You know, sometimes it feels like we're already living in the future. After all, our smartphones, they give us so much information. Whenever we want it, wherever we want, instantly. Cars are beginning to drive themselves. Our watches can track our heart rate, our step count. Rings know how we sleep. And artificial intelligence, I'm not even sure where to begin with that. But it turns out humans have been into tracking and trying to better understand themselves for a long time now. In fact, more than 500 years ago, just think about that, 500 years ago, the famous artist, thinker, and inventor, Leonardo da Vinci, he sketched something that looked very much like a basic step counter or a pedometer, which honestly is not that different from how many of us use fitness trackers today. But it turns out, even back then, people were trying to figure out how to measure their own health. People have long been fascinated with their own bodies and trying to quantify it in some way. And these days, wearable technology does way more than count steps. They can flag heart issues. They can detect signs of high blood pressure. They can even pick up on hearing loss. They have quickly become surprisingly powerful tools for preventive care.

We feel almost a responsibility because we're with you all the time to actually make you live a healthier life.

That's Dr. Sumbul Desai. She is Apple's VP of Health. She's a physician and a clinical associate professor at Stanford Medicine. For years, she's been thinking about how to bring medicine and wearable technology closer together. So I wanted to ask her, can these devices really help us catch health issues early? Is there a fine line between information and panic or even drowning us in data? How smart are these smart devices, really at knowing when something's gone wrong? And does it actually ultimately lead to longer, happier, healthier lives? We'll find out. I'm Dr. Sanjay Gupta, and this is Chasing Life.

Dr. Desai and I sat down together at the Paley Museum in New York City for this conversation in front of a lovely live audience. Well we are delighted to be here at the Paley Museum to do a live version of the podcast, Chasing Life, and delighted you could all be a part of this. So thank you very much, and thank you for being here, Dr. Desai.

Thank you for having me, this is such an honor.

Let's get a little bit of your background. So you're a physician, but how did this all start for you?

You know, what I do today is really a culmination. It's interesting, you always set out, especially coming from an Indian background, I think we like to plan out our lives. And when I sit back and now look back, I think everything happens for a reason. And the choices I've made have been actually very helpful. But I went to an engineering school and was admitted to a six year BSMD program, directly out of high school. And to give you a little bit of a sign, I cried the day I got in. I was like, oh God, I'm gonna have to go. And um...

You had to make that decision pretty young.

Well, I didn't really make the decision, my dad was pretty insistent that I'm going to do it. So I did it. And I, in my way of rebelling when I was in college, my first semester, I literally have every grade in the alphabet because I purposely just was trying to tank it to make a point to my dad.

Wow. OK.

Including a Z because a Z is actually when you don't show up for the test.

It's funny that nowadays that whenever I hear things I have three daughters are 20, 18 and 16 two of them in college So as you're telling me the story stuff starting to percolate through my own head about what they might be doing to me one day.

It all turns out fine.

Okay. Yes.

'Yeah, it turns out right Um, so I you know went back my first semester My dad was like for the love of god do what you want to do. Just be happy So I am I still did a respectable thing. I changed my major to computer science and I minored in communications. And so post graduating from undergrad went and worked in broadcast media got very interested in the business side went over to the walt disney company and did that for the studios? I, in 2001, my mom in August of 2001 had a massive stroke. I'll never forget, I think, those moments of feeling incredibly helpless. We took care of our mom, who basically went from a healthy, thriving 55-year-old to basically having to relearn how to walk.

Stroke at 55.

A stroke of 55.

Wow.

'It was in August of 2001, and September 11th happened. And we were in a New York City hospital. We were right in the suburbs of New York, and they had cleaned out the hospitals because they were hoping to get folks back from the towers. And so my mom went from a ICU to a lower-level care hospital, a rehab hospital. So we had to get very involved in our care, and I decided that I wanted to do something to actually impact an individual's health day to day. And that was kind of the turning point for me. It left a lasting impression. So I went back to medical school older in life. So I was 30 when I started medical school. But then I finished medical school, started at Stanford, and what stayed with me were some of the lessons that I learned through medical school and that experience with my mom is that, one, always treat your patients the way you would want your mom to be treated. And two, that voice of like, how do you empower patients to have asked the right questions to me. That was very important so as a physician and I always felt the need to make sure that people were informed with the right information and that feeling of like how do I empower people I now get to do that at scale and that's really what drives the work we do.

Fantastic. So you were a physician at Stanford. So how did the transition to Apple happen then?

