9/30/23: A Field Trip to the Island of Stability

Author’s Note: This story is a direct sequel to The Island Of Stability. It will therefore make more sense if you read that part first; but this is not a strict necessity.

---

Medical lingo

Nocturnist: a hospitalist who works night shifts

AMA: Leaving the hospital “Against Medical Advice”

Frequent flyer: Someone with frequent repeat admissions

CDU: Clinical Decision Unit - a low-acuity emergency department unit that monitors patients who don’t necessarily need to be formally admitted

---

It was 2am when the pager went off, yet again. 

Judith groaned. She had broken her own rule, which was to never work more than five nocturnist shifts in a row. But a coworker had called in a favor, and so now she found herself at the end of a seven-night stretch.

She picked up the phone and dialed back.

“This is Dr. Yelson returning your page,” she said, smoothing out the annoyance in her voice.

“Hey Judith. Got a softball admission for you,” the voice on the other end said. 

“Hey Martin,” she said, recognizing his voice. “Your softballs are never actually softballs, you know that right?”

“It’s that dude James Laurel again.”

“He’s back? Already? He was discharged, like, 18 hours ago.”

“He wasn’t discharged, he AMA’d,” Martin said. “You know how it is with these alcoholic frequent flyers.” 

“You’re not supposed to say ‘frequent flyer,’ Martin - “ Judith began, almost out of reflex.

“Yeah yeah, sue me. Anyway, he left the hospital, went to the nearest Walgreen’s, downed half a liter of rubbing alcohol, and now he’s here again. Non-arousable to sternal rub, blood pressure a little soft with systolics 90’s, tachycardic to low-100’s. I gave him a liter of normal saline just to see if he would perk up, but no dice.”

“Can’t you just throw him in the CDU?”

“Judith, come on now,” Martin said. “Help me out a little here. Last time he was in the CDU, he found a jug of hand sanitizer and drank the whole thing. If I try to admit him there, they’re gonna bite my head off.”

“Okay okay,” she said with a sigh. “Didn’t mean to snap at you. Just been a long night, that’s all.”

“I feel you, bud. You accepting?” 

“Yeah, I’ll admit him. Take care, Martin,” she said. 

“You too, Judith.” 

She hung up the phone and rubbed her eyes. She wanted nothing more than to go to the call room and lie down, but she had a suspicion that a micronap would just make her feel worse.

Martin wasn’t lying though - it truly was an easy admission. The first time James Laurel had presented to the ED, she’d called the Poison Control Center. Isopropyl alcohol poisoning was not something she’d ever seen in residency. But now, fifteen admissions later now, it felt bog-standard.

“Why do you do it? Drink rubbing alcohol, I mean?” she’d asked him.

“You know how much a liter of it costs at CVS?” James asked.

“I don’t know. Ten dollars?” she said. 

“Four bucks. A bottle of jack would be twenty bucks, easy,” he said.

What a rational explanation, she’d thought to herself. And so the cycle continued. He would present to the ED, completely obtunded. He’d be admitted for altered mental status and acute kidney injury. And he would AMA upon waking, before he even started going through alcohol withdrawal. 

It took her thirty minutes to see him in the ED, make sure he was still breathing, throw in admission orders, and write her admission note. 

Afterward, she was in the workroom, drinking her third cup of coffee for the night. Her muscles had a particular sourness to them, like they had been soaked in vinegar. She thought again about going to the call room, but the superstitious side of her just knew that she’d get another page as soon as she lay down. 

She scrolled on her phone instead. It was a simple, mindless thing to do. There was a trend recently of acrobats doing physical comedy, and their videos dominated her feed. She was ten minutes into that particular rabbit hole when suddenly an ad appeared on her feed.

“Want to change the world? Have an outlandish idea but no idea how to implement it? Add your idea to the Island of Stability’s Game-Changer doc. YOU PROVIDE THE IDEA. WE’LL MAKE IT A REALITY,” it read. 

She frowned.  

The Island of Stability had never run advertisements before. They didn’t need to. Over the past twenty years, they’d recruited the cream of the crop of scientists from the world over. If she had even an ounce of a drive to do research, she’d have applied to become a citizen there.

She clicked the link.

Before she even realized what she was doing, she was typing out a submission. 

