https://motherboard.vice.com/en_us/article/43pngb/how-to-make-your-own-medicine-four-thieves-vinegar-collective
Meet the Anarchists Making Their Own Medicine
The Four Thieves Vinegar Collective is a network
of tech-fueled anarchists taking on Big Pharma with DIY medicines.
The first time I encountered Michael Laufer, he
was throwing thousands of dollars worth of
homemade medicine into a packed audience at
Hackers on Planet Earth (HOPE), a biennial conference in New York City.
“Does anyone here suffer from anaphylactic shock
and not have access to epinephrine?” Laufer asked
the audience. A few hands went up and Laufer
stuffed a homemade EpiPen into one of them.
“That’s one of the original ones we made,” he said. “Use it well.”
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After a few minutes of gloating about
<https://www.vice.com/en_us/article/xw79pk/where-is-martin-shkreli-now-prison-fort-dix-new-jersey>pharma
bro Martin Shkreli “rotting at Fort Dix” for
raising the price of Daraprim, a lifesaving HIV
medicine, from $13 to $750, Laufer grew serious.
“It’s been two years, but despite everything
that’s happened, the price of Daraprim hasn’t
changed,” he said. He reached into his pocket and
produced a handful of white pills. “I guess I
better hand out some more,” Laufer said as he
tossed the Daraprim into the audience.
With a shaved head, dark beard, and an
ever-present camo jacket, Laufer doesn’t look
like the type of person you’d seek out for
medical advicebut that’s exactly his point. As
the founding member of
<https://fourthievesvinegar.org/>Four Thieves
Vinegar, a volunteer network of anarchists and
hackers developing DIY medical technologies,
Laufer has spent the last decade working to
liberate life-saving pharmaceuticals from the
massive corporations that own them. Laufer has no
formal training in medicine and he’ll be the
first to tell you he’s not a doctor. In fact,
from a regulatory standpoint he’s more qualified
to do mathematical work on nuclear weapons than
treat patients. But Laufer’s never really been
the type to let rules and regulations stand in his way.
I met Laufer at a bar across the street from HOPE
after he finished his talk on DIY medicine. He
was meeting with his Four Thieves collaborators
who had flown in from all over the country to
attend the conference and unveil the new medical
technologies under development by the collective.
Laufer kicked off the celebration with a toast.
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“A toast to the dead, for children with cancer
and AIDS,” Laufer said, raising a glass of
bourbon and
<https://www.youtube.com/watch?v=USL3toR8grw>quoting
the hip hop artist Felipe Andres Coronel, better
known as Immortal Technique. “A cure exists, and
you probably could have been saved.”
In the last decade, Four Thieves has run afoul of
the Food and Drug Administration, billionaire
pharma executives, doctors, and chemists at some
of the United States’ most prestigious
universities. Indeed, Laufer and his
collaborators can’t stop pissing off powerful
people because Four Thieves is living proof that
effective medicines can be developed on a budget
outside of institutional channels.
At the pharmacy, a pair of single use Mylan
epipens can cost over $600 and the company’s
generic version costs $300 per pair, but an
ongoing shortage means you probably can’t find
them, even if you can afford them. In response,
Four Thieves published the instructions for a DIY
epipen online that can be made for
<https://fourthievesvinegar.org/blog/2016/09/introducing-the-epipencil>$30
in off-the-shelf parts and reloaded for $3.
Shkreli drove the price of the lifesaving HIV
medicine Daraprim sells up to $750 per pill. So
Four Thieves developed an open source portable
chemistry lab that allows anyone to manufacture
their own Daraprim for just 25 cents apiece.
The pharmaceutical industry is valued
at<https://www.statista.com/topics/1719/pharmaceutical-industry/>
$446 billion in the US and its walls are tightly
policed by regulatory agencies like the FDA and
Drug Enforcement Administration. By freely
distributing plans for medical devices and
pharmaceuticals, a loose collective of anarchists
and hackers is threatening to pull the rug out
from under one of the most regulated and
profitable industries in the world. And they’re just getting started.
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FREE DRUGS
Four Thieves claims to have successfully
synthesized five different kinds of
pharmaceuticals, all of which were made using
MicroLab. The device attempts to mimic an
expensive machine usually only found in chemistry
laboratories for a fraction of the price using
readily available off-the-shelf parts. In the
case of the MicroLab, the reaction chambers
consist of a small mason jar mounted inside a
larger mason jar with a 3D-printed lid whose
printing instructions are available online. A few
small plastic hoses and a thermistor to measure
temperature are then attached through the lid to
circulate fluids through the contraption to
induce the chemical reactions necessary to
manufacture various medicines. The whole process
is automated using a small computer that costs about $30.
