Riderflex Podcast - Guest Interview #399 - Joe Brew

Good, how are you, Steve?

I think it really came into fashion in college, right? But yes, it's a great name. And in addition to meaning beer, which is unto itself great, it also means coffee, as does the word Joe. So you can brew a cup of Joe. There was a period of my life where I worked at a coffee shop with a girl named Laurel Coffee, which is also amazing. So my caffeine addiction, I fully blame on my name, and I won't get into my beer addiction, but it's there.

It's funny. It happens to my siblings too because I have three of them. Rarely do people call me Joe or did they call me Joe growing up? I was Joe Brew to everybody. My sister was Annabelle Brew, my brother was Brew Brew. They're such short names that you can just say it as one. So you can call me Joe Brew if you want. I totally get it.

I did not grow up in Spain. I do live there now. My wife is Catalan, so that's a region of Northeast Spain. Okay, okay. Yeah, so it's kind of home now.

I did. I went to undergrad in the United States, Sewanee, Tennessee.

Well, I'm a Floridian, so you know, we're hard to classify. I'm a Southerner, but an interesting one. And then the rest of my schooling I did outside of the US. So I was in France, Spain, Denmark, Netherlands, and yeah, I met my wife while studying a master's in public health in Spain. And you know, I fell in love with her, of course, and fell in love with Europe, and that's where I'm raising my kids.

No, she wasn't. You know, it's funny. When I was doing my master's, I was dirt poor and I lived in a house shared by ten students. Two of those students were Catalan. They were friends of mine. I remember finding it so fascinating as an American wrestling with the idea of what do you mean you speak a different language but you're Spanish? Are you not Spanish? I thought it was a cool interesting thing in Catalonia. My wife came to visit one of them because they were friends, and that's when we met. And we kind of hit it off. I had that summer scheduled to go to Ethiopia, northern Ethiopia, a very difficult region to do fieldwork in maternal health. And she joined me. It was kind of a trial by fire dating for a few months. But you learn a lot about a person when you take them outside of their comfort zone. We hit it off and we bonded, and we said, 'Hey, you know what, this works really well.' I feel like in those few months together in Ethiopia, we got a few years' worth of dating experience.

Yeah. Later we moved to Mozambique, southern Africa, we went there with our one-year-old at the time. That was very much a super malaria endemic region. You're stepping in the bed net, 40 degrees Celsius, 104 Fahrenheit every day. Ethiopia was different. It was highlands, so it was high altitude. Where we were, I think it was around 2,000 meters, so 7,000 feet or so. High enough that there's no malaria, but plenty of other diseases. Tuberculosis is very prevalent, HIV/AIDS. But it meant you didn't have to sleep in a bed net, you didn't have to take malaria prophylaxis. It was one of the great things about highlands Ethiopia.

I grew up in Gainesville. In fact, I was just there the other day visiting. Gainesville is a great place. It's north Florida, and north Florida is very much the South, a kind of traditional, old-school place. Swamps and rivers and springs and oak trees with Spanish moss. But it's also a big university city, which brings a lot of diversity. People from all over the world come there to study, teach, and research. I think my parents, there were four of us growing up, four kids, and they did a very good job of instilling in us a sense of openness and wonder at the world. From the exotic Korean biochemical students doing their PhDs to the Central American farm workers marching through town, I saw how my parents related to those different kinds of people and treated them as equals and people to learn from. That instilled in me a sense of wonder and curiosity about culture, even though I didn't travel a lot growing up. I was really fortunate to go to a small liberal arts university in Sewanee, Tennessee, which does a really good job of exposing young people to the world. I studied abroad, I got funded to do summers in different places like Guatemala, and I got to see the rest of the world as a young man. I fell in love with international work, and that's how I stumbled upon public health because it's so applicable to international work. If you get your JD or MD, you're kind of locked into a country, but if you study public health, people need health everywhere. So it kept all the doors open globally.

My mom is still a kind of farming expert. She works a lot in organic farming and translational farming practice, teaching communities and schools about farming, farm-to-table stuff, school programs, farming as part of education. My dad is an engineer; he worked at a power plant, a kind of blue collar job. I would say their professions were not super influential on me. It was more what they were doing outside of work, when they were with me, that had a lot of influence on my growing up.

I never thought of it. I guess I am. I actually don't think much about degrees. The more time I spend with a lot of people with a lot of letters after their names, the less I think they signal anything besides a willingness to waste your 20s. So I don't pay much attention to it, including my own. I'll never present myself as 'Doctor,' especially given that I have no medically helpful experience of any sort.

I think I'm a typical male: we bloom a little bit late. We have to be motivated to apply ourselves.

