Wow, that's a blast from the past. Say a little bit about what drove you to wanna come to Silicon Valley in the first place?

Honestly, I wasn't even aware of Silicon Valley or this whole concept of startups and tech companies. I'll be honest, like until 2005, I thought these were just websites built by some amateur hobbyists. So I was really interested in programming, design, development, but I didn't— I hadn't realized the kind of business aspect for a very, very long time. And when we started Udemy in Turkey in 2006 and 2007, so there was no funding available. Eventually, I started working at nights as a contract developer for Silicon Valley companies as a way to fund the project in Turkey. And then eventually, they asked me to come to Silicon Valley and maybe just work in person a little bit. And then while I was visiting Silicon Valley, I realized that there's this complete new world. of technology companies, their businesses, their professionals, they do things differently. So I got involved, I went back and forth, and eventually really I realized that to really build the vision we had for Udemy, we had to be in Silicon Valley.

What was it like the first time? I remember even just, I grew up in San Diego, so not nearly as far as Turkey. And yet even for me, the first time that I drove around Silicon Valley and saw the the headquarters of all the companies that I had had all these relationships with as a customer, as a developer. It was a profound thing. What was it like for you?

It was a very interesting experience as in it wasn't what I was thinking Silicon Valley is. I thought I would come and there would be these massive buildings, really like technological infrastructure and screens everywhere. So I was imagining it more of an Asian kind of Hong Kong type of city.

Almost like Blade Runner.

In my head, it was like Silicon Valley, and I came in and it was a bunch of kind of suburban houses.

Yeah, it's very boring.

Yeah, it was a lot more boring visually, but I loved the weather. I loved the fact that it wasn't intimidating. It was just a bunch of people, smart people, very welcoming, very open to people from other cultures. So I was surprised with how unintimidating it was for a newcomer. But I think I just quickly adapted and I realized it wasn't just about writing software, things like customer service, marketing, growth. Those ideas were becoming— they were very refreshing because those ideas are very unique to Silicon Valley, or at least back in the day, they were very unique to Silicon Valley.

Mm-hmm. How would you contrast the difference? I think one of the things that we who have the privilege of being here in America, in California, in Silicon Valley, we don't even see and appreciate the water that we swim in. So sometimes it takes an outsider with an outsider's eyes to help us understand what is distinctive about it. So what were those differences that caught your attention when you first immersed yourself in the ecosystem here?

I was really shocked with how collaborative the whole ecosystem was. I mean, I was observing our founder, CEO Simon. He would ask for help and they would meet us and just give us all the information we needed. So it was weird that like you could just literally ask help from anybody and they would try to help. And yeah, I think because I think most other countries have more of a kind of cynical approach to businesses and every company's thinking of each other as a competitor. So Silicon Valley just felt super open. And it also made me think that like there is the opportunity for people like for newcomers to come in and be successful there. But on the negative side, the whole world of raising money, investors, that part felt intimidating. So, like, there's definitely the feeling that you just sometimes you didn't belong. Like, when essentially I interacted with money, then I felt a little bit more like foreign. But when you talk to the people in the ecosystem starting companies, that was very open.

That's really interesting. And that is a common experience we hear from outsiders, that there's really 2 cultures of Silicon Valley. And when we get into the funding and financing of companies, that's really where the bias can come in. Was there a particular moment you remember or a particular story of just feeling like you didn't belong or someone treated you in a way that you look back now, you realize was about that difference?

I remember 2 things. One is occasionally we would sit down on the table, like the small talk is the hardest thing for immigrants. So you talk about the American sports and American sports are also very different than the rest of the world's sports.

Indeed.

We're trying to adapt that through Like that was always like a tough challenge for me to just be a part of, try to be a part of it. And I also, I mean, I'm still a man and I just also understand if you don't even enjoy sports, like those type of like small talk subjects were always like the most challenging. I would feel more stressed in the first couple minutes of a discussion. So, and the second thing is like occasionally a lot of people would assume I'm a technical, like CTO of a company. So, most people would make the assumption, like, that I'm not the CEO of the company even after we started Udemy.

Yeah, I've heard that story from a lot of folks. I'm sorry. You know, we actually have a lot of listeners of this podcast in Turkey. It's actually consistently one of the top countries for reasons I don't totally understand. But I'm curious, given that we have a lot of listeners from Turkey, if you have words of advice for them or if there's anything you'd you'd want them to know if there's the folks listening right now who hope to emulate your footsteps someday?

Yeah, I think most people from Turkey ask me whether they should move to Silicon Valley. Is that still a requirement? And my answer is really, it isn't. I think since 2005, a lot has changed. I mean, the reason we have so many listeners from Turkey is good proof that the information is more democratized at this point. So, you don't have to be physically in Silicon Valley or San Francisco to Honestly, get access to the best advice, and also the funding has also been democratized. I have made several investments in Turkey. I mean, when we first started, somebody had asked me in a conference whether they thought there would ever be a billion-dollar company from Turkey. Since then, Udemy had Udemy, which is I guess in fairness, I started Udemy in Silicon Valley formally, but it's still a five ten billion dollar company started by Turkish people. And then there were also two other companies. started in Turkey, which were multibillion-dollar exits. And there's another one, I think, which is on the path to be a $10 to $20 billion company. So I think the last 10 years, the Turkey ecosystem has— I guess the concept of Silicon Valley has been less about the physical location at this point and more about—

State of mind.