“Proposal: Develop a non-hepatotoxic artificial alcohol. Current burden of disease from ethanol consumption is astronomical. Sequelae of ethanol results from accumulation of its metabolite, acetaldehyde. Alternative alcohols such as isopropyl alcohol have similar GABA-nergic properties and are consumable by humans, but are broken down into metabolites with similar hepatotoxic effects. Theoretically there should be a cousin of ethanol that provides the same social lubricant and anxiolytic effects, without deleterious metabolites. There’s no reason the world needs to have so many cirrhotics.”

The moment she hit the submit button, her pager went off - yet another summons by the emergency department. She put her phone away. There were five more hours left in her shift. Five more hours before she was home in her own bed, snuggled next to her cat. 

She picked up the phone.

“This is Dr. Yelsen returning your page,” she said. 

---

Two days later, Judith was watching the latest season of the Bachelorette in her pajamas, when there was a knock on her door. 

“Coming!” she said, standing up. Her cat, Jinx, jumped off the couch with a startled meow. 

She opened the door to a neatly-dressed man carrying a messenger bag. It was a beautiful autumn day outside. As she watched, an oak leaf carefully deposited itself on his head.

“Dr. Judith Yelsen?” he asked.

“Yes?” she said blearily. She still had not quite day-shifted, and so it even though it was 2pm she wanted nothing more than to take a nap.

“My name is Terry Sanchez. I’m a Field Representative from the Island of Stability. You submitted a proposal a few days ago. Do you have a moment to talk?” he said. 

“…No?” she said. 

“I’m not trying to sell you anything,” he said. 

“Oh,” she replied, while thinking through how best to close the door on him. “Still no, then?”

“We’d be willing to pay you for your time,” he said, digging through his bag. “Wait one second… okay here.”

He handed her a check. 

It was for ten thousand dollars.

Judith stared at it. 

“…what the literal fuck?” she said. 

“Half an hour of your time, to be precise,” the man said. He fidgeted with his bag, looking very uncomfortable. 

She’d never met anyone who was actually from the Island of Stability. Her old college roommate, Larson, had been a computational biologist and had disappeared there. 

“They have gobs and gobs of money,” Larson had emailed her. “It’s amazing here. I just walked in, and they gave me an apartment. You have to come and visit sometime.”

But it was one thing to read about the Island on the news, or hear about it in the abstract, and another to be handed check, apropos of nothing.

“Is this a scam?” Judith said. 

“No,” Terry replied. “Although to be frank, if this was a scam, I would say still say no.”

Judith looked down at the check again. It looked, for all intents and purposes, real. 

“You’re not an axe-murderer either?” 

“Axe-murdering is not very good for job security in my line of work.”

“Well, you guys sure know how to make an entrance,” she said. “Alright, come in. Sorry about the mess.” 

She closed the door behind them, and they sat down at the kitchen table. She spied Jinx hiding in the closet by the corner. He’d never liked strangers.

“Cards on the table, I’m here to recruit you,” Terry said. 

“Recruit me?” 

“Two days ago, you submitted a proposal. It’s been trending on our internal funding website,” he said. 

“Trending?”

“Funding at the Island is based on a ranking system. People submit ideas - not grants, mind you, just ideas - and it gets entered into a publicly editable list. Every month, every citizen on the Island gets ten votes to distribute based on how high-impact they think a certain idea is. The most up-voted two hundred ideas then get funded based on a ranking algorithm. It cuts down on the amount of time researchers spend writing grants.”

“I just wrote a paragraph though. It’s not even an idea. It’s an idea of an idea.”

“People have expanded on it,” Terry replied. “Right now, it’s number 67, right between ‘gene-drive to kill off mosquitoes’ and ‘bioengineered algae diet to reduce methane emissions from cow flatulence.’ It also seems like low-hanging fruit, which tends to be a crowd-pleaser.”

Judith sat there for a while. Her thumb rubbed against the check absent-mindedly. She had never wanted for money, but it still felt absurd to have a stranger just hand her a check in order to talk to her. 

“It seems insane to me that funding is done by direct votes,” Judith said. “I’m still trying to get over that.”

“I have a spiel for that. Do you want the short version or the long version?”

