In 2020, an explosion rocked Satartia, Mississippi.

A thick cloud engulfed the town as 911 calls flooded in. One mother begged for help as her daughter gasped for air. Residents passed out standing up

Satartia is the most important infrastructure failure you've never heard of. Satartia, Mississippi is a small community on the banks of the Yazoo River in western Mississippi.

Most residents were unaware that a 24-inch CO2 pipeline ran near their town-- part of a system the White House sees as key to defeating climate change.

Every week, a dozen new companies boasting "tech-enabled healthcare for the rich" announce massive funding rounds.

I think nearly every single one fundamentally misunderstands the business of high end medical care.

Here's how to build a real executive physical killer: over the last two years I've done basically every single executive physical.

I've flown to the Mayo Clinic in the middle of winter, five times, I met a referral only infusion clinic in an empty warehouse filled with buddha statues, I've done every variety of full body MRI

five thoughts on choosing who you work with/for: 1) moral alignment matters more than incentive alignment

people focus too much on aligning incentives. incentives are messy and can hardly be aligned. find people you share convictions and faith with, and keep working with them for long amounts of time. it'll work out.

within months you will be able to buy genomics data from 14 million americans for +/- $200m?

the inevitable fire sale of this mess to an overseas PE firm is going to be a national security matter on the scale of which we haven't seen in healthcare in years in general, hhs has left open a dangerously large hole around healthcare data sales

the reg we have now are so deeply embedded in precision oncology/2010s-RWD that they are completely unprepared to address what post-LLM healthcare data sales will actually mean

what’s the best truly banned book?

not like 1984 banned — I mean PDFs that are literally unprintable, truly arcane knowledge the McKinsey internal firm history is an obvious one though easy to get these days

the sequoia history that mm wrote is an obvious one (unless @shaunmmaguire 🤝)

The AI/healthcare discourse has reached new levels of insane this week

A close friend, a MD at a prestigious medical center, recently shared the following memo with me. He asked me to share this anonymously.

"What we don't talk about when we talk about AI/medicine" 1. Standard of Care isn't Standard Care

Novel modalities of care (AI-assisted, etc.) are measured against a platonic ideal of SOC that doesn't exist in clinic

Medicine is as much of an art as a science, providers are overworked, tired, and often veer dramatically from SOC.

The Executive Order on AI issued by the White House today represents the beginning of a complete overhaul of the regulatory landscape for healthcare AI.

Here are my notes on what matters from the 100+ pages: Let's start with a quick summary of the EO's requirements:

- Within 180 days, HHS shall publish a plan to promote responsible AI use in public benefits like Medicare/Medicaid. The plan should address access to benefits, notice, evaluation for unjust denials, etc

(Section 7.2b)

healthcare is having its top deck of the titanic moment

what happens in the next year will define the next century of american healthcare, and basically everyone is ignoring it.

here's the real story: Healthcare has been defined by four factors:
1. Extremely limited supply (MDs are scarce and costly).
2. Principal-agent problem with payments (your insurance pays, not you).
3. Inelastic demand and high trust (you need it and have confidence in it).
4. Regulatory capture.

You can outperform most venture funds by buying LEGO.

I analyzed the last 20 years of secondhand LEGO pricing data, and found randomly purchasing sets will match most VC's returns

if you're somewhat intentional about what you buy-- you massively outperform even the best firms I pulled data on 16,000 LEGO releases since the year 2000. I dropped any promotional items, duplicate items, or any other oddballs. This got me down to 10k or so.

For each, I then pulled in resell data from bricklink for each item to get current market price (ebay prices higher)

Norton Commons is the most underappreciated development project of the last few decades.

A hyper-walkable, basically car free, traditional community built in the middle of Kentucky in 2003

No venture funding, no twitter threads on vitality. They simply chose to build well.



Norton Commons is in Prospect-- a farming community roughly 15 miles west of Louisville.

The land was originally a family farm owned by the Norton Trust. Mary Shands inherited the farmland in 1988 and wanted to preserve the rural character of the land.

Last year, I paid thousands of dollars for a physical at one of the best hospitals in America

I wanted to see how different healthcare was for the ultra-rich, and what this meant for the rest of the healthcare system

Here's what I learned: I work in healthcare.