The state of mind industry we are in.

Yeah, that is a hard thing for folks who've never experienced it directly and who tend to mythologize this physical place. It's not like the sunshine and the low-rise buildings you were describing and the strip malls is the thing that makes it magical. It is a certain ethos about innovation and about people, and that kind of cross-cultural collaboration has been emulated now by people all over the world. I think that's actually an incredible positive development.

And I think, like, Eric, I think you've been a part of this idea that if you really democratize the advice and the methodology of starting companies and Everything else, funding and physical space and talent, those things are actually sold over time.

Yeah. Well, I appreciate you saying that. That certainly has been part of my mission now for a number of years. So, thank you. I got to ask you one question about Speed Dating. I'm really curious, you know, for now when founders encounter Lean Startup, you know, it's a famous old idea for most folks. And yet, when you were at Speed Date, you were the head of engineering there, I think. At a time, that was before the book had been published, before even Lean Startup was especially famous. What was it like to be on the receiving end of that advice at a time when it wasn't very popular?

I was actually, I remember actually the first time the Lean Startup ideas came and it immediately resonated with me because we had spent 18 months building the first version of Udemy in Turkey. Which was a live education platform for learning. And we spent all this time building, we obsessed about a lot of details and we launched it and we realized there's no way a live marketplace for online learning is going to work. Like literally after 18 months, in 10 days, it became obvious that by the time people schedule a session to participate, like we were losing 90% 5,000 people. And most people were really horrible at live teaching. And unfortunately, we did not have any resources to like do a take 2 of that. So I had to shut down the company, move to Silicon Valley full-time. And then we came to Silicon Valley and we launched the first version of Speed Date, I think in 7 days total.

Mm-hmm.

We had to raise some seed capital. I literally took the original Udemy live video platform converted to a live video dating application. In 7 days, we launched the application. Like, we literally did not have a forgot password button and the app had like a million bugs and issues, but we just launched it and started having users and iterated with the user feedback. So that was the polar opposite of what we had intuitively done in Turkey.

Mm-hmm.

And then I think that was right when I think you and Steve like had this ideas of iterating with customer feedback. So, to me, I just sucked in all that knowledge because back in the days, it was a very refreshing concept. At this point, I think it has been so mainstream, so people have seen it as the default.

Yeah.

So, back that time, it wasn't default. The default was spending 2 years trying to perfect an application and doing a big launch and demo day or I mean, TechCrunch, Disrupt, and the goal was that in the first day of launch, you would get so much press, you would get a bunch of customers, and then some of those customers would retain. That used to be the playbook back in the day.

Yeah, it's actually such a short time that this has changed that a lot of new founders can't believe it. And so I'm glad to get you on the record just as a testimonial about what it was like. It was only 10 or 11 years ago that we're talking about.

Exactly.

Yeah, it's been a wild time.

And I think, like, one of the things, I'm gonna jump to Carbon, but I think since then, the concepts have evolved quite a bit. So, we are now realizing it's not a single playbook, but when we first started Carbon Health, so, in healthcare space, it's not easy to just build an application 7 days and launch it, right? So, because we were trying to be a technology-enabled primary care provider, but to be a healthcare provider, you have to get the license, And you have to incorporate, you have to have a physical location. You have to be able to prescribe medication. You have to be able to order labs, medical imaging, referrals, insurance billing. Like the bar is fairly high, but, and we didn't launch the first version in 7 days. I think it took us 10 months to launch the first version, but there was still some similarities. We, when we launched the first version, what we tried to prove that was first was that patients would actually want this technology-driven, mobile app-driven customer experience. And to prove that, we started accepting patients, but we couldn't tell them that the service was going to be free. So, we literally did not have an actual billing infrastructure, but we didn't tell people it was free. We just acted like we are going to submit a claim to their insurance company. We just never actually did it. just so that we can prove some of the thesis earlier. I guess that wasn't your typical, let's launch an application and mount an iterate model. But then even in healthcare, there's a similarity. I think the concept has actually evolved. The methodologies are just getting better and better, are changing based on the industry.

Yeah, of course. I think that's something that people miss often is that Lean Startup is a philosophy. It's a set of principles. It has to be translated into specific tactics and strategies that are very context sensitive. And so, yeah, when you're in a highly regulated industry like healthcare or finance, the playbook is going to look really different, but the mindset is really what we're trying to cultivate. So I actually think it's really an interesting example of you taking something that was learned in online education and online dating and then to take it into a, you know, a much more— if you forgive me for saying— a much more serious problem domain of healthcare. Um, I'm of course, you know, really honored to have played even the smallest part in that. That's— that was, you know, that was my aspiration in writing the book originally. But I'm curious why you made that choice to make that switch. How did you— tell us kind of how Carbon Health came about. It's a much more difficult problem to tackle. What inspired you to do it?