“Short, please. Actually wait, no - long. If I stall for the next half hour and our conversation runs over, do you just hand me another check for ten thousand dollars?” 

“No,” Terry said with a rueful chuckle. “I’ll give you the short version then. Do you know what ARVC is?”

“Arrhythmogenic right ventricular cardiomyopathy,” Judith said.

“Yes, in fact. It’s a a relatively rare condition; its incidence is around 1 in 5000. But it is extremely well-characterized, and has received a disproportionate amount of funding. The reason is that a wealthy billionaire - John C. Boglehead, of Bogleheads fame - was diagnosed with the condition and then proceeded to invest a fortune in it.”

“And that’s… bad?”

“Quite. I mean, at least he invested it in science, rather than the toys and whims of billionaires the world over. But it’s vastly inefficient as a means of allocating resources. Now, you may say to yourself, ‘but isn’t that exactly what Jane Pearson, the Island’s founder, did with Alzheimer’s research?’”

“Isn’t that exactly what Jane Pearson did with Alzheimer’s research?”

“Har har, very funny. But yes, Pearson described it as her ‘wealthy trillionaire’s problem.’ So she created a crowdsourced list of open problems in biomedical sciences. Democracy works for prediction markets and also for governments - well, for the most part - so why shouldn’t it work for science? So the citizens of the Island vote on the rank-order of different projects, and the Council puts bounties on each and every problem. For example, a cure for Alzheimer’s has an outstanding bounty of ninety billion dollars; with additional bounties for each subgoal or deliverable on the roadmap. Investors from outside the Island then fund scientists working on the problem, and the bounty is divided amongst all parties involved once the problem is considered solved.”

“Seems complicated. What do you need me for then?” Judith said. “I’m a physician, not a scientist.”

“The Island is a bubble. We’ve been thinking recently that there needs to be fresh blood circulating through it on a monthly basis. It would help prevent stagnation, inject new ideas. It’s good marketing too; you’d come back to your life here in Atlanta with a positive impression of the Island, and that kind of impression spreads.”

“Propaganda, in other words.”

Terry shrugged. 

“It’s an all-expense paid trip to the only place in the world that has a plausible claim on a true solarpunk utopia. You going to turn it down?”

Judith had already made up her mind earlier, but she hadn’t wanted to say yes too quickly lest she sound too eager. It was a bad habit of hers. She cared too much about what others thought of her.

“I’ll need someone to take care of my cat,” she said, looking at Jinx who was still hiding in the corner. 

“Your cat can come too,” Terry said, smiling. 

“Oh. Well in that case…”

---

The next day, she found herself peering out a window as her plane circled over the Island, waiting to land. 

It was less glamorous via a bird’s eye view than she expected. She’d seen pictures, of course, and knew that when the Island was being built, architectural modesty was a guiding principle. But somehow in her mind’s eye she had still expected skyscrapers of glass and steel. Here from the plane, all the buildings looked squat and ugly.

Terry, who was sitting next to her, seemed to relax once they landed. 

“I’ve never liked flights,” he said. “They give me the heebie jeebies.” 

The first thing she noticed as they rode the tram out of the airport were the murals. The buildings, for the most part, all appeared to be made out of concrete, but it seemed like every available surface of every building was covered in meticulous artwork. 

“It was decided early on that concrete was the fastest method of construction,” Terry said. “All the sides of the buildings are standardized, so that an automated layering device can roll up and down and spray-paint murals. Each building gets a refresh every five years or so. That one over there is one of my favorites.”

He pointed at what looked to be a combination coffee-shop and firehouse. There was a lanky dragon of blue and white sitting on a boat, holding a fishing pole. 

“It’s Tiamat, the goddess of saltwater. There’s a petition circulating to keep her permanently. Her counterpart, Apsu, is on the desalinization plant over at the other end of the Island.”

The tram was clean and quiet, winding its way through half a dozen neighborhoods. 

“It’s more… chaotic than I expected,” Judith said. “I was expecting more straight lines. More of a grid layout.”

