9/15/23: Unevenly Distributed

“Gene-editing technologies, which include the CRISPR-Cas nucleases and CRISPR base editors, had long been theorized to have the ability to permanently modify disease-causing genes on a population level. The landmark 2028 FREEDOM trial was the first to demonstrate the durable near-complete knockdown of PCSK9 in the liver after a single infusion of CRISPR base editors delivered via lipid nanoparticles. This “once-and-done” approach appeared to lower lower-density lipoprotein cholesterol by approximately 95-99% for all trial participants. Many within the medical community heralded this as the beginning of the end for atherosclerotic cardiovascular disease - the leading cause of death worldwide.”

• Human Bio-Augmentation, A History; 3rd Edition, by Wily Nelson, MD

---

It was a cold Cincinnati morning, and John’s partner had called in sick yet again. 

“Sorry kiddo,” his supervisor said. “Larkin says his kid came down with a tonsillectomy. You know how it is.”

“His kid caught a tonsillectomy?” John asked.

“Got a tonsillectomy. Caught one. Doesn’t really matter. The point is, you’re on your own today.” 

It was the third time that month, and John could have asked to pull in someone else from the department, but he was too tired to fight it. Their department’s budget was actually more than adequate. But staff shortages were a pervasive problem across the entirety of the DEA, not just their department. He was also remarkably hungover from the night before. Spending the day working by himself sounded almost pleasant.

With a sigh, he put on his uniform and drove to the first location of the morning. For months, he had been trying to track down an illegal CRISPR lab. He was always three steps behind; by the time he arrived, the warehouse or basement would have already have been abandoned for weeks. 

So when he approached the apartment and heard the sound of Beethoven from behind the door, he froze. Could he have finally caught up?

It would be nice to have a win, he thought. I haven’t had a win in ages.

He pulled out his firearm, keeping it aimed towards the floor. Then he rang the doorbell and waited.

The Beethoven that had been playing from behind the door shut off abruptly. Then there was the sound of a chair scraping across the floor. 

“This is the DEA!” John yelled. The lines felt familiar to him now. They hadn’t, at first. “I have a warrant; open up!” 

The sounds of scraping across the floor continued. Someone was moving furniture, or boxes in the apartment. John banged on the door again, but the noises continued. 

“I’m going to count to three, and then I’m going to kick down the door!” he replied. The non-hungover part of him wondered if he should be calling for backup. There were protocols for this. The adrenaline-marinated, hungover portion of his brain politely ignored that thought.

“One… Two…”

And then he kicked down the door. 

He hadn’t expected the first kick to work, but it did. The frame was brittle and positively ancient, and the entire thing fell into the room like it was a stage prop.

Standing in the middle of the room, surrounded by a mess of computers and stolen laboratory equipment, was a panicked-looking mouse of a woman.

“Freeze!” John said, his gun still pointed down towards the floor. He tried not to point it at people. Pointing it scared them, and scared people were liable to do stupid things. It also made him feel like a bad person.

The woman put her hands in the air.

“I declare surrender,” she said, nervously. “I mean. I surrender.”

He recognized her face from the case files he’d been given. 

“Cara Levine?” he asked.

“Yep that’s me,” she said, the tremble in her voice smoothing out. “Cara Levine. Surrendering. Don’t shoot me please.”

It was the simplest arrest he’d ever made, and after only a few moments, she was handcuffed and sitting down by the side of the room. 

What am I supposed to do next again? the hungover part of his brain asked. Oh right. I should tell someone about this. 

But neither his phone nor his radio were working.

“That’s to be expected,” Cara said helpfully from the side of the room. “This building is in a weird dead zone. None of the mobile carriers cover it.” 

“You have the right to remain silent - “ John began.

“You’ve said that already,” Cara said. 

Ah. Right. He had, hadn’t he? He looked around the room, clacking the space bars on the keyboards in front of him. None of them worked. He saw an oddly shaped disk attached to a handle on the desk. 

“Did you magnetize all the hard drives?” he asked in disbelief. He brought it against a leg of one of the tables, and sure enough, it stuck there. 

“No comment,” Cara said. 

He looked around the room. Some of the laboratory equipment was hastily destroyed. The window was open - when he looked out, there was debris on the street twenty stories below. She must have thrown some of the evidence out the window. 

