Episode Thirteen

Biotech Innovation in the COVID Era:

Levi Sani of Nalagenetics

6 April 2021


ALAN  0:12  
Thank you for joining Episode 13 of the Indo Tekno podcast. I'm Alan Hellawell, founder of Gizmo Advisors and Venture Partner Alpha JWC Ventures. Selamat datang kembali, semuana. Now throughout the roughly one year that the Indo Tekno podcast has been on the air, we've been able to explore innovation applied to many aspects of the average Indonesian's life. This conversation becomes even more meaningful for us when we can analyse its impact in addressing society's most pressing needs, such as those in the areas of education and health care. Today, we're extremely pleased to have on as our guest Levana Sani, Cofounder and CEO of healthtech startup Nalagenetics, a leader in pharmacogenomics. Thank you for joining us today, Levi.

Thank you so much for having me.

ALAN  1:00  
Now Levi, my staff tell me that pharmacogenomics stands as the longest word we've ever used on this show. Could you describe to us what it means and what exactly Nalagenetics is involved in?

Yeah, happy to. Thanks so much for having me on the show. Pharmacogenomics is a study within genetics that tries to answer how it impacts drug metabolism. So that's where "pharma-cogenomics" comes from. Nalagenetics itself does testing for pharmacogenomics. But within the bigger picture, it actually tries to answer the question of how do we make genetic testing more impactful for different ethnicities in the world. So one of the things that we noticed when we first wanted to create a genetic testing company was the fact that about 80% of genetic discoveries in the world are based on Caucasian populations. This means that drugs, vaccines, guidelines that are implemented in the rest of the world don't take into account a majority of the people of the world. So we wanted to make sure that when we give genetic testing access to providers and patients in Southeast Asia, we also actually collect the data such that we can make better decisions overall to make sure that population genetics can be used to make better decision-making for doctors. So Nalagenetics actually answers four different questions. Number one is: Who do we test? Number two: How and what exactly do we test? Number three: What to do after we test? And number four: How effective is our testing? And we do that by giving providers access to cost effective genetic screening services, and also a population genomics platform that collects and drives insights based on the patients that they test.

ALAN  3:01  
Crystal clear value proposition. Now Levi, where does the greatest value of Nala lie? For instance, what percent of our value is in the software we write? How much might be in the actual test kits? Where would you place the greatest area of value add within the Nalagenetics value proposition?

The greatest value of Nalagenetics actually is in designing the most cost-effective testing for local populations. So our pharmacogenomics test, for example, is the most cost effective on a per-drug level for Southeast Asia. We are able to do this because, instead of taking a solution that has already existed, we understood that the current genetic screening for drug response is reactive, meaning one drug at a time. But increasingly, there are more use cases for preemptive testing, or many drugs at a time, and that the results can be used in the future. We're able to do this with our four pillars within the company, which is: 1) the genetics team, 2) Bioinformatics, 3) software engineering and 4) product management. And together we're able to design a product localised for the Southeast Asian population. Another key aspect to the value that we drive is to drive the adoption of genetic screening by increasing outcomes measurement. So, rather than having to design a clinical trial, which is how outcomes generally are measured, every time we want to roll out a new biomarker, we create a platform where these outcomes' data is continuously reported as part of the service. This shortens the time for new tests, and increases relevance and impact of the test itself.

ALAN  4:48  
So Levi, clearly cost effectiveness and the preemptive element of our test kits are quite crucial to our success here. Now, a recent write-up on the KRAsia news site relates a pretty fascinating story that began for you at the Genome Institute of Singapore and led you to work with leprosy cases and Papua. Can you tell us more about this?

Of course. When Nalagenetics first started, we didn't have this giant business plan of this scope of business that we have today. It started out with a very simple goal of commercialising or validating or productizing more like, one biomarker that was found in leprosy populations. So this biomarker can detect whether or not a patient who is taking Dapsone (Dapsone is a very common antibiotic that actually is very effective against leprosy), and tell whether or not they will develop Dapsone Hypersensitivity Syndrome if they take it. And the problem is that people don't actually die from leprosy. It is very debilitating, but they don't die. But they instead die from the adverse drug reactions that are caused by this drug. So it's a very ironic problem. And we wanted to make sure that it was productized after being found. One of the biggest populations for leprosy is in Papua. So we found a collaborator, her name is Hana Krismawati, who's an amazing scientist and nationalist. And since then, she's validated our test in 1,000 Papuan leprosy patients, and we are now increasing the study to Nepal and India. And since then, because the project was successful, we increased the use cases to not only leprosy, but chronic conditions as well.

ALAN  6:36  
Fantastic. Now Levi, looking at your bio, I see you pursued a Bachelor of Sciences in Biochemistry at USC. Were you indeed quite early in deciding upon a course of study that eventually led you along to your present day career path?