Honestly, I think from Udemy to Carbon, in my perspective, I had a very linear approach, but I can totally see how it feels nonlinear. So we started, I was at SpeedDate, left to start Udemy in Silicon Valley again in 2010. And Udemy became, I would say, like wildly successful. We grew quite a bit in the first 5 years. I was a founder and CEO. And Udemy's mission was really making online education more accessible. But broadly, I was fascinated with this idea that you can use technology to make something really essential accessible to more people. And I was really thinking Udemy was a great example of techno-optimism. So when you build the platform, a lot of people who are not your typical Ivy League college professors can be teachers, can make a living, but also they can actually share their expertise with with like hundreds of thousands of other people. So, and then I started thinking about what other industries need this type of transformation. And healthcare was really top of the list for me. And then while I was thinking about it, my mom had this disease called neuropsychoidosis. So she had this full body stroke, which was completely unexplained. She's back in Turkey. So I moved to— moved back to Turkey for a couple months. My sister is a physician. We were going from doctor to doctor and trying to understand what was happening, and we were carrying thousands of pages of documents, lab results, DVDs with MR, CT scans. And I think we kind of— we just jumped around 13 really kind of specialized physicians. And there's no sad story here. So the physician number 14 diagnosed it and the treatment worked fairly well. But I just directly observed that the technology, the tooling for doctors were really far from what they needed to operate at a high productivity level. And I actually made a sketch back in 2013, like 3 years before I started Carbon. And the story here is we were going from doctor to doctor. Every doctor would look at these pages and they'd just go through hundreds of, like, thousands of pages and write some things in their notebook. And then they use their notebook to understand what might be happening. And I asked my sister, I said, what are they writing on their notebooks? And she said, they're making a chronology of the case. And my immediate naive reaction was like, why don't we give the whole content in a chronology format in the first place if that's how they are thinking about the problem. And I made a sketch about how I would design the physician's interface if I was building a new healthcare software platform. And I just left that around. When my mom recovered, I came back to Silicon Valley and continued to be the CEO of Udemy. But, that idea kind of got stuck in my head that the largest, the most expensive resource of any country was one of the worst utilized. And, I said somebody should really rethink how a doctor operates, how they communicate with the patient, how that whole concept of care delivery works. And, I and a couple friends, we kind of sat down and started making some sketches. I, I realized that this was one of the thorny problems with a lot of regulatory challenges that most founders were not wanting to work at. So there were healthcare founders, but they always wanted to take a, take a slice of the problem. Um, and what I really wanted to do was just bring the strongest technology product physician kind of clinical operations people together to, to figure out whether you can use technology to make great healthcare accessible to more people. So, really, what was disappointing for me was that there were healthcare companies using technology, but they were all exclusively focused on young, affluent, high-income patients. And, I hadn't really seen even a single company who's trying to serve the average Average retail worker, average teacher in this country. That domain was almost completely unserved from the technology space. And understanding how complex this problem was, I thought somebody should spend 10 years of their lives just obsessing on this problem.

So how did you get from somebody should really do something about this to you're going to do something about this?

I initially tried to look for founders to invest. So, I met a bunch of founders. I then realized the intersection of the founding team who's technical enough, who's product-driven enough, with the intersection of the founders who are open to learning this new concept, just not making any assumptions about how healthcare works. Instead, we were willing to just come in and learn from some of the people in the industry as well. And the intersection, the third part of the intersection is people who are willing to work on a thorny problem, right? Like mass market healthcare delivery. I literally couldn't find anybody that I thought was doing it the way I thought it should be done. And I decided that at that time, Udemy was already at the maturation phase. I think we were a fairly sizable company and we had a strong executive team. And I thought just hiring a CEO for Udemy and then me taking on this new challenge sounded like the right thing to do considering how important the problem is.

So what is the mission of Carbon Health?

It's very simple. It's all about how you can provide really high-quality healthcare to the entire population. And especially focusing on the demographics which are not being served. So really, it's just combining this very software-driven, very technology-driven approach with day-to-day healthcare. But more tactically, we decided that we have to start from the front door of the healthcare system because that's a consumer decision. So, things like primary care, urgent care, virtual care, maybe even mental health, these are decisions that consumers make. So, we did just theorize that if you provide an amazing experience without increasing the cost at all, you could really kind of dominate that front door. And, if you can become a very sizable healthcare provider in the front door of the healthcare system, what happens is the rest of the healthcare system like specialists and hospitals and imaging centers, things like that. So, those really rely on your patients to really, I mean, to feed their business. If you become their primary really customer acquisition channel, you can now use your influence with the front door of the healthcare system to create a more democratized marketplace for the rest of the healthcare. So, that's really kind of the thing. It's a little bit more complex, a little bit more complicated in reality. But it's really owning the primary care with high quality, low cost, very modern care, and then really trying to pressure the rest of the healthcare system to have the highest, best clinical outcomes at the lowest cost possible.