I was always aware that executive physicals— ultra-high-end, luxury concierge care— existed, but I had never met someone who went through one.

and now, due to an accident with my flexible spending account, I ended up with enough cash to try it out.

if you ask anyone, they’ll tell you hard tech is … well hard

they’d be wrong

there’s a secret playbook to raise billions as a deep tech entrepreneur

without ever having to ship product

here’s how: step 1: problem selection

the perfect problem is easily explained over cocktails, and sounds straight of of a sci fi novel.

the best problems are known to be impossible at the outset for reasons outside of your control such as “physics” or “the law”

on the 28th of January, 1983, 15kg of dynamite annihilated a data processing plant in Toulouse, France during the dark of night.

the blast caused $30m of damage

marking the beginning of an unprecedented campaign by disgruntled software engineers to kneecap tech progress the attack was claimed by a group calling themselves the Committee for Liquidation or Subversion of Computers.

CLODO, "bum" in french

the group claimed to be IT workers radicalized by the growth of computing its role in facilitating violence, surveillance, and office drudgery

Healthcare spending makes up 20% of the U.S. economy,

yet only 1 of the 100 largest software companies in the world is a healthcare software company.

Why has healthcare been a graveyard for enterprise software? And why is it actually the best place to build a saas monopoly Healthcare seems like the perfect vertical for enterprise software:

- Huge market (20% of GDP)
- Growing rapidly (5% YoY)
- Ballooning IT spend (3% YoY)
- Huge unmet need -- today's bad software leads to poor quality of care, physician burn out, inflated costs

founders/vcs are making a huge mistake by applying generative AI to healthcare delivery

GPT3 isn't going to replace your doctor, but it will change how healthcare runs.

Let me explain: Technology in healthcare has a massive trust problem.

Every "generational shift" in technology has lead to big expectations, and even bigger failure in healthcare.

from "AI" like IBM Watson to RPA companies, billions have been burnt on big dreams and little impact in clinic.

On Saturday night, a gunmen opened fire on two power transformers in North Carolina

The attack plunged 45,000 homes into freezing darkness.

This is the second sniper attack on a US power station-- the most important terror campaign you've never heard of. The event is a sober reminder of the Metcalf Power Station attacks just a few years back

Where an unknown attacker opened fire onto the power station powering the entire Santa Clara Valley. That attack is still unsolved, with no motive or suspect.

https://twitter.com/WillManidis/status/1533814922366308360

I've never seen VCs make a bigger mistake than generative AI.

They are funding many projects that are destined to be abject failures.

Even worse, they are totally missing the places where ML will actually have impact and generate enterprise value.

Let me explain: To be clear-- innovations in large language models and ML broadly are real. We've made a decade of progress in the last month alone.

I've been running a large language model company for four years now, I am not a skeptic. These things will change the world.

if i were an intelligence agency, and i was concerned my adversaries were using crypto to launder funds-- how would i stop that?

first i'd find the central casting idea of a tech founder-- mit dropout, finance, cargo shorts, long hair, sleeps on a beanbag kind of guy then i'd stick him offshore and claim he's discovered an "arbitrage" on a forex market. the details don't matter, but it should require unauditable otc transactions and credibly add up to a couple billion bucks.

all that matters is its mildly believable and its not on chain

In April, a team of cyberattackers attempted to breach an undersea cable off the coast of Hawaii.

The cable is part of a network that carries over 95% of the world’s data.

The attack is one of in a series of mysterious attacks on US infrastructure. Let's dig in. Submarine cables are one of our most essential pieces of infrastructure. Hundreds of them are in operation ranging from just a few miles to over 10k miles.

These are the highways over which global information flows.

compromise one, and you have everything.

Freeport, one of the largest US plants exporting liquefied natural gas, exploded on Wednesday.

Freeport represents a critical piece of infrastructure in Europe's divestment from Russian oil. Yet this story is almost no where in the mainsteam news, so let's dig in. Freeport is represents over 20% of US natural gas exports. A ten billion plus+ capex project, the plant processes two billion cubic feet a day of pipeline-quality natural gas.

the plant spits off $7.4b in revenue yearly. 80% of its shipments are direct to Europe.

On April 16 2013, a team of highly skilled gunmen opened fire on the Metcalf Power Substation in San Jose California.

In just under 10 minutes, they disabled 17 transformers and caused $15m in damages.

This is the most important terror attack you've never heard of. Quick thread The PG&E Metcalf substation provides most of the Santa Clara Valley with power-- Facebook, Stanford, etc. are all on this grid.

The attackers are still unknown, they were never caught, and the motive is still unknown.