Yeah. I just liked sciences growing up. My family's business involves a lot of machines in factories. So I always have been familiar with loud noises or things being made. And I wanted to stick to sciences for as long as I could, knowing that a lot of people actually pursued a different career path even after graduating with a science degree or a post-graduate science degree. So I've always been curious to see why things are possible or not. And I think it's just one of those things where my stubbornness to stick with science led me somewhere where it could really have not. So I think I have been very lucky. And I was very lucky that I could join Genome Institute of Singapore as a research officer and then met the people who became my co-founders, and still have their trust until today. 

ALAN  7:44  
Fantastic. So Levi, describe for me your present day focus.

Yeah. Knowing that COVID has impacted all aspects of health care, it has also been an important focus for us, similar to how other companies have pivoted to find a solution to fight the pandemic, especially in health care. Early on, we wanted to see how our platform can also be used to gather data and make PCR testing for COVID a lot more effective. So to that end, we actually have built two things. One is called "QuickSpit". It is a saliva collection kit that does not need extraction, which means that you can spit into a tube, and the lab can directly process it with whatever PCR kit that they currently have. And it's an open system, which means that it is compatible with many PCR kits. Number two, we also built "covidmeter.id", which is a machine learning algorithm to stratify risk of COVID-19 using a simple survey, and this is optimised for employers and medical workers. We have a lot of collaborators here, including Ikatan Dokter Indonesia (IDI), and also CISDI (Center for Indonesia's Strategic Development Initiatives). That is a nonprofit to empower primary care in Indonesia. We have also been trying to ride the wave of QPCR being a lot more ubiquitous. Even Gojek drivers know what they are. And so our test is run on the same platform. A lot of these hospitals that have QPCR platforms now can test not only for COVID, but also for pharmacogenomics tests. And so this conversation with hospitals have been very helpful to introducing newer test cases that we've always been familiar with.

ALAN  9:36  
Gotcha. I guess it should not come as a surprise to any of us that so much of your basic value proposition is quite relevant to the challenges of the pandemic era. Now I'm wondering Levi, is there an intensely personal component to your decision to found  Nalagenetics? I ask because when we first began our research into the company for this podcast, we came across the passage that "two of the cofounders of Nalagenetics have seen and felt firsthand the betrayal of drugs that were supposed to cure their family members, but instead caused them permanent side effects." Would you be willing to share with us more of the background to this story?

LEVANA SANI  10:15  
So I'll tell my side of the story, and maybe give a blurb for my cofounders. Right before I joined Genome Institute of Singapore, my grandpa passed away. And a few months before that incident, he was taking a lot of drugs; 8 to 12, I think at a time. And the reason for that was because he had a heart condition. And we weren't really sure if the drug was working. And so going to many different doctors, they kept on prescribing more and more drugs. We finally had to go to the US to understand what was actually going on with the weird effects that he was having at the time. And one of the main reasons was because the initial drug that he took was not so effective for him. And the doctor said, "Oh, this is actually quite normal for Asian populations." And so it was really sad that back home, we couldn't figure this out, but in the US we could have. And so that really impacted the quality of life of my grandfather. And I think for my cofounder, it was a similar story where a drug that was given in the hospital when he was sick with another disease actually caused him to be a paraplegic, which means that he has to be in a wheelchair full time because of the drug that could doctor prescribed him. It was only known much later on that it could have been something to do with his genetics. But at the time, it caused a lot of confusion as well.

ALAN  11:45  
Sad to hear these two stories, but also paints a lot of the picture behind where you guys have come from so far, and where you're going to go. Now Levi, how much of our current work relates to Indonesia?

LEVANA SANI  11:57  
Revenue-wise, a lot. We have offices in Indonesia and Singapore, and we have manpower scattered both sides equally, and in some other countries as well. And Indonesia has been interesting, especially as we look at the opportunities for healthcare. So healthcare is a very localised market. But the product that we are designing has to be regionally minded. It can target many different countries using the right regulatory pathway. Indonesia has been interesting, because the regulatory landscape for genetic testing is still unclear. It means that there's a lot of people or entrepreneurs in the field who wanted to take opportunities in COVID-19, as well to benefit from it. But as a company who has been in genetic testing for a while, I think we have also a certain responsibility to educate and also raise awareness about best practices in the field that we've learned in other countries like Singapore as well, and implement those best practices and the services that we have to patients and partners. In addition to that, Indonesia is quite a unique market and quite a unique population. We are so diverse. And there really isn't anybody answering the question of how an interconnected biobank for Indonesia might benefit clinical use cases in the country. And so whatever that we feel like we're doing for Indonesia, hopefully it will be useful, and inspire a lot more research in exploring diversities of drug responses, risk factors of chronic conditions and many others in the country.