So take me back in time to right before the pandemic, the start of 2020. Where was Carbon Health at that point? How big had it gotten? How many clinics had you opened? And just give us a sense of the stage of the company as you wound up facing the pandemic.

So we were in a very interesting phase because we— I started Udemy in 2016. So we were a 4-year-old company and we had spent the first several years really nailing the unit economics, the customer experience, the really the software operations finance. And we had finally come to a place where the numbers were just undeniably working. So we had managed to provide a really modern healthcare experience with very high NPS score, very high retention, while still having a very strong provider experience. And lastly, in a way where we were seeing very good profitability with Medicare reimbursement rates. So that essentially, we had finally hit the benchmark, which I considered as the benchmark to just start scaling the company like crazy. It was several years of optimization and then we would actually scale at that moment. I think January of 2020 was when we said, okay, now we are going to just take this, scale as fast as humanly possible. And I think we had 7 clinics just at that moment, but we also had a pipeline of 20 clinics for 2020. And the pandemic hit us actually fairly early because we have this system that takes the details of the patient's problem. And when we started seeing the news from China, we put some additional questions to screen for COVID risk. And as early as January, we started seeing patients who were coming from literally from Wuhan, China. to California and they were coming to our clinics with respiratory symptoms. So, we caught this really early and then started really getting into this crisis management mode in January. So, by the time it was considered a pandemic in March, we had decided that this is going to be our focus for the foreseeable future.

Did I read correctly that the first case in California was found in a Carbon Health clinic?

So, yeah, so it was, it was one of our patients which we couldn't get tested, uh, but then eventually, because, uh, CDC— only CDC was providing testing at that point. Oh, that's right. That patient, we were monitoring a lot of patients, not just one patient. We were monitoring thousands of patients remotely. So we were asking them to stay at home. We would actually check back with them, with them daily, uh, and then if their symptoms get worse, we would actually then suggesting to go to other places. So I think one of the patients, one of those patients went to ER and then got tested by CDC in a community hospital and was considered as one of the— I think it was considered the first community spread patient.

Talk a little bit about your mindset as this information was rolling in. You know, this was before the general public really had an awareness of this, and obviously the American response and kind of our level of alertness to this crisis was very slow. What was it like having that information? How did you know what What actions to take? What did you view as your guiding light as you started to navigate those difficult waters?

So, there was a lot of uncertainty. I would say the CDC guidance honestly was very weak. It didn't really tell us anything substantial about what we should be doing as a healthcare provider. And, there were some people who's in the company even who said like, this is Going to be a massive problem. We have to just put all of our resources to fight this pandemic. And then there were also other people who thought this might be a three-month kind of problem, and it might be gone by the summer. And I had to make the kind of final call as the CEO. And there was also this like massive PPE shortage. Like we were literally short of N95 masks. And I just discussed with our clinical leadership and we just, we made the decision to just be on the front lines of this pandemic and offer testing as soon as possible. Essentially, we like, I mean, I and clinical, just our clinical leadership said like, we just have to be in the solutions part of this problem. Because just to kind of put that like, at that time, most healthcare providers, I mean, pretty much all of them were trying to like shut down clinics, reduce hours. They were mostly trying to reduce their risk factors, and they were hoping that the government, the public health departments would actually take ownership of the response there. So we decided to just go to the other direction. And I remember talking to my wife about this because I felt really horrible. I got it. I mean, the analogy I gave my wife is I said, like, I feel like I'm a generalist, general sending soldiers to the front lines.

Mm-hmm.

Because we really did not know what the real risk factor is. Um, and for all we know, we could have, I don't know, 10% of our staff getting, getting infected. And because in, in Italy, the news about healthcare providers were very, I mean, they were not good, but our clinical leadership actually had a lot of experience in from the original SARS epidemic. back in the day, pandemic. So, they thought that if we have the right protection, right protocols, we could actually safely help our communities. But as I said, I think our clinical leadership made the final decision to just lean in. And I felt horrible, I would say, for our employees. I mean, I just— we started trying to— and I just said, the entire team is now there. Your job is to support our frontline workers. And as the situation became more and more dire around end of February, we had this executive meeting and our head of product, Iyo, said, let's just think about what we wish we would have done if we knew that this is going to be a devastating pandemic. And I had brought actually a list of like really crazy ideas. for that meeting. And my goal was just to kind of inspire some other ideas. And I kind of had this list of 10 crazy ideas that we could consider if you really want to kind of take this pandemic very seriously. And I think what happened is over the next 18 months, we have implemented every single one of them.

Hmm. Give some examples.