Post residency, I got very involved, because I had a business background, I started working on the health system side. And I got involved with technology. So the computer science kind of came back into play. And we were rolling out video visits at that time. It was kind of like the time where technology was starting to get integrated into healthcare. And there's more talk about digital health. This was 15 years ago, but I got very involved with working with local startups in the Stanford area. And through that, I got to meet the Apple team. And so you know, when you get recruited to Apple, they never really tell you what you're going to work on. So, you know our secrecy thing like is real. So we, they were like, hey, why don't you come and visit us? And I had no idea what I was going to do. And I started consulting and didn't know the project I was really working on. Cause when you consult, you actually work on a very narrow part of what you working on and got to know the Apple team, and in 2017, decided to move over to the company. I got offered a job and decided to move over there.

It is pretty cloak and dagger.

It is.

Is there something that you think in the back of your mind that you would love for these devices to be able to do?

Yeah, I mean, in taking care of patients, what you learn is so many things, like if you look at cardiovascular disease, 80% of it's preventable, right? I mean there's obviously genetics play a role, but there's a lot of lifestyle things that play a roll in your health. We feel almost a responsibility because we're with you all the time to actually make you live a healthier life. And if we can get you to be proactive, pick up conditions before they happen and truly like focus on prevention, you know, we learn prevention in medical school But it's so hard to practice it with the way our health system is like if we can truly move from taking people and what we call break fix to actually driving people to be proactive and preventative around their health And get them to live longer and healthier lives I think that is the impact that we really want to have and I think our devices can do that. Just by the fact that we're with you.

Does it surprise you at all to sort of think of Apple as a health company? You know, you think of it as a phone company, you think it was a communications company. Health, is that an obligation for a company like Apple or a nice thing to do, profitable? What is the motivating force?

So there was a small health team before I joined, a very small team, and what we initially did was roll out Research Kit. I don't know if that rings the bell. Research Kit is a framework where you can actually enable researchers to do research. And when the board asked our leadership at that time, why are you doing this? The answer was like, we're just doing this because we think this is a right to do here. We're not looking to get into health. That was actually the initial thinking. Interesting. What ended up happening was. We introduced heart rate on the watch for accuracy of the calorimetry calculation.

To adequately be able to measure energy burn.

Energy burn, exactly, so for those of you that have a watch, there's the move ring. To make sure that the move ring is accurate, we introduced heart rate sensing on the watch. And what ended up happening was we started getting letters from customers, and this is just by virtue of wearing the device saying my heart rate was elevated and I went to the doctor and I learned I had an allergic reaction, or I learned I had AFib. Or I learned I had a heart condition. That kind of got our engineers thinking, wow, this is actually having impact in a way that we didn't expect. And then we pulled the thread and did a high heart rate alert. So if you're sitting at rest and your heart rate goes above 120, we will give you a notification. We got even more letters. And we actually do get letters from customers, like almost every day on our health features. And that led the team to pull the thread even more, and then we introduced atrial fibrillation notifications, which is an irregular heart rhythm notification. So when your heart is beating irregularly, we send you a notification. And the reason I share that with you is that health was truly very organic. Like our work was very organic, we never sat back and said, hey, this is a strategic priority for us, it's a big business opportunity. We really got into it because we heard from our customers, we wanted to pull the thread, and we decided to do more and more in the space.

Were there features that the customers seemed to be clamoring for or really wanting out of it?

It's interesting. I would say yes, and some more of that surprise and delight when it came out. And what I mean by that is the irregular heart rhythm notification, and then we also introduced the ECG feature, which is when we first met. That I would no one was clamoring for, but once it came out, the letters that we got just increased exponentially.

It seems like part of the Apple thing. You don't necessarily know what you want. We're going to tell you.

We're going to tell you and we put it out there and that was the first time we did a few things we put an ECG on a wrist which measures kind of the electrical signal in your heart .Traditionally done in a physician's office. We brought that to you. So we really think of that as democratizing access to certain things that you can traditionally have to go to a doctor for. The other thing that we did knew with those two features is we first did our first regulated products so those were our first FDA cleared features and what we call software as a medical device and that also got us to work in a different way, think in a difference way, interact with the FDA and other regulatory bodies. So that was a meaningful, those two features are very meaningful to us for a number of reasons.

'It is a very consumer-facing product. When it comes to something like blood pressure, that sort of surprised me because you think about a cuff on the arm, measuring a systolic and a diastolic, how could a watch do that?

Well, one I'll just say, this goes back to the question you were asking, is my other hope for what we're doing is we find new ways to measure things. We took an approach using machine learning. If you are in stage one or stage two of blood pressure, which is over 130 of systolic and over 90, we'll notify you. So how did we do that? And I'm going to show you on the back of your watch, there's these green lights that's called the photoplasmograph. So it's our PPG. So we took data from over 100,000 participants in one of our studies and looked at how the PPG signal can correlate with signals of hypertension. So when we see enough of the pattern being consistent with hypertension, we provide a notification. What's really interesting about that is traditionally blood pressure cuffs are what measure your blood pressure. That's the way we've done it. We don't know if that's the only way to do it in medicine. There could be other physiological ways to measure things, and that's what we've uncovered through this process. The one thing I'll call out is we won't pick up every case of hypertension. So it's a screening mechanism. So we pick up about 41%. But if we notify you, the predictive value of that is 92%. So if we notified you, we're very confident that you have stage one or stage two hypertension. And the last thing I'll just say, the reason that's so important is when you're doing a consumer product, it's more important to us to make sure we don't have false positives. We really want to make that when we're notifying someone, they have the confidence that when they go to the doctor, they actually will learn something that is correlated with the message we give them. So we tune our algorithms to achieve that.