To date, Four Thieves has used the device to
produce
<https://fourthievesvinegar.org/download>homemade
Naloxone, a drug used to prevent opiate overdoses
better known as Narcan; Daraprim, a drug that
treats infections in people with HIV;
Cabotegravir, a preventative HIV medicine that
may only need to be taken
<http://www.natap.org/2013/CROI/croi_38.htm>four
times per year; and mifepristone and misoprostol,
two chemicals needed for pharmaceutical abortions.
Given the Trump administration’s
<https://www.reuters.com/article/us-usa-court-abortion/top-supreme-court-candidates-views-on-abortion-under-scrutiny-idUSKBN1JT2BF>candidates
for Justice Anthony Kennedy’s seat on the Supreme
Court, the collective feels an increasing sense
of urgency to perfect its abortion drugs. They
fear that the federal government will soon allow
states to choose whether or not abortions can
legally be offered and many residents will be
left without any recourse to abort a pregnancy.
This was a motivating factor for Tim Heilers, a
former Navy sonar technician from Louisville, to
join Four Thieves last February.
“Kentucky is a very conservative state and I
think we have a very real possibility of becoming
the first state with no abortion access
whatsoever,” Heilers told me. “Giving people the
ability to make mifepristone if they need it is
something I think is very important.”
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Although Four Thieves has successfully produced
five drugs, so far only the Daraprim is available
for download on the collective’s website. This is
partly due to the disparities in how hard the
various molecules are to produce. Naloxone, for
example, is particularly challenging because the
antidote to opiate overdoses uses the same
precursors as the opiates themselves. These
precursors are controlled by the federal
government and only allowed to be possessed by
approved labs in small doses. To get around this
issue, Laufer and his collaborators adopted a
seemingly counterintuitive protocol: They’d make medicine from poison.
Even though they couldn’t legally buy the
Naloxone precursors, Laufer realized that the
opiates themselves are remarkably easy to obtain.
After obtaining oxycontin on the street,
collective members were able to perform a few
chemical reactions to extract the necessary
precursors from the drug and used them to make the Naloxone.
"Would you rather break the law and live, or be a
good upstanding citizen and a corpse?”
“Some very clever drug dealers in the 90s
discovered that you can do a one shot reaction
[with oxycontin] and get oxymorphone, which is
something like six times as powerful,” Laufer
said. “You can make Naloxone from oxymorphone in
one step. It’s fairly easy and now you’ve made medicine from poison.”
These sorts of unorthodox approaches to
healthcare are the name of the game in pharma
hacking, where the goal is to help people at any cost.
There’s a drug called cabotegravir, for instance,
which is a pre-exposure prophylactic that has
been demonstrated to
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263045/>prevent
the spread of HIV through shared needles in
macaques. Unlike other pre-exposure prophylactics
that need to be taken daily, cabotegravir may
only need to be taken
<http://www.natap.org/2013/CROI/croi_38.htm>four
times per year to protect the user from HIV.
Although the initial clinical results with
cabotegravir were extremely promising, Four
Thieves grew impatient with waiting for it to
become commercially available. (The drug is
<https://aidsinfo.nih.gov/drugs/513/cabotegravir/0/patient>currently
undergoing Phase III FDA trials, which means it’s
being clinically tested on a large cohort of
human subjects.) Moreover, based on other
pre-exposure prophylaxis drugs, cabotegravir
would almost certainly be sold at an exorbitant
costTruvada, a comparable drug that needs to be
taken daily,
<https://www.npr.org/sections/health-shots/2018/06/30/624045995/rising-cost-of-prep-a-pill-that-prevents-hiv-pushes-it-out-of-reach-for-many>costs
around $2,000 for a 30-day supply. So the group
figured out how to make it themselves.
After Four Thieves synthesized cabotegravir, it
was just a matter of convincing at-risk
populations to use it. According to Laufer, some
Four Thieves affiliates began partnering with
heroin dealers to cut their product with the
cabotegravir. This would ensure that users would
receive a regular dose of the preventative
medicine every time they used heroin.
“Their heroin has a new side effect,” Laufer
said. “You don’t get HIV from it any more.”
Clearly, Four Thieves Vinegar Collective walks a
fine line when it comes to the legality of their
enterprise. Although Laufer has turned subversion
of the medical industry into an artform,
litigation remains a perennial threat to his
mission to liberate medicine. When a
pharmaceutical company manufactures a new drug,
they own the patent on the molecules that make
the drug effective. Nevertheless, Laufer and his
colleagues are able to reproduce these molecules
because they are described in patent filings and
often in academic journals. All it takes is the right technology.