By the time I got to college, I had a reason to be motivated. I had seen that education can open lots of doors. High school maybe a different story. In college, I was an athlete. I loved to run, and athletics teaches you all sorts of lessons in life: discipline, perseverance, consistency. Also, especially at those formative ages, it keeps you out of trouble. A Friday night, if you're thinking about competition the next day, you're less likely to make mistakes. So by almost sheer luck of being an athlete, I stayed out of trouble.

Yeah, absolutely.

That's my experience too. Knowing lots of fellow athletes, I also worked part-time all through college to make ends meet. But I used to think it was just fun—I just like to win, I just like to race. Then you realize you're touching on something much deeper. I was D3, by the way. It doesn't matter. A lot of collegiate athletes finish college, don't go on to be pro, and they have this hole in their life. I rediscovered sport later in my 20s. I realized I was missing consistency and routine. Even just the ability to enjoy a meal after a really hard workout, the good sleep you get when you're a little drained. So I've rediscovered sport not with a sense of wanting to win things, but as part of my general well-being. Now, working as an intellectual worker, trying to get your brain to come up with ideas and solve problems, so often the best ideas come in that one hour of forced silence, almost meditative silence, when you're out on a run, a swim, a bike ride. It's not just staring at a screen or in a meeting. So it's such a good routine breaker to have some sort of athletic discipline in your life, regardless of what it is—lifting weights or dancing.

100%. And you don't even have to try. The reality is when you take away distraction, the brain has processes that are ready to go and they start piecing things together. If you just sit and don't constantly expose yourself to dopamine through social media or whatever, the brain starts to say, 'Hey, wait a second, what if we did this this way instead of that way?' And you have one of those breakthrough light bulb moments. Couldn't agree more.

I have three: one girl, two boys. The youngest is turning two today, so we had a cupcake and candle morning. The others are five and eight. So I'm in the thick of it.

I don't have a lot of free time, but I enjoy everything I'm doing. So I get to my bed at the end of the day, put my head down, and fall right asleep.

She's busy with three little toddlers at home, so that's a big part of it. She is a teacher by profession, has a master's degree in educational psychology. She was teaching for several years, stopped now, and she's starting a space in our town for alternative pedagogical activities. Her specialty is early childhood education. How do you engage children in activities that are healthy, where they're growing and learning, but are not forced discipline of school structure, because they already get that? And you're talking about doing stuff besides staring at their tablet. She's a big fan of the Steiner/Waldorf tradition of education—simplicity. Even the toys don't have faces; you just have a wooden block so it can be anything. It's a police one day, a doctor the next, a teacher the next day. So it's very much trying to stimulate children's imagination and do education through play.

Fortunately, I think she limits her application of expertise to children, although I'm very close to her target population in terms of maturity. It's a huge benefit to our family because she's an expert in children. My kids are acting up one way or another, I have an instinct to do something, and she says, 'Hold on, maybe he just needs to cry it out, maybe we need to listen.' So I learn a ton from her. She's been a teacher for many years, so she has a lot of experience with kids, and I benefit from that for sure.

In my early 20s, I was a wanderer trying to figure it all out. At one point, a guy who was really formative in my thinking, a professor of medicine at the University of Florida, an epidemiologist, now in his 90s, Dr. Parker Small. He gave me a book called 'The Death of a Disease' by D.A. Henderson. None of us know Henderson's name, he's not famous. He was the guy who, for the CDC and later the WHO, led the smallpox eradication campaign in the 1970s. Basically eliminated smallpox. Parker Small's gift to me of that book, and him prodding me to do public health, convinced me that if you want to save dozens or hundreds or thousands of lives, go do medicine. If you want to save millions of lives, go do public health. He was steering me away from medicine and towards public health, which I didn't know was a thing. That set me on a course to get really interested in it. Henderson is such a great example of a guy none of us know about, but he saved millions of lives because he was able to do that. His patient was not an individual, but a population, in his case the global population. There are so many public health problems—infectious disease like malaria, tuberculosis, HIV/AIDS, to chronic stuff that many Americans don't see.

I think it's true that the big burden of infectious disease is no longer as large in the United States, but we also have populations that suffer unduly. Diabetes, chronic heart disease, obesity—there are epidemics raging that get no airtime. They're not flashy, not trendy, but they cause a lot of suffering. To the extent that you can move the needle ever so slightly on any of those things, you can affect thousands of people's lives.