Do people buy these products with the expectation that they're going to use them in that way?

I think when users buy these products they want to know there's something, what we call an intelligent guardian looking out for you. What we are hearing more and more from our customers is they appreciate that there is a product out there that is gonna notify you if there's something going on and you can do something about it. So for them, I think it's much more about the information and that empowerment. I will say two things. One, I feel very strongly that we are providing consumers with information that traditionally sometimes is given to them by a doctor. So we have to hit a level of accuracy that we feel really strongly about and that we feel even better about. And two, I truly believe that the science has to drive the work we do. And so I want to make sure we're scientifically grounded in the work that we do so that consumers have confidence in the messages they're getting.

You probably have engineers who are trying to figure out how to make this work and then you have researchers who are figuring out is it actually working and correlating with blood pressure. But this number 41%, what do we need to do with that? So if I'm buying this and I'm worried about hypertension, it'll catch 41% of people who have hypertension that may not know it.

'Exactly. So the way to think about this is a few things. One, if you don't get a notification, it does not necessarily mean you don't have hypertension. But if you do get a notification, we feel very confident that you at least have pre-hypertension and if likely stage one, stage two. What I will say is if you think about a traditional blood pressure cuff, the sensitivity of that is 50%. But if think about it, how many people actually take the time to go to the doctor. In the first year alone, we're predicting that we will notify about a million people who did not know they had hypertension. So those million people are going to get care that they didn't think they needed to get. That could be meaningful to them and they can make meaningful lifestyle changes to hopefully improve their trajectory.

How has the medical establishment sort of responded? I mean, if you have all this data, are people sharing that with their physicians?

So for every product we build, we actually create a physician report. And our goal of that is we want these products to be used really to enrich your relationship with the doctor, not replace a physician. Perhaps we're biased because it's a group of physicians that are involved in this process, but we're looking for you to have more data to kind of create snapshots of your life. So when you go to the doctor we create a glanceable in 15, 30 seconds, a physician can look at it and understand what that means. We actually specifically gear it for physicians. So we do that for our hypertension products. We did it for our AFib products. We do it for women's health products, our hearing products. We do across the board. And we're starting to see more and more physicians use Apple Watch in clinical settings, which has been very interesting. The American College of Cardiology just came out with guidelines about how to use watch in the practice. As a physician, you should always be cynical and be thinking about if this is good for your patients. And we've had healthy conversations with doctors. We engage a lot with the medical community. So we build our products using key opinion leaders from external sources. So while we have a group of physicians internally, we actually work with physicians in the academic community who we get input from during our product development process.

Up next, how Apple's AirPods went from a way to simply listen to music or chat with your mom to a surprisingly effective tool for medical testing. How did that happen? We'll be right back.

I recently did the hearing test at the strong suggestion of my wife, who was very convinced that I had a deficiency in my hearing. I scored a perfect score.

Nice!

Which I happily shared with her. But I thought that was really interesting. There was this new proposal by the government to basically fund hearing tests and fund hearing aids for people, which I thought was really good because there's so much correlation between poor hearing and dementia and all these other things. And like hypertension, often unrecognized, AirPods are obviously popular. How did the idea of using headphones to test hearing, how did that come about?

'For a long time with AirPods, we did a few things. We did noise cancelation, and that was kind of something that the engineers were working on, and then we did conversation boost. This was pre-hearing aids. And candidly, during those conversations, especially during conversation boost, internally there was a lot of excitement from our engineers of, hey, could we turn this into a hearing aid? Like, could people use this as a hearing aide? And. So we rolled out the Apple hearing study with your alma mater, University of Michigan and the WHO. And through that hearing study, one, we tested doing a hearing test through AirPods within that research study. And we saw that people were actually using it and doing it at home and we could get pretty good results. The other thing that we did is because we had those two building blocks in place, we had some initial work thinking about, could AirPods be used as hearing aids? But you know when the study came out around showing the impact on brain health and modifiable risk factor for dementia, that pushed us over, I think, a little bit more to be like, okay, we're doing this. And then the over-the-counter hearing aid guidance came out shortly thereafter. And so we initially were going to just do the hearing aid portion, but it was almost the confluence of things coming together in a really beautiful way. The hearing test piece. Was already being tested through the University of Michigan study. And so we decided to bring the experiences together to do the hearing test and then be able to turn on hearing assistance, which is basically a hearing aid for mild to moderate hearing loss. And we joined the experiences together and launched it last year.