“You could have killed someone if they were walking there,” he said. 

“No comment,” Cara said again. “Although, can I say just one thing? Can we skip to the part where you take me to the police station? Or DEA station, or whatever you guys have nowadays? These handcuffs are killing my wrists.” 

He ignored her, and looked more around the apartment. It was dilapidated and pathetic-looking. The beams of one of the walls were exposed. He took pictures as he walked through the rooms one by one.

“Where’s the CRISPRinter?” he asked. “They’re usually the size of a mini-fridge. Can’t exactly push those out the window.” 

“No comment,” Cara said. “Though if we’re going to be here a while, could you get me some water?” 

He studied her face. She radiated false confidence. 

“Sure thing,” he said. 

“Glasses are on the second cabinet to the left in the kitchen,” she said. 

The kitchen was in a profound state of disrepair. He poked around in the freezer, hoping to find something incriminating, but the only thing there was a bag of frozen tilapia. He poured water into a mug (“Berkeley BioLab” in bold letters wrapped around the side), put a straw in it, and held it in front of her face.

“You’re not particularly good at this, are you?” Cara said, after she took a sip. “I’ve been arrested before. They seemed more like they knew what they were doing.”

“Shut it,” he said, not even bothering to be annoyed. “Alright, stand up. We’re heading to the station.”

The hallway had paint peeling off the walls, and the lights were flickering like they were on their last legs. The entire building gave him the heebie jeebie’s. 

“You got a cabbage?” Cara said to him in the elevator. The door was having trouble closing. He pushed the button again.

“Sorry?” he said. Then the words crystallized in his head. “Oh you mean a bypass. A CABG.”

“You have a scar on your forearm,” Cara said. “They used your left radial artery, didn’t they? A bit unusual, that.” 

“I thought you were a bench scientist, not a surgeon,” John said. He pushed the close button a few more times, and the elevator doors finally squeezed shut. There was a jolt, and they started moving downwards at a snail’s crawl.

“Usually they harvest the radials only if you’re getting a quadruple bypass,” she said. “Or if you have fucked up saphenous veins and they’re desperate.”

The elevator made a groaning noise, like metal on concrete. Then it shuddered to a stop. 

“Fuck,” he said. He pushed the open button, but the door didn’t respond. “Fuck fuck fuck.”

“Yeah the elevator has been having problems,” Cara said. “Sorry about that.”

“Fuck,” John said. He checked his phone - still no signal. He pressed the open button again, but the door stayed shut. “How did you end up in this shithole of a building anyway?” he asked. 

“I’m a wanted woman. Hard to make ends meet,” she said. “I wasn’t exactly doing it for the money.”

John tried over the next few minutes to pry the elevator door open with his hands. They didn’t budge. There was a “Help” button on the bottom right of the panel, but it wasn’t clear that pushing it did anything. 

“There’s an old Russian lady who lives on the floor below me,” Cara said. “She’s the only other person in the building. Wouldn’t leave even after it was condemned. She comes home in the evenings and can’t take the stairs. So if we’re still in the elevator by then, she’ll call someone.”

“Good to know we’re not going to starve here then,” John said. 

“We’d die of dehydration first,” Cara said helpfully. 

John pounded on the doors, trying to make as loud a racket as he could. For the next fifteen minutes, he proceeded to yell his voice hoarse.

“I’m telling you, there’s no one else in this building except for me and babushka. If we’re going to be stuck here anyway, can you at least take off my handcuffs?”

“No,” John said. 

“Have it your way then,” she said, sliding down the wall until she was sitting on the floor. 

He found himself having a strong desire to pace, which was an item on a long list of things he couldn’t do in an elevator. For the third time in as many minutes, he found himself cursing the fact that he had come here without backup. 

“So when did you get your CABG?” Cara asked. “Not a ton of them done much anymore. Not after the 5th generation stents came out.”

“What do you care?” he said, sliding to the floor himself. He felt suddenly very tired. This was possibly the worst day he’d had in the DEA in a long time. And he had had a lot of bad days. 

“I care more than you could possibly know,” Cara said. There was a manic gleam in her eyes. She looked alive for the first time since John had met her. 