Since Four Thieves isn’t actually selling or
distributing the medicines made by its members,
what they're doing isn’t technically illegal in
the eyes of the FDA, even though the agency has
issued a public warning about the collective’s
DIY methods. Shortly after Four Thieves unveiled
its $30 DIY epipen, the FDA issued a
<https://www.in-pharmatechnologist.com/Article/2016/09/22/US-FDA-warns-against-30-alternative-to-Mylan-s-EpiPen>statement
to the media that said “using unapproved
prescription drugs for personal use is a
potentially dangerous practice,” but didn’t refer
to Four Thieves by name. Ironically, only a few
months later, the FDA
<https://www.nytimes.com/2017/09/07/health/epipen-fda-malfunction.html>issued
a warning letter to Pfizer for failing to
investigate “hundreds” of complaints about epipen
failures, some of which resulted in the death of
the user. In May, the FDA
<http://fortune.com/2018/05/09/epipen-shortage-fda/>issued
another warning that declared a chronic epipen shortage.
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As for the DEA, none of the pharmaceuticals
produced by the collective are controlled
substance, so their possession is only subject to
local laws about prescription medicines. If a
person has a disease and prescription for the
drug to treat that disease, they shouldn’t run
into any legal issues if they were to manufacture
their own medicine. Four Thieves is effectively
just liberating information on how to manufacture
certain medicines at home and developing the open
source tools to make it happen. If someone
decides to make drugs using the collective’s
guides then that’s their own business, but Four
Thieves doesn’t pretend that the information it
releases is for “educational purposes only.”
“The rhetoric that is espoused by people who
defend intellectual property law is that this is
theft,” Laufer told me. “If you accept that
axiomatically, then by the same logic when you
withhold access to lifesaving medication that's
murder. From a moral standpoint it's an
imperative to enact theft to prevent murder.”
“So yeah, we are encouraging people to break the
law,” Laufer added. “If you're going to die and
you're being denied the medicine that can save
you, would you rather break the law and live, or
be a good upstanding citizen and a corpse?”
DOCTORS WITHOUT ORDERS
The catalyst for Four Thieves Vinegar Collective
was a trip Laufer took to El Salvador in 2008
when he was still in graduate school. While
visiting a rural medical clinic as part of an
envoy documenting human rights violations in the
country, he learned that it had run out of birth
control three months prior. When the clinic
contacted the central hospital in San Salvador,
it was informed the other hospital had also run
out of birth control. Laufer told me he was
stunned that the hospitals were unable to source
birth control, a relatively simple drug to
manufacture that’s been around for over
half-a-century. He figured if drug dealers in the
country were able to use underground labs to
manufacture illicit drugs, a similar approach
could be taken to life-saving medicines.
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Laufer started the collective shortly after he
returned from Central America, but its existence
was only made public at HOPE in 2016. During his
first talk at the hacker conference, Laufer
demoed the group’s $30 DIY “EpiPencil,”
distributed some homemade Daraprim to the
audience, showed off an early prototype of the
MicroLab, and gave Martin Shkreli a call on stage
(he didn’t answer.) When Four Thieves began,
Laufer was mostly working by himself. Now that
it’s emerged from the underground, the group is
much larger, although Laufer said it’s impossible
to know its actual sizemembers come and go as
they please, contributing as much knowledge and time as they can.
Everyone I spoke with at Four Thieves comes from
a technical background, but none of them were
medical professionals. Laufer, for instance, has
a background in nuclear physics and is the
director of the math program at Menlo College in
Silicon Valley for his day job. The result of
Four Thieves’ diverse pool of technical expertise
speaks for itself. The collective now has
independent biology, chemistry, data science,
programming, and hardware teams whose degree of
collaboration is dictated by the project at hand.
Four Thieves doesn’t sell anything, but the
collective has two core ‘products.’ The first is
open source hardware like the epipencil and
MicroLab chemical synthesizer, which can be made
from off-the-shelf and 3D printed components. The
second is the instructions for how to use these
tools to produce the drugs, which includes
everything from how to use the MicroLab to
perform simple reactions to how to procure chemical precursors.
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“I think it’s absolutely imperative that
information about how to make your own medicines
should be as easily accessible as possible to
everyone who might have even a passing interest,”
Laufer told me. “The goal of the group is to make
it possible for people to be able to do these
things on their own. The idea that someone could
download the instructions, read the list of
materials, order them, read the instructions for
how to assemble it and program it, upload the
code, order precursor chemicals, and then manufacture medicine.”