Where in society will something like this fit in then? I mean, is this to replace certain hearing aids, ultimately to replace hearing tests?

Our approach in general is how do we democratize aspects of health experiences that you traditionally do in the doctor's office that you should be doing more often, and how do bring it at home and make it easier for you to do? And so the hearing test is a great example of that. I think the other thing that we wanted to do is stigmas are a real issue when it comes to hearing aids. For anybody who has loved ones who use hearing aids, there's concerns around that. There's also how they work and how they fit. And so the fact that people were already using AirPods was very attractive to us, because we're like, people already know how to use this. And now if we can add the hearing aid function, that would be really empowering. But our goal is not necessarily to replace hearing aids. I think the way we talk about it and feel about this is if we could get more people taking hearing tests longitudinally, so they pick up hearing loss sooner, about 75% of people who know they need hearing assistants don't get it. And we learned that from our Apple hearing study. So if we can get those people to actually use the hearing aid functionality and then engage in using it because it's a form factor they're comfortable with, that's a win. So when they need a traditional hearing aid, should their hearing progress, they're more comfortable with using it. So it's little bit of an onboarding to it and gets them using the product to help them with their brain health as well.

You know, I do come back to this idea that, so you're sitting in meetings at Apple, Jeff Williams, I don't know who, is that who you report to, by the way, Chief Reporting Officer?

'Yes, mm-hmm.

Good guess.

A good guess.

'And you're making the case that, you know, we have these AirPods, they can have these dual purpose or even three purposes to the AirPods. Just just not not to be cynical, but is the objective to try and sell more air pods like I mean, you're a company a multi-trillion dollar company.

Yep.

What what is the motivation for that kind of innovation?

'One thing to just kind of put the proof behind it is the hearing aid functionality is available on existing AirPods. You can actually just do it through a free software update. So we actually didn't make anybody purchase it. You know the motivation truly is of course we want our products out there. We know people care about health. But our CEO has said and all of our senior executives have talked about this, we talk about this is that we truly want to empower people to live healthier lives. And the impact that we know we're having already just by the letters we get is almost the fuel that drives a lot of the innovation and the interest in this space. It is the most rewarding thing when you get letters from customers. One of the most meaningful ones I received, and it's just a simple thing like picking up your heart rate, was a pregnant mom who her high heart rate alert went off and she was in her third trimester. She went to the hospital, turns out she was thyroid storm, which means that if your thyroid's overactive, it can turn your body, but all of the sympathetic systems in your body kind of are in overdrive, which could be problematic. The physician was like, if you hadn't come in, not just you would have passed away, but you would've lost your baby. And so when you think about health, what's so powerful is we're not just helping the individual. Health is something that impacts the family, right? It's your loved ones. It's the people that you impact, you know, your day-to-day community. And if we can have that impact on someone's life in that way where we can potentially save them from a really poor outcome, I mean, there's nothing better than that. And doing that with information in the way that we can drives us to do even more.

Yeah, I mean, it's a beautiful story and it's got to feel very gratifying, and I think, you know, you're a physician, you get to experience that as a physician. I don't think people think of corporations that way, just to be totally candid.

Totally, yeah.

I mean you know I don't think I'm being overly cynical when I say I'm still like wondering what the competitive advantage is of this sort of thing. I get that it's good thing to do, but you do wonder whose responsibility in society is it to do those things. And I don't think 10 years ago, 15 years ago he would have said, well, Apple is going to be the ones to democratize the testing of hearing.

Yep.

Or they're going to democratize finding people with high blood pressure.

Yep.

It's sort of an interesting story to me. Does it surprise you?

'It does surprise me. I mean listen, you know, it surprises me is when I put a pitch together and there's not a clear business plan to it But it's the right thing to do and it still gets approved. So that's and that happens and that's pretty powerful and when you have engineers who don't get to do what we do and get to have that letter come in that their product Actually save someone's life you'd be amazed the motivation that that drives for people. I mean, health is one of those areas where people love working on it, even on the side. They may have other jobs within the company, but they'll still do engineering explorers to be able to find new things. And I think it is truly that impact that drives a lot of the day-to-day teams to be be able continue to push this. Now, of course, we want to use our products to have impact. This is like a broader story for us. Like, we wanna have impact, but we're in a lucky spot. In the ability that so many people use our products. So it would almost be a terrible miss to not take advantage of it, and that's the way we look at it.

That was my conversation with Apple's Vice President of Health, Dr. Sumbul Desai. We were live at the Paley Museum in New York City. Thanks so much for listening, and keep chasing life!