He had read her file of course. She had been a post-doc at a Berkeley lab, producing work of middling quality, before suddenly disappearing with millions of dollars in equipment. A few months later, a new notice appeared on the homepage of Saffron Road. 

“FREE DOSES OF PCSK9 KNOCK-OUT CRISPR TREATMENTS DELIVERED RIGHT TO YOUR DOORSTEP,” the banner read. “THIS IS NOT A DRILL.”

There was a ten page manifesto attached, along with detailed instructions on how to use the auto-injector and notes on quality control. People were skeptical at first. PCSK9 CRISPR treatments had been well-validated years, but the cost for a single dose ran close to a half-million dollars and wasn’t covered by any insurance company. A single company, Tepathic, had a chokehold on the market. 

But the allure of something so too-good-to-be-true was powerful. Anecdotes began appearing of individuals who tried the injector and who a month later had cholesterol levels of near-zero. The volume of orders on Saffron Road increased. Several labs at major academic centers verified that it was, in fact, indistinguishable from Tepathic’s product. 

“You do care, don’t you?” John said with a sigh. He felt resigned. Either the old Russian lady or the DEA department would eventually find them. But until then, they were stuck. 

“Yeah,” Cara said. 

John checked his phone again, but of course there was no signal.

“Did you get a Tepathic dose? After your CABG?” Cara asked hesitantly.

“No,” John said. “Too expensive.”

“Do you want one?” Cara asked. 

For a while there was only silence, as the two of them sat on the floor staring at each other. 

“Are you trying to bribe me?” John said. 

“No no,” Cara said. “I’m just… I know that this is it, you know? I had a good run. But this is it for me. I figured I’d hand out one more dose. God knows you need it more than most.”

“I’m not going to use black-market CRISPR made in someone’s kitchen and fuck up my genes,” John said. “I read about what happened with the generics.”

When Tepathic patents had finally expired, the market was initially flooded with generics. Every one of them had quality control issues. After the third death, the public was spooked, and the FDA placed a moratorium on non-Tepathic products. 

“Entirely overblown and fabricated,” Cara said. 

“Didn’t take you for a conspiracy theorist,” John said. 

“I know for a fact that Tepathic sabotaged its competitors’ production line,” Cara said. 

“And what, your doses are just as good as theirs?” John said. 

“I’ve given out forty thousand doses, and followed up with thirty thousand users. Not a single notable side effect. The sample size is large enough for me to say that I believe in my product, thank you very much. So you want the dose or not?” Cara said. 

“You realize that I can’t legally take this from you,” John said. “You realize that this is trap. I know it’s a trap, you know it’s a trap. We both know it’s a trap. It’s a half-million dollar bribe.”

“It’s not a bribe if there are no strings attached. There’s an auto-injector in my right pocket. If anyone ever asks me, I’ll deny everything. No one else will know.” 

“You truly mean it, don’t you?” John said, with a hint of wonder. 

“I never did this for the money. I did it for people like you. If Tepathic hadn’t exploited the patent system and extended their rights by ten whole years, if they hadn’t sabotaged their competitors, if they hadn’t fucked up the generics - you would have had a dose in your hand ten years ago. You would - probably - have never had a heart attack. You never would have needed anyone to open up your chest and fuck with your plumbing. The actual cost of making the doses is dead cheap now, with the next-gen CRISPRinters. The future is here, and I was fucking going to evenly distribute it.” 

She said all of this with almost a religious fervor. For a second, John was envious. He wished he believed in something - anything - as strongly as she did.

“Did you know that my dad was an interventional cardiologist? He put stents in people for a living. You know what he said to me when the first Tepathic doses came out? He said, ‘This is going to put me out of a job, and I just love it.’ He had that dream! The dream was there - it just never materialized. And you know what? I have no regrets. I’ve saved an order of magnitude more lives than my dad ever did. If he was still here, he’d tell me he’s proud of me. And so yeah, this is the end. But I’m going down with my head held high. And if you take the dose from my pocket, that’s one last good deed that I’ve done.” 

He hesitated.

“Right pocket, you said?” 

She nodded. 

After a few moments, he fished it out of her pocket. It was a small pen-like device. The only auto-injectors he’d ever seen were Epipens; he’d never seen something like a Tepathic dose in real life.

