In a flashback, we see Juliette trying to help her sister, Rachel. They live in Miami, but initially we think they are on the island, since she passes Ethan Frome in a hallway. Juliette has been stealing some kind of experimental drug. Her ex-husband, Edmund Burke, runs the research hospital where Juliette also works. He realizes what she is doing, and says that they can collaborate and make the research legitimate.
We are introduced to Richard Alpert who says he works for Mittelos Bioscience. He says that they are located “just outside Portland.” He shows Juliette x-rays of a womb, she estimates that it is a woman in her 70s but he says she is in her 20s, and offers her the chance to do research to find out what happened to her. Juliette says that her ex-husband would never allow it, and when Alpert asks what it would take, she says “If he were hit by a bus.” Her sister gets pregnant thanks to the experimental drug. But the sister also has cancer. As Juliette talks to Ed about the experimental drug working, he is hit by a bus. Ethan Frome accompanies Richard Alpert to talk to Juliette when she is at the morgue. Richard says he does not even remember her saying about wishing him to get hit by the bus, and says she should not blame herself. Richard knows her sister is pregnant, and says they are very thorough in their recruitment process.
Juliette tells another of her people to get Ford and Austen and bring them back, killing them if necessary. Jack insists that he is not bluffing. Juliette tells him that they are not on their island but another smaller one two miles offshore. Juliette suggests that they find some kind of peaceful resolution. She insists thst Jack will never let a patient just die. Jack tells the Others that Juliette asked him to kill Ben and make it look like an accident.
Alex helps Sawyer and Kate when they are being pursued. She leads them to a hiding place. She offers to let them use her boat, if they help her rescue her boyfriend, Karl. Aldo is guarding the room where Karl is kept, while reading A Brief History of Time. They use the “Wookie prisoner trick.” Karl is in Room 23. There is lound noise and video screens with images, and he has illuminated glasses in and is drugged. Words in the screen say things like “God loves you as he loved Jacob,” “We are the cause of our own suffering,” and “Everything changes.” When they make it to the boat, Danny finds them, but Juliette shoots him. She tells them to go, but tells Alex to stay, as the condition for Ben letting Karl live. Jack talks to Kate via walkie talkie and asks her to promise to never come back for him. Jack then finishes the surgery. He asks Juliette what Ben said to get her to want him to survive the surgery. She tells Jack that she has been on the island for three years, and that Ben promised that he would finally let her go home if she let him live and helped Jack.
At any rate, one thing the episode clearly indicated is that the Others were a potent force off the island and not just on it.