Yeah. So, the first one was just building— the simple one was building a risk assessment system to evaluate code risk. The second one was, I think, just buying a bunch of trailers and converting them into mobile testing centers and going to underserved communities. Another one was partnering with companies to help them operate safely. for if they are essential companies. I think another one was really kind of partnering with local governments on this part and trying to help them. And one of the most immediate things was going to residential— so not residential, the assisted living centers and registered nursing homes and try to actually screen them on a weekly basis. So, I mean, in retrospect, these look like straightforward ideas, but I think the only thing we haven't done in that original list was building a makeshift ICU center. So, if the hospital ICU beds get completely booked, we were considering to work with military to build a makeshift ICU center. like a portable ICU kind of system. So, I think aside from that, everything else became necessary. Actually, one more was doing at-home testing. So, all of those kind of original crazy ideas became reality in the last next year or so.

If you could go back in time and give yourself a piece of advice from those early days, is there something now you go back and you wish you had done or had done differently?

I think the only thing that we didn't anticipate was how long this was going to take. So we funneled all of our resources into responding to the pandemic, assuming it was going to be a 3 to 6 month problem. And then after, I guess, a little bit more than a year, we are in better shape. But I honestly don't think we would have done much differently because we just— there were certain solutions we built that we realized wasn't the most important solution, but I think our attitude was correct because we just decided to take this more seriously than pretty much anybody else in the country.

So, fast-forwarding a little bit, you wound up becoming a critical part of the vaccine infrastructure and vaccine response. How did that get started?

So, the story of vaccine is like our involvement with vaccine actually started last summer. when we— when I was observing how the country was so unprepared to do testing on scale.

Mm-hmm.

So, and then seeing that vaccines might come in sooner than people expect. So I had actually written an article and I said like, we have to start preparing the infrastructure for vaccines like from today. We should essentially build them as if the vaccine is going to be ready 6 months later.

Really smart.

So, and we were opening these pop-up clinics, the trailers, and my goal was that when vaccines were available, we would be using pop-ups as the kind of core vaccine distribution infrastructure. But, when the vaccines actually came out, there were 2 things that like I hadn't calculated. Number one, the storage requirements were very strict. Like, keeping them at -80 Celsius was not going to be something you can do in a small clinic or pop-up. And then, number 2 is for especially older high-risk patients, you had to monitor them for 30 minutes. So, I realized that vaccinating somebody takes 2 minutes, but the monitoring is 30 minutes. So, your main bottleneck is going to be the physical space. So, we quickly pivoted from this mobile clinic-based model to thinking about how we could do mass vaccination. And, I sketched something over the New Year's. And, I think early January, the vaccine rollout in California was really bad. I think California was one of the worst states in terms of the vaccine distribution. And, Los Angeles was particularly struggling. It was a fairly sizable city, and there was a state-based, state-launched system which was not working very well. They were really struggling. So, we quickly showed them what we thought should be available to do vaccine distribution on scale. And to the credit of the mayor's team and the LA Fire Department, they saw what we had built and sketched, and they said, What's the fastest you could imagine launching this? And we asked them for 2 days and 2 days later, 2 days after our first meeting, we launched a website to just get people to sign up or join the waiting list for getting vaccinated in LA. And then we launched the front-end scheduling system first. And then we, like in 7 days after, we built our first version of the provider platform. And this is not completely from scratch, to be fair. Because we own our entire technology stack, we had all the infrastructure for scheduling and triaging patients, like the provider platform, registering medication administration. We already had the infrastructure. We just built a new skin on top of our existing software platform.

Yeah.

It was this, like, we have a bunch of these pieces. But we had to bring them in a different structure so that it's the most efficient you can imagine because the staffing was very limited back in that time. So yeah, so we launched this and then 7 days after the original handshake and launching the scheduling website, we helped launch Dodger Stadium, which was the single largest mass vaccination site in the country. And that was another just amazing example of, I think, being lean and just iterating because I had to go there with at least 30 or 40 people from our technology team, executives. We all just physically went to Dodger Stadium, stayed there. We actually built some of the software on the ground there. And then the first version was working fine. It was better than what existed before Carbon, but it was far from perfect. It was not very accessible. It was not great for— I mean, as an example, if you were using a landline, you couldn't use it because we required SMS verification. So we knew about these issues, but we launched it, but it was still better. And then every day since mid-January, we have been making iterations on the platform.

After a couple of months, I would say it is now a state-of-the-art Do you know how big of a fraction of the California vaccine rollout you guys have been?

I think we have done 1.3 million vaccines.

Wow.

And California should be 30 million, so around 4%. And I would say we had capacity to do at least 3 times more than what we did if we had enough supply. So there was definitely a supply shortage. We had capacity, like we were built enough to do 40,000 vaccines a day, but everything worked well. But then around like one week ago until last week, we were barely able to kind of handle the demand and supply was the main constraint. I think last week the constraint went from supplies to the demand.

So, we've been talking about getting to that tipping point now for a couple of months. You know, that at some point we would switch from demand to supply constrained. So, what do you think needs to happen next now that we're going to enter into a period of being demand constrained? What's your view about what needs to happen to eventually reach herd immunity?

I mean, what has to happen is we need to vaccinate roughly 30% more of the population. I think give or take, like 50% are getting vaccinated or are—

We have to get to about 80%, right?