“Pearson said that everyone she knew who lived in Solano County hated it. Part of that was that it felt so centrally planned, with their sterile boulevards and rational grids. So she copy-pasted each neighborhood here from organically-evolved cities; alleyways, tiny shops, little surprises, non-ergonomic streets and all. The building materials are all different of course; the concrete here actually has passive carbon-scrubbing features; the murals are meant to hide that. But it turns out that when you have a seamless automated tram-gondola system and all the cars of self-driving, a grid-layout doesn’t provide much in the way of efficiency gains. No loss there. Here - we’re about to pass through the Budapest neighborhood - they have the best sandwich shops on the island.”

The tram had a tiny jolt as they were lifted into the air. Below them, she saw a gang of three year olds chasing a dog down the street. There wasn’t an adult in sight.

“I know what you’re thinking. The kids will be fine. They’re not entirely free-roaming. They all have a walkie-talkie if they need to call home.”

The small carriage the two of them were sitting on split from the others in the tram-gondola, and after a few minutes arrived by the balcony of an apartment building. It reminded Judith of the trip she took to Venice as a child, stepping out from a boat directly onto the stoop of the hotel. What remained of Venice was no longer open to tourists; she cherished the memory dearly.

“Well, this is you,” Terry said. “Sunset is in a few hours. You can walk around the city however you like. If you need to get to ground floor, there’s a ladder by the side of the balcony. I’ll meet you here at 8am tomorrow for the formal tour.”

That was another difference, Judith thought. The house was entirely non-ADA compliant. It probably broke a hundred different fire codes. 

Terry gave her a small mock-salute, and the gondola swept him away, leaving just her on the balcony. A gentle sea-salt breeze ruffled her hair. She should have packed a warmer jacket.

The apartment itself was modest. The lights came on with a warm glow when she stepped inside, somehow matching the hue of the sunlight outside. She was feeling grimy from the flight, and stepped into the bathroom. A small placard sat by the sink. 

Dear Guest,

The water at the Island of Stability is treated with several compounds, which include:

Pitavastatin

Telmuglutide

Yeltiflozin

Janitformin

These compounds and their risk-reward profiles have been reviewed and voted upon near-unanimously by the Island’s citizens. Contrary to popular belief, Island water does not contain Lithium or any medication in the SSRI or benzodiazepine class; see the FAQ section on your Welcome App for more information. If you prefer to use non-treated water, please contact your building manager with the QR code below.

Warmly,

Island Welcome Service 

Judith recognized the first three medications, and could only assume that the last was a cousin of Metformin. She shrugged, then washed her hands and face. When she poured herself a glass of water later, it tasted fine.

She opened the welcome bag; it had a small pastry, a toothbrush with a small tube of toothpaste, and a note.

Dear Guest,

Happy Mid-Autumn Festival! As an Island of immigrants, we observe approximately 2.3x the number of holidays than the average country in the rest of the world. The pastry attached is a mooncake, made using Pearson’s mother-in-law’s traditional recipe. The one alteration is uses Incredo-Sugar, which has the same chemical structure as sucrose but a higher surface-area to density ratio; allowing the same sweetness but with a 70% reduction in calories.

The toothbrush included here contains a strain of bacteria which produce ethanol rather than lactic acid. It outcompetes oral flora and achieves population fixation usually in under 24 hours, providing lifetime protection from cavities. Please note that this product is not currently legal in any country outside of the Island (see FAQ for extended explanation). Please note that extended oral contact (aka French kissing) has a high probability of spreading the colony to others. 

The toothpaste included contains gut bacteria (see complete colony composition in FAQ) which have been selected for their neurohormonal modulatory effects; associated benefits include a reduction in incidence of Parkinson’s disease, Alzheimer’s disease, chronic fatigue syndrome, fibromyalgia, postural orthostatic hypotensive syndrome and its various tachycardia-inducing subtypes, and a near abolishment of irritable bowel syndrome. Users with inflammatory bowel disease in general report a reduction in frequency of flares, with Crohn’s patients deriving greater benefit than those with Ulcerative Colitis. Certain bacteria strains contained in this toothpaste affect intestinal absorption of calcium, which provides a protective benefit against bone demineralization in post-menopausal women. Please note that this product is not legal in any country outside of the Island, and may not be taken outside of its borders. It has been validated using rapid iteration human-challenge testing and not the clinical trials format with which you may be more familiar. For more information, see FAQ, under section title (“Is this just a fecal transplant?”)