I don't know the exact number. I think of obesity a lot because I go back and forth between Europe and the United States, and it's drastically different. I know Europeans really well and Americans really well. It is not a question of willpower—it's an obesogenic environment in the United States. Food deserts, it's extremely difficult to get around without a vehicle, forcing people to drive everywhere. In Europe, the same people with the same attitudes about exercise end up much healthier because the environment lends itself to healthy activities. Walking three blocks instead of driving—if you live in downtown Paris, you can't hop in your car to go to the grocery store, you have to walk. That repeated over a lifetime is the difference between a healthy heart and functioning muscles and a narrow waistline versus being obese. There's so much judgmentalism around it, like it's a personal decision, but it's really a collective thing. We have to build collective spaces that promote health and make it easy, as opposed to making it very difficult. Imagine riding your bike to work on a six-lane highway—it's a death sentence. The United States has a long way to go in making healthy choices easy.

I don't follow the space closely. Whatever people need to do, do it. I'm not at all opposed to medical interventions, but that stuff is so downstream from the bigger problems.

Sure. Dirty water largely kills young children. Diarrhea is one of the largest murderers of children on earth. Cholera, a disease that causes diarrhea, is prevalent in many developing areas and can kill by dehydration. If you live three minutes from a hospital or an ambulance, once your baby starts convulsing as their fluids go down, you call and get an IV and probably save that kid's life. If you live a seven-hour walk from the nearest health center, which is likely unstaffed, that kid dies. Diarrhea is preventable and treatable, just like malaria, another mass murderer of children. We have methods for water sanitation—it's not rocket science. We know how to do it. It's a question of resources and values as a society where we put those resources. If we think of air as a right and not a privilege, it makes every sense that water should be the same. No child deserves to die from dehydration regardless of economic decisions or the lack of a filtering system. There's a human rights perspective on many diseases that affect children, like waterborne diseases. Every single child deserves clean water and rapid treatment when sick. Same for sanitation. People don't choose to defecate in the open or have sewage flowing in a trench. It's lack of resources, corrupt governments, money going to wrong places. Nobody wants to live in filth. I've seen this again and again in Nepal, Mozambique, Guatemala. I've seen illnesses that should never have happened, severe cases that should never have gotten severe, and deaths that never should have occurred. Life expectancy used to be 40, now it's 80—not because people started living longer, but because more children survive. In South Sudan, DRC, Afghanistan, it's largely not people dropping dead at 43, it's child mortality. If you get through those first five years, your likelihood of living to 80 is pretty high. It's these mass murderers of children—malaria, pneumonia, diarrheal disease—that we haven't dealt with in 2023.

I think it's worth going easy on people because that apathy or indifference is largely driven by ignorance. A lot of folks don't know what's going on in the world. They don't know how good they have it or how bad others do. It doesn't have to be rich versus poor world. I have functioning legs, I'll never understand what it's like to be in a wheelchair. There are all sorts of forms of privilege. I happen to be free of mental illness for the moment—I don't have the bear of depression on my shoulders. Absolutely, infectious disease and sanitation are huge global issues, but in Africa, many people would kill for clean water, but they'd also like to be invited to a birthday party. In some ways, we're so similar across cultures. I think it's the duty of educators, not just formal teachers, to point young people towards sources of interesting, real truth and experience that shakes them out of their comfort zone. I was fortunate to receive a good education that shook me to my core and made me uncomfortable with lots of things. That's not a question of virtue, it's something I received. I can't hold resentment against those who didn't receive that gift; I can try to share it through education and awareness.

Yeah, they're still alive. They're not together, but they live in the same neighborhood. They cross each other walking dogs. When I visit, I hop from house to house.

They love to visit. Spain is a great place to visit. I'm sure they would love more real FaceTime with grandkids, but it's nice to have an excuse to go to Spain.

Hyfe is a cough company. We're obsessed with cough. Not because it's a narrow niche, but because cough is the world's most prevalent symptom—the primary reason people show up at a doctor's office. It's a symptom in everything from chronic conditions like COPD or asthma to infectious disease like flu, COVID. If you think about the experience of modern medicine, precision medicine, you go to the doctor and get poked and prodded in every way—temperature, blood, tests. But when you go with a cough, what do they do? They ask you, 'How's your cough?' And you're supposed to answer without knowing anything about your own cough. Then the doctor, who knows even less, treats your disease. A couple days later, they say, 'Hey, it's working. How's your cough?' And you say, 'It's better.' It's like measuring temperature before the thermometer, just putting your hand on the forehead. Imagine managing blood pressure without a cuff. It would be criminal negligence. Meanwhile, people are treated for cough without measuring anything. So cough needs to be measured. Ask any doctor if they'd like to know when and how much and what kind of coughing their patients are doing—of course. Unlike temperature, you can't measure cough in the doctor's office because it's sporadic and longitudinal. Unless the doctor comes home with you and sits by your bed with a stopwatch. So we came to the idea that cough needs to be measured first. Years ago, thinking about tuberculosis, I was living in Nepal working on TB projects with Dr. Peter Small, former head of Stony Brook School of Global Health, now CMO of Hyfe. We realized cough is so useful in TB for diagnosis and monitoring treatment. So we started collecting audio of TB coughs, looking at algorithms to filter coughs from non-coughs, counting coughs. It was a side project, largely academic. Then COVID hit. In early 2020, this crazy new pathogen with high mortality was spreading around the world. One symptom was a dry cough. We had no testing available. We thought, hey, this cough stuff might be applicable beyond TB. Maybe we could use people's microphones to detect cough across a population, create heat maps to see where the pathogen was spreading. That's when we decided to take cough seriously and form a company.