ALAN  13:39  
Understood. I have to say Levi, you are first biotech-focused entrepreneur on the Indo Tekno programme. And when I think biotech, I think of other parts of the world, such as Silicon Valley, Boston, maybe London. What do you think is the future of biotech as it relates to Indonesia?

LEVANA SANI  13:57  
There are more companies in biotech Indonesia these days. So I think it's going on a very good trajectory. And it's a very exciting group to be associated with. And there are definitely a lot more companies that you should check out. I think biotech in Indonesia, and in general is going to take centre stage, as we all figure out how to have capabilities in designing vaccines, rolling them out, or making decisions based on data sets that are developed in Indonesia, what's best for us and our people and our challenges. And so having that capability is going to be very important moving forward. And so it's a very good time to invest in or look into this field, for sure. And I'm very optimistic about it. I think one of the key challenges for Indonesia is going to be figuring out where the grants for innovation are going to come from. When we apply with universities in Indonesia for research projects, their grants are too short to actually develop longer term and "moonshot" - not even moonshot - but longer term projects, which may be important for certain types of discoveries. Number two is to figure out how these innovators may be physically located together. And having that access to talk about ideas and collaboration in a very open and collaborative manner is something that is quite missing here as well, we feel. And then the third one is maybe more collaborations with the private sector. I think a lot of the ideas and use cases, once you have the push from the users, is going to be a lot faster, together with the government's system and regulations that are put in place.

ALAN  15:45  
So it sounds as though biotech ventures are going to be an increasingly large part of the startup landscape. Now Levi, how are things different at a biotech startup from say, an e-commerce or fintech startup that may be one of your fellow HBS grads went to join? Are project timelines different to the best of your knowledge? Does the pace of work differ?

LEVANA SANI  16:06  
Yeah, I would say so. Although I never have personally worked in a big tech company. So all the things that I've learned are really through, like you've mentioned, friends and peers. What I understand from the B2C startup land is that it's very fast to experiment. You can get data much more scalably. I think sometimes in biotech, you still have to wait for things to grow or things to be read. Certain chemistries can be made faster, but there are certain biology or chemistry reactions that just require some time. And so because of that, sometimes experiments and product development takes a little bit longer. And not only that, you have to make it a lot safer. There's a lot more at stake. When we develop products, we keep in mind risk assessments related to the regulations and standards that we abide by, like ISO13485, 27001, HIPAA compliance and other types of regulatory frameworks that we need to follow. And so this has really pushed our engineers, who previously have also worked in maybe other tech companies, to adjust to that timeline and documentation and checking, that they have set to be a lot more rigorous. But also at the same time, Nalangenetics is a "B2B2C" company, which means that we sell to hospitals and labs our services and products. So B2B enterprise sales, and product development is quite a unique industry on its own. And we have learned through so many mistakes that we have to understand the exact processes in-house of the clients before building anything. And there's very little margin for error. And there's no such thing as a "beta launch", especially medical technologies. And number two is that for us, I think we need to treat our clients as colleagues, and understanding their feedback and inputting that into our work processes is very important. And especially when we hire as product managers or engineers, everyone has to be a negotiator, a seller and a collaborator at the same time. A lot of the things that we build together with our B2B partners will impact a lot more people that they are going to test. And so we design things together. And that's why having that seller and collaborator aspect to all of our team members is actually pretty important.

ALAN  18:38  
Great. Now Levi, you've mentioned how "Nala is playing a bigger role with genetics and real world evidence and healthcare." Can you explain that statement to us?

LEVANA SANI  18:49  
Yeah. So real world evidence is a way for regulators to look at data sets that are already being collected as the intervention or the drug or the product is already in the market. So we would record things that happen as they happen without a clinical trial setting. It is a new trend that is being taken into notice because it accelerates a lot of the medical devices and pharma development. And at the same time, it also makes it a lot more cost effective to design unique products, like for cancer and chemotherapy, where it's really hard to find a specific patient with that specific genetic variant to be tested on a specific drug. So real world evidence has been a big trend. Nalagenetics is contributing in this field by contributing to the larger data set of Asian populations, especially Southeast Asia, starting with Singapore ,with Chinese, Malay and Indian populations, and collecting both their genetics and drug responses (a.k.a. real world evidence) to see the responses, remissions, relapses, adverse drug reactions, and also adherence to medications, and see how genetics and those aspects actually play together. And these are data sets that currently don't exist. And hopefully it will be useful for pharmaceutical companies, insurance companies and other players in the healthcare ecosystem as well.

ALAN  20:23  
Fantastic. Now Levi, what might headcount be for Nalagenetics by, let's say, the end of 2022? And probably more importantly, where are you likely to find all of that new talent?