Please feel free to discard after use.

Warmly,

Island Welcome Services

Judith stared at the toothbrush. 

“What a weird fucking place,” she said.

Then she squeezed out some toothpaste, and started brushing.

---

The next day she took the official tour of the Island. Terry accompanied her.

“Only if you want,” he said at first. “New visitors often find it comforting to have a familiar face with them. I contacted your old roommate from college, Larson, but he’s actually off-Island studying lobster hemocyanin off the coast of Maine.”

She was relieved. She and Larson had had a tumultuous relationship, which had improved considerably after they were no longer living together. But even on the best of days, they started to get on each others’ nerves after a few hours.

The tour started by the Wind Spinners. 

“What are we looking at?” Judith asked. The fog had rolled in, and while she was no longer shivering after Terry had given her his jacket, she still felt acutely uncomfortable. There were rows upon rows of large metal anchors slammed into the ground, and metal cables attached to them that ascended into the sky. There was a steady thrum-thrum-thrum sound in the background, as if someone had left the engine on in the parking lot.

“Wait for it,” Terry said. 

They stood there, mildly uncomfortable, until after a few minutes the sun flickered through the fog for a brief minute. In that moment, she looked up, and saw a flock of windmills drifting in the wind up above them, daisy-chaining ad infinitum.

“It’s quite the sight, isn’t it?” Terry said. 

Judith’s mouth parted slightly in spite of herself. 

“There’s no way that is cost-effective,” she said. It was clear now, that the thrumming sound was coming from the turbines above.

“It is, if you can make cables strong enough to create multiple tiers of turbines. And if there are no local land laws that forbid their use. And if no one complains about losing their view or the turbines being noise pollution. And if the local airport doesn’t block you, citing it as a hazard. And if there’s no environmental review process that makes you conduct studies about non-existent bird migration patterns.”

“There’s no way.”

“The birds are fine with it,” Terry said. “In case you’re wondering. The breakeven point is at the 4 year mark, compared to traditional wind turbines. The turbines auto-adjust so that they don’t whip into each other. They actually extend about half a mile higher than you can see from here.”

The fog rolled back in, and they hustled their way back to the tram-gondola. 

“Okay, two questions,” Judith said. 

“Shoot.”

“What do I call this… tram-gondola amphibian thing? Tramdola? Gondram?”

“Tram is fine,” Terry said with a shrug.”

“Second thing is; what is that,” she said, pointing at a device behind a glass case on the tram.

“Oh! It’s a defibrillator, with a few extra bells and whistles,” Terry said. 

“Bells and whistles?”

“A traditional AED has two pads, to conduct current right? This one, if you were to open it up, just contains one large pad, that wraps around the entire chest. The entire wrap-around pad is piezo-electric and is essentially a flotilla of ultrasound probes and transducers.”

“A flotilla?” 

“The ultrasound probes that you’re used to at your hospital are like a single whale swimming at the surface of the ocean. They shoot a beam of sound down through the chest, that then hits a surface, that then bounces back to the receiver. The problem with this is that ribs get in the way of things; so your ultrasound beams can’t image certain angles; or they get blocked by too much fat tissue or whatever. So imagine a flotilla of whales, all shooting ultrasound beams through the chest in a predefined rapid-fire sequence; each whale can also then act as a receiver for the others. And because you have a flotilla of transducers, you’re shooting beams at every possible conceivable angle. The end-product is that you wrap someone in this pad like they’re Cleopatra in a rug, and you have a perfect three-dimensional reconstruction of their entire thoracic cavity, including their heart, using no radiation.”

“Wait. Why don’t I have this at my hospital? This just… exists? Why am I walking around with my shitty Butterfly ultrasound probe, hemming and hawing about whether someone has a pericardial effusion or not, when I could be just - “

“Well, the folks who made this went one step further. The transducers can deliver therapeutic ultrasound; lithotripsy, in other words.”

“Why in the world would you want lithotripsy of the chest?”