We need to get to around 80% because 15% of the population is strictly against vaccination. I think those are really hard to convince otherwise. And there's another 4 to 5% which are immunocompromised. So, they can't get the vaccine or even if they did, it's not going to be as effective for them.

Mm-hmm.

And if we really completely want to go back to normal, like no masking, no social distancing, saying, if you want to forget about this, you roughly need 75% of the population to be vaccinated. So, it's really the challenge right now is how do we convince the remaining 25%? And I think we have to change our approach here. So, the paternalistic approach where we act like people are being dumb for not getting vaccinated, that's wrong because that's what we are missing is like there's still an accessibility issue. An accessibility issue has gone from physical space accessibility to now information accessibility. So, you and I are always, like, following the beat of this. We track the latest developments, and whenever CDC has new guidance, we are aware of that. But a lot of the population actually doesn't have this, like, as fast of a— I mean, essentially, they're not on top of the news cycle as much as we are.

Of course.

We just had to push the information that vaccines are indeed very reliable, fairly low risk, and most people, like majority of the people in the clinical world, they're all getting vaccinated. Essentially, we really had to push the information to the rest of the population who are not actively like on Twitter kind of following the news here.

Are you optimistic that we can reach that threshold?

I am optimistic, but I think the remaining 30% is going to take a lot of initiative from not just local governments and Department of Health and clinical providers, but we'll also need the help from other community leaders, maybe religious groups. We will need help from celebrities, athletes, sports teams to just really help help pass the message because there's definitely a lot of confusing information. So, people need to hear this from the people that they trust. And honestly, clinical, I mean, CDC or the local governments are not always the ones that the entire population trusts completely.

Yeah. Well, we live in an era where trust in institutions is at an all-time low really with the exception of the private sector.

Exactly. I think the, I mean, Yeah, I mean, unfortunately, right, like more people are getting medical advice from Joe Rogan than Fauci at this point.

Lord help us. Well, you know, it's interesting though. We had Ron Klain on in an earlier episode of this podcast from, from before the election even, and, and for those who haven't heard, it was fascinating now to compare what's happened to his predictions and his philosophy, but one of the things that he has been going on about quite a bit in public is the idea that there was going to be a whole-of-government response to COVID, and people kept asking him, well, is that— does that include FEMA? Does it include the military? And he kept being like, what part of whole of government are you not understanding? We're going to mobilize every resource and asset, you know. And leaving aside the question of, of how well they've done, you know, obviously the jury is still out, but it seems like it's going pretty well. I kind of feel like we are still missing the kind of whole of society response.

Mm-hmm.

Like, we're now at a moment where, you know, elites and leaders of companies, of communities, of religious leaders, like all of us who have a privileged position in society, seems to ought to be coming together to try to reach this goal. It's not just so that we can have the convenience of the old normal back. It's much more so that we're talking about still quite a lot of lives to be lost or saved. And I wonder if you have a view, kind of having been on the front lines, if you had an ask, if you could say, hey, if there are people out there who are listening to this right now, what would you want them to do to mobilize and to help even now in this late date?

I would say we are entering the phase where Now everybody can have a sizable impact on this. So because when it's all about just the hesitation to get vaccinated or maybe not evaluating the importance of it, so I think this is, this is where everybody can like play a role. Like 3 months ago, um, the person in a church like was not very relevant to the response because it was all about scaling, distribution, and administration of vaccines. So companies like Carbon Health had a more central role. But at this point, when you— when it comes to convincing and educating the population, and like, this is one, one place where we have to work as a whole society. And honestly, when people look at the response in Asia, that's one of the differences. I think like they actually have worked really as the entire society together to, to solve this problem.

Mm-hmm.

So I think at United States it's a little bit more fragmented. There's a lot of— this, this problem has been just very unnecessarily politicized. Uh, so, and thinking of economic discussions about do, do, should you shut down, should you just reopen everything, and schools, like, like, I mean, and a lot of people have opinions about these subjects, as they should, but That kind of inner fighting is really becoming an obstacle when we are about to solve the problem completely.

Yeah, this is— I mean, it's literally one of those unite or die moments. You know, if we can find the unity, if we can find the sense of common purpose, we can beat this thing. But if we don't, all the energy we face, we spend on ancillary issues, I just— it feels like such a waste.

Yeah, look, I was always very optimistic about just beating the pandemic, because this must be the first time where majority of the civilization just worked towards the same goal.

Mm-hmm.

So we found this moment where we were all united in fighting against this pandemic and this virus. And I think we made a ton of progress and we are about to knock it off for good. But it's just like we need to— it is the last quarter, but we just still have to play the last quarter because otherwise this is going to just stay as an endemic. It's going to be persistent and people will learn how to live with it and that might be okay. But you know what would be better than learning how to live with it is just really eradicating it.