All of Four Thieves’ tools were developed on a
virtually non-existent budgetthe only money the
collective has is whatever its members supply out
of their own pocketsand so far the medicines
they have produced haven’t killed anyone. Yet
some experts caution against taking medicines
produced by DIY tech that hasn’t been sufficiently vetted.
HARM REDUCTION
Eric Von Hippel, an economist at MIT that
researches “open innovation,” is enthusiastic
about the promise of DIY drug production, but
only under certain conditions. He cited a pilot
program in the Netherlands that is exploring the
<https://www.nature.com/articles/nbt.3888>independent
production of medicines that are tailor made for
individual patients as a good example of safe,
DIY drug production. These drugs are made in the
hospital by trained experts. Von Hippel believes
it can be dangerous when patients undertake drug production on their own.
“If one does not do chemical reactions under
just-right conditions, one can easily create
dangerous by-products along with the drug one is
trying to produce,” von Hippel told me in an
email. “Careful control of reactor conditions is
unlikely in DIY chemical reactors such as the
MicroLab design offered for free by the Four Thieves Vinegar Collective.”
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His colleague, Harold DeMonaco, a visiting
scientist at MIT, agreed. DeMonaco suggested that
a more rational solution to the problems
addressed would be for patients to work with
compounding pharmacies. Compounding pharmacies
prepare personalized medicine for their customers
and DeMonaco said they able to synthesize the
same drugs Four Thieves is producing at low
costs, but with “appropriate safeguards.”
“Unless the system is idiot proof and includes
validation of the final product, the user is
exposed to a laundry list of rather nasty stuff,”
DeMonaco told me in an email. “Widespread use [of
Four Thieves’ devices] would provide an entire
new category for the Darwin Awards.”
Von Hippel and DeMonaco were in agreement that
the ability to purify DIY drugs and run quality
control tests on the final product is paramount
for their safe use by patients. Von Hippel
suggested that scientists with a background in
medicinal chemistry will be necessary to address these issues in DIY pharma.
“I see Michael Laufer’s activities as a valuable
form of social activism that points the way to a
promising future,” von Hippel said. “But I think
the equipment and the medicinal science issues
have to be much further developed before DIY medicine production will be safe.”
In a way, Four Thieves is just doing a
small-scale version of what many hospitals are
doing already. Faced with rising drug prices and
shortages, many hospitals have
<https://www.nytimes.com/2018/01/18/health/drug-prices-hospitals.html>started
to manufacture their own medicines on site to
save costs. The difference, however, is that
these hospitals often have access to
sophisticated laboratories and trained medical
personnel, which significantly lowers the risk of something going wrong.
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Four Thieves isn’t naive about the risks of
providing the documentation to allow others to
make their own medicine. It’s always possible
that someone follows the group’s instructions
incorrectly and inadvertently produces a toxic
chemical. Yet there are ways to reduce the
likelihood of this happening and one of Four
Thieves’ most significant contributions to DIY
medicine is prioritizing harm reduction in its research and development.
There’s more than one way to produce a given
molecule and some synthesis pathways are simpler
or allow for far greater margins of error than
others. Thus Four Thieves aims to discover
synthesis pathways that lower the risk of toxic
reactions to the lowest possible level. When the
collective was first starting out, they had help
doing this from a startup called Chematica, which
had collected 250 years of research on organic
chemical synthesis into a database and developed
software that used this data to predict and
create new synthesis pathways to desired
molecules. With this database and software, Four
Thieves was able to create simple and safe
synthesis pathways that would produce life-saving drugs.
This worked great until
<https://www.chemistryworld.com/news/merck-kgaa-to-buy-chematica/3007276.article>Chematica
was bought by Merck, an international
pharmaceutical giant, last year. After the sale,
Four Thieves lost access to the software and,
more importantly, the database. Laufer told me
that the Four Thieves data science team has
created an open source version of Chematica’s
software and has even compiled a small database
of organic chemicals to test it on. The software
is crude compared to Chematica’s, but Laufer said
that it works well enough. To improve the
software, however, the collective needs more
data, which is now the property of Merck.
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But as any hacker knows, sometimes data “falls
off a truck,” which is a nice way of saying that
Chematica’s database is currently posted on a
password protected website on the dark web.
During his talk at HOPE this year, Laufer
implored the audience to help with cracking the
password and releasing the data into the world.
Getting access to Chematica’s data on synthesis
pathways would blow open the door for a new suite
of DIY medicines, but until then it’s going to be pretty slow going.