“Well, currently, the echocardiograms you’re used to can sometimes see coronary arteries right? But they’re shitty images; and maybe you can only see the ostium of the left main coronary artery or whatever. So what happens when you have a perfect reconstruction of the heart using ultrasound with ultra-high fidelity? You can see coronary plaque and acute occlusions. So, let’s say that you collapsed on this tram right now. I’d roll you up in the pad, the device provides an EKG; not a 12-lead EKG by the way, but the equivalent of a 1000-lead EKG. And it images you in real time; and if it sees that you’re having an acute coronary occlusion, it delivers high-intensity targeted ultrasound beams to break up your coronary plaque. You don’t even need to go to the cathlab afterwards, it’s that good. Oh, and it can defibrillate you too, I guess.”

“You haven’t answered my question - you’re telling me that you have a device that makes cathlabs obsolete, and its sitting there in a box. Why isn’t it available at my hospital?”

“Because there was a non-invasive coronary lithotripsy clinical trial, 9 years ago, in the U.S., which was canceled early due to two patients who had strokes. And so the FDA put a moratorium on research into them, and so any device like that is dead in the water outside the Island. The flotilla - we actually call it that; the Flotilla device - was actually controversial here on the island because no one gets myocardial infarctions anymore, ever since we put statins in the water supply. But it’s on every tram ride because they’re cheap to make and it’s good propaganda.”

Judith sat for the rest of the tram ride, somewhat sullen. In a box, opposite her in the tram, was a device that would make an entire department at her hospital obsolete. 

“Can I - “

“No, you can’t take it home with you. You’re not the first to ask. Alright, we’ve arrived!”

They stepped out onto the platform. 

“Mind the gap,” a pleasant female voice intonated from above.

“We stole that voice recording from the British Metro,” Terry said. “Though then they sued us, so I don’t know if it was quite worth the effort.”

The Organ Farms were infamous internationally. Ever since the Island had solved the problem of xenotransplantation, it had become a center of medical tourism and also the target of animal rights advocates groups. 

“We can just… walk in?” Judith said. 

“Well. This is the most surveilled place on the Island,” Terry said. “Mostly because folks from the outside tried to sneak in a few years ago to ‘free the pigs.’ So not quite.”

Judith had been expecting a factory farm, or something that approached a lab. But instead, it was just field and fields and fields of grass, with slowly moving lumps which appeared to be grazing.

“Are those…” she said, beginning to point with her finger.

“Those are the pigs,” Terry said. “Here, have a binocular.”

She looked through the binoculars at the lumps in the distance. They were large, lumbering masses on four feet, but that was where the similarities with pigs ended.

“They don’t look like pigs,” Judith said. “Where are their heads?”

“Well. They’re really only pigs in name, now. They’ve been genetically modified to have as little consciousness as possible. They’re probably closer to jellyfish in mental processing power than they are to pigs. They don’t produce methane either; we’ve been hoping to export our flatulence-emissions program to other countries but there’s been a good deal of pushback.”

“But PETA says that you - “

“PETA says a lot of things,” Terry said. “All the organs that are used for transplantation come from these farms. We do around eighty thousand heart transplants a year, and that number is growing quickly. A good deal of the Island’s revenue now comes from medical tourism actually, although of course Pearson batteries are still the mainstay. All of our meat products come from non-conscious animals now too.”

Judith thought about the pork chilaquiles she’d had that morning. 

“I don’t know how I feel about this,” she said. “If they don’t have heads, where do they even eat grass from - wait you know what? Don’t answer that.”

Terry shrugged. 

“You get used to it.”

She was quiet on the tram ride leaving the Organ Farms. It was the first thing on the Island so far that had made her feel like a stranger in a strange land. Genetically engineered mouth flora felt like one thing, but headless pigs roaming a field was another. 

The tram passed by a statue of enormous proportions; that of a woman, twenty stories tall, leaning on a walking stick. It dwarfed all the buildings that surrounded it. 

“That’s of Pearson, isn’t it?” Judith said. 

“The one and only,” Terry said. 

The statue was surprisingly life-like. Judith could make out crow’s feet on the side of her eyes; it must have captured a time in Pearson’s forties, just before she went into cryogenic storage. 

“She never really wanted a statue of herself. She said it smacked of megalomania. Said she didn’t want to be worshipped. The Council said it would be good for Island morale though. People looked up to her so much. They still make pilgrimages here. I don’t know how she would feel about that.”