This was a little before cash. It was just 'what if instead of spending 10 minutes a day, we spend three or four hours a day?' Then 'what if we made this into a company, a product?' We went through a few people in our network. A fellow we worked with, Julian Chirita, a Romanian living in South Africa at the time, now in Austria. He had a young guy he worked with, Paul Rădulescu. The three of us were co-founders. We said let's make an app applying AI algorithms I had written, ship them on Android and iPhone into the wild, and see if we can start counting coughs. Maybe this will be the killer COVID app.

We didn't. We just stuck it out there. We made a landing page. People started signing up. This is where a useful startup lesson comes in: to learn, you have to do. You can't learn first and then do. So we thought we'd make a COVID app because everyone was doing COVID. People with COVID didn't want to download the app, they were busy worrying. But we got dozens, then hundreds, then thousands of downloads from chronic coughers—people for whom cough was itself the disease. I came from an infectious disease background and had never heard of chronic cough. I didn't know it was a disease. If you're one of the 4-10% of Americans with chronic cough, you live with discomfort. They started leaving reviews: 'This is great, but I went on a hike and said I coughed 500 times, it was detecting my dog's bark.' The app was half-baked, but they were so desperate for a tool that they stuck with us. We retrained the model to not pick up dog barks. That user became a user for life because they felt they contributed. We built one thing thinking it fit the market, but it fit a completely different market. We never would have learned that by brainstorming. We had to build it and put it out in the wild.

Correct. Hyfe.ai. You can find it on Apple and Google.

Right now, in the United States, Cough Tracker is free and will remain free. In the rest of the world, it will one day transition to a premium model.

We license our algorithms and analysis platforms to those studying cough, like researchers and pharmaceutical companies, and to those who want to use cough to save money, like remote patient monitoring companies. They're interested in preventing costly hospitalizations or ER visits from those with COPD, asthma, congestive heart failure. Knowing when a cough deviates from baseline early can prevent a person from showing up at an ER. That knowledge is extremely valuable to insurers or monitoring companies.

The ability to monitor, quantify, and analyze a symptom they never could before. Often they show the data to their doctor. For many, it's validating because the doctor takes them seriously. They show 900 coughs in one day, 135 coughs from 3 to 4 AM, and the doctor says, 'Oh wow.' The therapeutics for chronic cough are often behavioral—cough suppression therapy. Many people don't know their triggers. With data, you can see patterns: 'I cough every day around 2 PM, right after I eat. One day I skipped lunch, no cough.' That leads to an insight about GERD. Another person might notice they don't cough while sleeping, which suggests a neural tickle cough sensitive to certain inhibitors. So the app provides useful information—like a step counter—without diagnosing. Chronic coughers are often citizen scientists; they know what to do with the data.

We have tens of thousands of users from whom we've collected cough sounds. At some point, the returns on that are diminishing. What we really need are users from research trials—people enrolled in studies with known conditions, where we can pair cough data with medical information. We consent them into studies and get age, drugs, outcomes. That pairing allows us to build algorithms that predict medical events.

100%. Cough counting is coming. There are players in the space; we're the best at it. It's too important and interesting not to become a common medical use case. Right now, we're in the wellness space, like step counting. That will change. We've carried out a trial for FDA clearance validation, had three pre-submission meetings with the FDA, and we'll submit by the end of this year for clearance to integrate into medical decision making. It's a process, step by step. This is a new biomarker and endpoint.

We got some non-diluting funding early on, grants for work in the developing world. Then we raised a seed round. We also have significant revenue. Pharma companies, especially in chronic cough, want to license our algorithms. Cough Tracker in the US was built with Merck, which is extremely interested in chronic cough. Have they offered to buy us? Not yet. We're not in a rush to be acquired. We're building cool stuff and love working with them. But who knows?

Thanks. Part of the job.

It was a lot of fun, Steve. Thanks a lot.