LEVANA SANI  20:34  
By the end of 2022, we hope to roll out a different application of our platform, which is for risk prediction of chronic conditions. So, a lot of the hiring is going to be on the bioinformatics side as well as the genetic side. So we're also opening labs in certain locations. People have to be primarily in Singapore, because R&D is actually mostly being done there. But Nalagenetics has product managers that work with the R&D team in Singapore are located in Indonesia as well. And some of our engineers are located in Philippines. So virtual work has been very comfortable for Nala, but for some workstreams, like genetics and things related to the lab, or wet-lab work will still need to be located either in Singapore for R&D or in Indonesia for manufacturing and some R&D as well.

ALAN  21:28  
Levi, what are your regional plans? How much of our original "genetic code" can we copy into a new market? And on the other hand, how much do we have to localise to each new market?

LEVANA SANI  21:39  
I think this is a great question. A lot of this guesswork is actually already being done by regulatory framework. So, when you enter a new medical technology, or medical product into a country, they would already have an FDA, who require certain validation and verification work to be done and to be shown and standards to actually publish. And a lot of the things that we replicate to other markets, as long as we fulfil the regulatory framework, we can always scale our products and software quite comfortably. Now the second question, or the deeper meaning to your question I feel like, is knowing that Nalagenetics aims to be a localised solution for providers, how do we fine tune that recommendation that, say was built in Singapore for a specific drug, to another population, say in Vietnam or Philippines? And so that's where our bioinformatics team will be able to answer these questions: "How different are the biomarkers? And in what way are they different." So for example, the frequency of biomarkers that we test; maybe some certain populations will just have a different frequency or a different variant in a highly polymorphic gene. "Polymorphic" just means that there's a lot of variance in one gene that ends up making the same "phenotype" or effect. So as long as we have those two pillars: 1) the genetics team is comfortable answering to the regulatory frameworks, and 2) the bioinformatics team understands how in different populations the effect in biomarkers are exactly different in certain populations; we can always tailor our solutions to each market that we enter

ALAN  23:27  
It would seem as though future generations of solutions providers may well take ample advantage of this database that you're creating on a regional basis. Is that correct?

LEVANA SANI  23:37  
Yeah, definitely.

ALAN  23:39  
Now Levi, how does Nalagenetics actually make money?

LEVANA SANI  23:42  
We sell our products, which include the genetic test service, or kit; and also the software to hospitals and labs. And we work with them to activate their doctors to prescribe these tests to their patients. And then over time, we work with them to collect data sets that make an argument for payers and population managers to scale this testing programme to a larger scale. So we would tell the pharmaceutical companies or insurance companies that: "hey, we found that this particular test for these patients, ends up being cost saving, and increases patient outcomes over time." So that's how we make money in the first stage, and then in the second stage to scale it up through payers and population managers.

ALAN  24:35  
And so, would there be any further articulation in that business model going forward? Or have you already have shared with us the basic revenue drivers?

LEVANA SANI  24:43  
As much as I know about the startup world, it's that the business model always changes. Whatever I say now may be different in a month's time or a couple of months' time. This business model, we've been able to show that it works for COVID-19 and also pharmacogenomics. The question is whether or not that business model needs to change based on certain metrics that are also familiar and other B2B businesses like CAC (customer acquisition costs) and LTV (long term value) for different types of tests that we've developed over time. So for example, pharmacogenomics is quite fast feedback; as in, you take the drug, we know in two months or six months time if it's going to be working for a certain population or not. But we might be developing a test, for example, for predicting Parkinson's disease or breast cancer, which might take a longer time to understand well whether the patients that we test actually develop those diseases. And so we need to be a little bit more creative about using data and following up patients, such that the products that we develop still can give the same value to our partners, although it may take a little bit more time to collect the data that we need.

ALAN  25:56  
Gotcha. Thanks for that. Now Levi, you're a self described "optimist, aspiring painter, and long life learner" according to the Nala website. Tell us about your painting.

LEVANA SANI  26:08  
I like painting a lot. I think it really calms my mind. And it takes me to a world in which I don't think about sciences as often. It has been very useful to think that science is also art in some regard. And it pushes the team and myself to be a little bit more creative, even though we're dealing with very serious stuff all the time. Particularly I like drawing portraits. I'm not so great at it, as you may be able to see in some of my background paintings, but I'm working on that for sure.

ALAN  26:43  
Fantastic. Clearly a woman of many talents. Well Levi, It's been really inspiring to hear the story of Nalagenetics, and its plans to enhance the well being of fellow Indonesians and those around the region going forward. Thanks so much for joining us.

LEVANA SANI  26:57  
Thank you so much for having me. This is so awesome.

ALAN  27:00  
We hope our listeners have enjoyed today's episode. As always, please consider sharing any feedback that you have about the Indo Tekno podcast with us directly. Terima kasih telah mendengarkan.  Sampai jumpa lagi!

Transcribed by https://otter.ai