The tram passed by the base of the statue, and Judith could make out words at the very bottom. 

“Friend. Scientist. Mother. Wife.”

And then below that: 

“If you’re going to literally put me on a pedestal you better make me look good.” - Jane Pearson, 2048.

They went to the Wet Labs next, and then to downtown where they had a nice meal at a Korean-Mexican fusion restaurant, and then the Unnatural History Museum. People stopped and said hi to Terry; he seemed well-liked. Occasionally Terry would ask if she wanted to talk to anyone else. But Judith was feeling overwhelmed already, and the last thing she wanted was to have to interact with another stranger. 

In the late afternoon, they made their last stop, arriving in front of what appeared to be a wine bar. A young woman in her twenties was standing outside, talking on the phone.

“I want you to meet someone,” Terry said. “Her name is Alia. She’s… well, I’ll let her introduce herself.”

They stood there for a few seconds, waiting politely as Alia continued talking on the phone. Her eyes were widened in embarrassment, and she mouthed “I’m so sorry” to them, while pointing at the phone.

“Well, maybe we should just go inside,” Terry said. 

They sat down at the bar, and the bartender poured them a drink without them asking. There were a few couples scattered about the room, and the lighting was low. It was the nicest bar that Judith had been to in a long time; and if she let herself, she could almost imagine that she was back in Atlanta. 

She felt, all of a sudden, very homesick. 

“Cheers,” Terry said, and they clinked glasses. 

The drink was gold-amber colored, and tasted vaguely like herbs. It was smooth, with a kick to it that only came in after a few seconds. 

“That’s good,” she said. “And I don’t even like whiskey.”

“It’s not whiskey,” said Alia from behind them, before sitting down next to her. “I’m Alia by the way. Nice to meet you. Sorry about the rudeness just now with the phone call.”

“Judith,” she said, sticking out her hand. “Don’t worry about it.”

She swirled the drink around in her glass absent-mindedly.

“Probably gin, then” she said. “It has a nice herbally taste to it.”

“No, actually. You’re the thirteenth person to have it. So it doesn’t even have a name yet,” Alia said. 

The room narrowed in that moment, until it was just Judith and the glass in front of her. She knew without asking, exactly what it was. 

“You figured it out?” Judith said. “Just like that?” 

“Well. It’s easier, on the Island, where there are no IRB’s and you can just whip up a couple hundred samples in the lab, throw a block party, and ask everyone how they feel the next morning. With careful blood samples, of course. You’re holding the winner.”

Judith took another sip. She had grown up stealing sips of whiskey from her father’s liquor cabinet, and the mouthfeel felt the same. And it might have been her imagination, but she felt just a little buzzed. 

“The hardest part was actually making sure it wasn’t too sweet. It’s too easy to make cousins of alcohol that are fructose-adjacent. There wasn’t any low-hanging fruit either. The search space is large.”

Alia had picked up a pen and was drawing a chemical structure on the napkin in front of them. By then, Judith was definitely sure that she was buzzed. 

“So I know you’re a clinician, so it’s probably been a long time since you took Biochemistry. But as you may remember, and as you said in your original submission, the tricky thing is figuring out a way to prevent breakdown into Acetaldehyde, which…”

Judith stopped following after that. Whatever Alia was drawing on the napkin was definitely not just a close cousin of ethanol, and was beyond her ability to really comprehend. What her mind returned to again and again was that she had written a post in a sleep-deprived haze, and now she was drinking a glass of artificially synthesized dream-liquor. 

“What’s the catch?” Judith said. “There has to be catch somewhere.”

“Well, the glass you’re drinking cost twenty thousand dollars in synthesis costs, but I think I can get that down,” Alia said. “Just give me a month or two and the whole Island will be drinking it. Though, the societal effects of a consequence-free GABA-nergic social lubricant is another thing. We’ll cross that bridge when we get there.” 

“I can’t do this,” Judith declared all of a sudden. “This is just like the toothbrush, and the Flotilla defibrillator, and the mooncake with deepfaked sugar, and everything else you have here that’s available on the Island only. I can’t bring this back with me. The guy that I see in the ED who comes in again and again… unless you can have this cheaper than rubbing alcohol and on every shelf in Walgreens, he’s still going to die of liver failure. And I’ll watch him die, one admission at a time.”