Indeed. I don't know why, maybe this will seem cheesy, but I have had Lord of the Rings on my mind quite a bit lately. And this idea that if we can find common purpose and not waste our energy, we can defeat this thing. It's really magical. And so for those who kind of have been on the sidelines or have been knocked out of the fight, I always think about— and we don't have Sir Ian McKellen here to deliver the line properly, but the idea that when Gandalf returns, he says, I come back to you now at the turn of the tide. And this is that moment. So any one of you can be Gandalf the White and be a hero now. In the fight to get us through this last push, and if we do that, if we come together to make that happen, think about the story we'll be able to tell our children and grandchildren about a world that is free of this kind of disease, but also hopefully not just this, not just COVID-19 is eradicated, but we learn what is necessary to defend ourselves against these kind of threats in the future too.

Absolutely, and to be more practical, like, If you are an employer, if your employees just give them time off to get vaccinated.

Yes, please, please do that.

I think one of the things we are observing is like, if you're affluent, it's a lot easier for you to take time off and go get vaccinated. So that's number one. And just kind of knowledge for everybody at this point, there's so much vaccine supply. I mean, I mean, you can just go get vaccinated. Same thing. It really will take less than an hour. Just drive somewhere. At this point, we no longer even require scheduling, so you can just come in, register yourself on-site, get in and out in half an hour or so. So that is easy. And also, if you know people who don't have a car, who need some maybe companion to get vaccinated, just do all of these things. If everybody brings 1 or 2 people to get vaccinated, we'll just You'll be able to just honestly do large gatherings faster. But otherwise, I'm slightly worried that I think— I mean, there's a fatigue in dealing with the pandemic. And if you just assume it's completely gone and revert that, there will at least be one more comeback. It is going to come back because right now the cases are fairly low because we are still in semi-quarantine mode. But if you reopen completely without the remaining 20%—

Yeah, yeah. If we leave the job half done, we will surely regret it. And we have seen that pattern through the pandemic multiple times, how many geographies, countries, cities have had a really effective response to the pandemic during some phase and then relaxed because they feel like they won, it's beaten. And conversely, ones that have had really disastrous responses sometimes bounce back much stronger for the next wave because they really learned their lesson. And so, we have this one chance, you know, this one chance to get this right. And now is the moment to be in action. And I know the fatigue is real and I know people have struggled, but one final push and we can eradicate this for good.

And by the way, I'm not saying that like we should keep continuing to quarantine. Like, at this point, it's safe to be outside and have dinners and take a haircut and like you should just enjoy these things. But if we completely revert, it's going to come back because we haven't vaccinated enough people yet. But if we do this in conjunction with also getting our neighbors, getting our friends who are maybe just feeling lazy, like it's just, if you have a friend that's like, who's not vaccinated, just come to get together, go get vaccinated. Like if we do these things while we are reopening, I think we'll be fine.

Mm-hmm.

If we do not get the remaining 20, 30%, but And by the remaining 50%, but I'm assuming that there is 15% that we won't be able to reach out to. So, so we still, we need essentially 60% of the remaining people also.

Mm-hmm.

Uh, but, but if you reopen 100%, if you forget about the virus completely, it is gonna come back. But if we slowly transition and do our job, then I think we can, we can just like forget about this problem like next year, or even like be able by, by this fall, we should be able to. We should be able to really just act as if COVID no longer exists.

That would be truly a miracle. Talk a little bit about how you've balanced and how you see yourself balancing the work of this COVID response with the core business of Carbon Health. Has that been a challenge? And have your investors understood and been able to comprehend that you have this kind of dual mandate? What's it been like trying to do that balancing act?

It certainly has been difficult. And there's no perfect answer here. And, but luckily our board and investors have been very supportive. So they generally, they know that like we are in this on a daily basis. So we understand, but, but the company has grown quite a bit since the pandemic started. So I think we were roughly 200 people in the beginning of 2020. And if COVID never happened, we would like to be 600 or 700 by the end of the year. But instead of Instead, we have gone from 200 people to 2,000 people in 14 months. And I think we might be one of the fastest-growing companies who actually have physical operations. And some of it has been really COVID-specific vaccine rollout testing type of efforts, but we have also gone from 10 clinics, 13 clinics to 67 clinics right now. Yeah, it is a dual mandate. cheap balancing resources. For example, when vaccine rollout was really problematic, we put almost all of our efforts to it for at least a month. And then after a month, we were able to pull back resources to primary care and our more longer-term healthcare initiatives. So again, it's a constant balancing act. It's all about if there's a truly urgent problem in our communities, we feel like we have to respond. If not, we try to invest in more longer-term kind of core business.

What do you think is the future of public health in this country, especially? How do you see the relationship between the government and private industry? You've kind of had to straddle both during this response. Has it changed your view about what public health might look like in the future?