THE FUTURE OF DIY MEDICINE
The most expensive drug on the market is called
<https://www.thebalance.com/the-8-most-expensive-prescription-drugs-in-the-world-2663232>Glybera
and is used to treat familial lipoprotein lipase
deficiency, a hereditary disease found in
<https://ghr.nlm.nih.gov/condition/familial-lipoprotein-lipase-deficiency#statistics>only
about 7,000 people worldwide. Lipoprotein lipase
deficiency prevents the normal breakdown of body
fats, which results in abdominal pains, acute
pancreatitis, enlarged livers and kidneys, and
the buildup of fat deposits under the skin.
Glybera helps treat these symptoms and is
critical to the quality of life of those with
FLLD. The only catch is the medicine costs each
patient $1.2 million per yearif it’s even
available to them. In 2017, UniQure, the company
that produces Glybera,
<http://uniqure.com/GL_PR_Glybera%20withdrawal_FINAL_PDF.pdf>stopped
selling the drug in Europe due to the extremely
limited demand. This means that the approximately
<https://www.thebalance.com/the-8-most-expensive-prescription-drugs-in-the-world-2663232>1,200
Europeans with FLLD are out of luck when it comes to treatment.
The situation is more or less the same for those
afflicted with other orphan diseases, which are
defined as conditions that affect
<https://www.fda.gov/drugs/resourcesforyou/consumers/ucm143563.htm>fewer
than 200,000 people worldwide. If a drug for the
disease exists, it is generally
<https://www.thebalance.com/the-8-most-expensive-prescription-drugs-in-the-world-2663232>prohibitively
expensive to obtain. If the company doesn’t see
enough demand for its product, it will likely
pull it from the market. So for many rare
diseases, a cure or palliative medicine may exist
but is too expensive for patients or not
profitable enough to put on the market.
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In the future, Laufer wants Four Thieves to focus
on manufacturing drugs for orphan diseases so
that those with rare conditions will never be
without their medicine. Yet these types of
medicines come with their own unique problems.
For instance, Laufer said that many of the
medicines for orphan diseases are made of
biological material, such as fungus. Laufer said
that Four Thieves is working to create a
BioTorrent site to distribute the organic
material need to manufacture orphan medicines.
BioTorrent would be like a normal file sharing
site like the PirateBay, but instead of
downloading music and movies, people could
download instructions for how to synthesize their
own medicine and share the organic material among
one another. Since biological cells are
self-replicating, this would simply require one
user to grow a sufficient amount of cells for
themselves before shipping some cells to another
user who would repeat the process, similar to the
way people ‘seed’ a media file on torrent sites.
The question, then, would be how to ship the
biological material cheaply and without getting
caught. To this end, Four Thieves is
investigating the use of books and CD cases as
grow media for biological precursors. Mycelia are
basically the ‘roots’ of many fungi and feed on
cellulose, which is found in abundance in the
pages of a book. So Laufer and his collaborators
began injecting books with mycelium, which feed
upon the pages and grow out of the book.
Similarly, compact discs are similar enough to
petri dishes that if they’re streaked properly
they can be used as a growth medium for bacteria
and other biological precursors. The advantage of
this is that Four Thieves members using the
BioTorrent site could ship these cells using the
cheaper
“<https://about.usps.com/notices/not121/not121_tech.htm>media
rate” charged by the US Postal Service for items
like books and compact discs while avoiding scrutiny from law enforcement.
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In the meantime, however, Four Thieves is still
mostly focused on improving its MicroLab and
synthesizing new medicines. Recently the
collective began producing its own custom circuit
boards for the MicroLab, which will make it even
easier to set up the device at home. Laufer said
he plans to begin giving these circuit boards
away as early as next month. At the same time,
the group is working on perfecting the synthesis
of Solvadi, a one-time treatment that can cure
Hepatitis C. This drug has been on the market for
nearly five years, but its $84,000 price tag
<http://www.latimes.com/opinion/op-ed/la-oe-stone-solvadi-drug-pricing-20160705-snap-story.html>makes
it inaccessible to many people who need it. If
Four Thieves has its way, Hepatitis C will soon
be a thing of the past for everyone, regardless of their income.
At a time when many Americans lack even basic
health care services, Laufer’s ideas seem as
intuitive as they are radical. His work is
predicated on the notion that too many critical
decisions about our health have been outsourced
to private actors who care more about their
bottom line than their customers’ well being. For
Laufer, Four Thieves is as much about medicine as
it is about the right to the free flow of
information and personal autonomy. As far as he's
concerned, one cannot exist without the other.
“Pursuing science is a human right,” Laufer said.
“In fact, it’s the human right from which all
other rights flow. You have to be able to do
whatever you want to your body and to think the way you want.”
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