“We’re not magicians,” Alia snapped. 

“I’m sorry about your friend,” Terry said.

“Not friend. Patient.” Her words were coming out slurred now.

“That’s why we need people like you,” Terry said. He’d been quiet until then, sipping on his own glass. “Well, there are two reasons, really. The first is that - did you know that there was no one else who came up with this idea on the Island, before you submitted it? Alia whipped this up in a day once she had the idea, but this is a world-changing idea, and no one thought of it because we live in a bubble here, Judith. It’s an ivory tower; every other person on the street has a PhD. There are no alcoholics here, or if there are, they’re highly functional. There’s no liver failure here; and the medical tourists who come here for liver xenotransplantation are a self-selected group; they’re predominantly the viral hepatitis cirrhotics, not the alcohol-induced cirrhotics. We need people like you who aren’t scientists, who have an outside perspective. And we need people don’t want to live on the Island. We need people out there in the real world, who can advocate for the Island.”

“You have so much influence though…” Judith murmured.

“Ever since Jane Pearson went into cold storage, the Island has been in existential crisis. The Council is made of a bunch of data scientists who have no idea how to play political hardball on an international level. The world is turning against us, Judith, and we need friends on the outside.”

“You need propaganda,” Judith said. 

“We need propaganda,” Terry said. “And so you’re the first of what we hope to be hundreds of thousands. Millions. Not just medical tourists, but tourist tourists. Pearson was once-in-a-generation, and had the world behind her. Without her, we need to court people outside the Island as we never have before.”

“And you want ambassadors,” Judith said. “You want people like me; well-educated, sympathetic. Who upon exposure to this utopia you’ve created, won’t want to just uproot their life and move here, but instead will stay on the outside.”

“Yes,” Alia said. 

“I have a name for your drink,” Judith said.

“Yeah?”

“Ambassador.” 

“Cute.”

“I like it,” Terry said. 

“And the answer is yes,” Judith said. “But you have to promise me something. If this drink is what you promise it to be, you have to get it onto every shelf in Walgreens. It can’t just be a toy on the Island like all the other things you have. You need to export what you have to the rest of the world.”

“We can’t control what other governments - “

“Okay fine, you can’t control what other governments do. You’ve lost Pearson, who you all worship as some kind of messiah, and now you’re all a bunch of nerds swimming in circles. But you have all the tools to change the world here at your disposal, and instead of exporting it to the rest of the world, other people are coming here to even have a taste of it. So yes, I’ll be your ambassador, I’ll do whatever is needed, but I want a seat at the table. If you want me to be included in this dream - if you want me to be some kind of ambassador, then this has to be the beginning of something bigger. Not just me flying home and saying nice things about the Island.”

“If you want to be that involved, then I need to make some phone calls,” Terry said.

Judith raised a glass. 

“Cheers to that,” she said. “A drink to the work ahead.”

---

Author’s notes:

Incredo-Sugar is made by DouxMatok and is currently available only in Israel; it offers a 30-50% reduction in calorie count from sugar. Unlike other sugar substitutes, it tastes like the real thing (apparently) because it has the same molecular composition.

I remember reading about the cost of adding statins to the water supply but can’t find the original paper. This is the only one I could find on cursory Google Scholar review.

Lobsters have hemocyanin, which carries copper instead of iron for the purposes of oxygen-binding. I’ve always wondered whether an anemic lobster would require copper-transfusions, similar to the iron-transfusions we give patients nowadays? There was a trial called IRONMAN that came out recently; so I think we would have to name this trial COPPERLOBSTER. Not quite the same ring to it.

The first pig-to-human heart transplant happened last year.

Admissions for rubbing alcohol poisoning are a real thing. It really does fundamentally come down to cost; it is significantly cheaper to get drunk (and delay alcohol withdrawal) on. On occasion, hand sanitizer really does have to be removed from hospital rooms. I don’t know if an alcohol that is non-hepatotoxic can ever be realized (companies like Sentia are working on them, supposedly?) but the dream is real.

One of the most striking graphs I’ve ever seen was for alcohol and suicide rates in Russia. I want to say that there was some kind of anti-alcohol policy in 1984 which led to the drop but forget the exact reason.