It has certainly changed. So, we are now formally building a public health division within the company. So, if you think about Carbon Health, so we have our consumer division working with clinics, direct-to-consumer, and then we have an enterprise division working with companies. And, I'm now formally incorporating a public health division. We'll have a GM, we'll have dedicated product people, engineers, operations, support, all of those things because I was able to observe firsthand that The traditional model where the government, a local government puts a big RFP and then a bunch of contractors respond to that RFP, that model is not working well because it just like RFPs end up becoming really convoluted and bloated. And then the contractors are building really software they think as like a one-time software they have to build. So they don't think of this as a living organization. So, what we are trying to do differently at Carbon is, like, I mean, essentially, we want to replicate what we did for vaccine rollout and some other public health problems. So, we want to be a technology-enabled public health partner. And there are, I mean, if COVID completely goes away, there are a lot of still, like, public health challenges from healthcare in rural areas to healthcare for maybe unsheltered population healthcare. Essentially, If we want to fix healthcare for the most underserved communities, it's very hard to do that purely as a for-profit entity. And then we actually kind of saw that there's nothing wrong with a private, for-profit, private company to partner with the local governments and nonprofits to just really solve the same problem. And I think that type of partnership worked extremely well when we helped with the vaccine rollout in multiple multiple counties and cities. And I just really like— I think that was like a really magical setup. I want to continue that setup for other public health problems in the future.

If we have some founders who are listening, any issues or problems in the space that you have learned about or noticed since you've been doing this that you'd encourage them to work on?

Sure. I would say even in places like Los Angeles County, there are big healthcare deserts, like literally places where you don't have good healthcare access in 50 miles. And that problem is not solvable purely from virtual care. So you need still some physical access points. So that's some kind of outstanding problem, I assume. I would say like working with kind of like schools, like in the school systems, there's huge disparity between the resources of different school districts, and some of them require more local government help. So yeah, honestly, I would just generally suggest that these whole public health projects are not something exclusively for large defense contractor type companies. Even smaller startups can actually operate fairly well, just help, as long as they listen to the local governments and understand their problems. Because some of the best solutions I've seen in COVID-related public health efforts were actually coming from technology startups. They were not the Google, Amazon coming in to save the day type of issues. If anything, actually, I was really disappointed with the response from large companies. I don't think actually any of them, any of these massive companies like have made a significant role in the pandemic, but then some smaller tech startups, smaller other entities have actually probably done a lot more than the kind of Googles of the world in this pandemic response.

It definitely was surprising. I spent a lot of time on the phone with companies large and small the past year, and yeah, the results absolutely speak for themselves. So, what do you feel like the long-term impact of the crisis will be?

I think the silver lining is like 20 years later, we will actually be in a far better position because so many more people are now entering the healthcare space. There are a lot more strong technical product people coming into the healthcare space. So, it's really between the funding, the interest from talent. I think actually it might end up becoming a net positive for healthcare because of such an increased number of people working on the space. You were not very involved in public health or healthcare in general. You are now You've not put a lot of mind into how technology companies can help here, right? So, I think that is actually very promising. Definitely increased usage of virtual care, but I think what you've seen is the omnichannel care idea is going to become more dominant. Essentially, patients are now expecting their healthcare providers to work with them both online and offline. So, that fragmentation, I think, is going to mostly disappear. in the future, uh, because now every single healthcare provider has learned how to do, do like virtual care. And then I think they will continue to doing this as a part of their practice. Uh, so, and lastly, I think some of the industries which went digital first, like, won't be coming back. I'm, I'm really hoping a lot of investor meetings will now be virtual first. So you don't, you won't have to travel as much, which might cause the capital to be more democratized around the, around the world.

Certainly.

I think there's interesting implications both for healthcare and also the kind of broader industry.

Absolutely. Well, Eren, I want to say thank you first for coming on and sharing the story with us. As well, thank you for all of the work that you've done as a founder and as a leader, especially here in California during COVID but also how lucky we feel that you chose to immigrate from Turkey and to do what you have done. Here in the Valley, it's just been awesome to get to see it all come together for you. So congratulations and thank you.

Yeah, thank you very much, Eric. And honestly, I'm mostly a spokesperson for the frontline workers we have, the people working in the product teams and technology teams and support teams. I mean, they really have done all the work. I'm merely just helping get people in the same direction. But thank you very much.

Well, a true servant leader, as we always look for. Let me ask you one final question. Which is simply, how do we get out of the crisis?

I think we are close. We really need to just stop politicizing this a little bit and realize that we are about to be over with it and everybody's on the same side here. Increase vaccine information and reduce the quarantines but still have some minor protections until we are until we are fully over the hump. And I think just kind of really just work as a whole society just together for the next really, I think, 3 more months and we are completely over this problem.

Eren, thank you so much for coming on.

Thank you very much, Eric.

This has been Out of the Crisis. I'm Eric Ries. Out of the Crisis is produced by Ben Ehrlich, edited by Zach McNeese and Sean Maguire. Music composed and performed by Cody Martin. Hosting by Breaker. For more information on ways to get involved, visit helpwithcovid.com. If you or someone you know is leading an effort to make a difference, please tell me about it. I'm @ericries on Twitter. Thanks for listening. Thanks for listening. Please rate and subscribe wherever you like to listen.