“How do I use it?” he said. “If I were to? Hypothetically, I mean.”

“You flick the orange button. That loads the syringe. Then you press it down against your thigh until you feel a sting. Hypothetically, of course”

“That’s it?” 

“That’s it.”

John thought back to when seven years prior. He’d been having more difficulty with stairs. Had been prescribed antibiotics for a pneumonia. And when it finally got bad enough that he went to a hospital, he felt like he was the only one out of the loop. 

“You’re having a MI,” a doctor said to him. 

John only realized once they started talking about bypass surgery that a MI meant a heart attack. He still had thought he was going to be treated for pneumonia. People in their 40’s didn’t get heart attacks, he thought. 

The surgery had gone well. He did his cardiac rehab like the good patient he was. Went back to work the next month. 

The DEA was dealing with the Second Fentanyl Crisis back then. He threw himself into his job, almost as a way of avoiding having to think about his own mortality. He rose through the ranks. Developed a drinking problem. Fell back down the ranks. The Crisis ended, and he had been transferred to the Biologics Black Market division a month ago. He’d never wanted the transfer in the first place. Had been looking for a way to get himself fired, if he admitted it to himself. 

What was he doing with his life? He had gone into the DEA to make a difference - had prevented overdoses, had cracked half a dozen Fentanyl shipping rings. And now he was here, in an elevator with a washed up postdoc who just wanted to save some lives.

He knew the data on Cara’s doses. Knew that they worked, that they were good. 

“Tepathic can’t dominate the market forever,” he said. “The market pressure is too great. Sooner or later there will be generics. Every baby in the country will get a dose, as part of their vaccination series. A vaccination against heart disease.”

“How long will that take? A generation?” Cara replied. 

“Less than that,” John said. 

“Whatever it is, it’s too long. Tepathic is not maximizing for the greatest number of lives saved, I can assure you that. I’ve run the numbers. The yearly opportunity cost of the lack of a generic is on the order of 2.3 million lives.”

“That sounds way too high to be true,” John said. “Even if it is, what are you going to do? Distribute it to everyone in the country?” 

Cara didn’t say anything. 

“You were, weren’t you?” John said. 

“It would have taken too much infrastructure,” Cara said. “I was always on the run. Could only ever make several hundred at a time in each batch. But yes, the dream was to systematically mail it to every person in the country. If Bed Bath and Beyond could do it with their coupon flyers, I could too.”

“That’s quite the - “

“A girl can dream,” she replied. 

In that moment, John made a decision. If he was honest with himself, he’d made it the moment he held the injector in his hand and felt that it was real and not just a hypothetical. 

“What if I was never here?” John said.

“Excuse me?” Cara said. There was a tremor in her voice.

“What if…” 

John took a moment to summon the courage to say it. 

“What if you had someone on the inside. Someone who could keep you several steps ahead. Someone who could lead the DEA down dead ends, keep them off your trail. Someone who could give you the breathing room to settle down, properly establish yourself. Build up the manufacturing capabilities to print out as many doses as it takes.”

“That’d be nice,” Cara said. “Hypothetically of course.”

“You and that someone would have to have burner phones. A way of communicating covertly. There’d have to be a protocol. They’d have to spoof their location-tracker so that they were never here.”

“Those are all doable,” Cara said. 

They met each other’s eyes. In that moment, they understood each other better than perhaps anyone else in the world. In that moment, they shared the same dream. It was a good one.

“Hypothetically of course.”

---

Author’s Note:

1. PCSK9 inhibitors are a class of medications which dramatically lower cholesterol. They’re usually once-monthly injections. They are quite expensive, although some insurance companies are beginning to cover them for patients who have failed statins.

2. CRISPR editing of PCSK9 is currently being investigated. The beginning header of this story is partially cribbed from here.

3. Cara is partially inspired by Owsley Stanley, who at one point likely accounted for a double-digit percentage of all LSD in the U.S. Pretty impressive for just one individual. Inspiration also comes from the difficulty in tracking Fentanyl orders via mail. Turns out that when the drug quantities are small enough to fit in envelopes and travel via U.S. postal service, it’s hard to crack down on distribution.

4. The original title for this story was “Elevator Pitch”