It was an intense year. I have endured 130 nights in the hospital over 8 months, 10 catheter insertions, 200+ injections, 50+ chemotherapy infusions, 15 spinal chemotherapies and 2000 tablets. I lost 14 kilograms and then gained back 19 kgs, went through a few days in delirium (a form of madness), had a pulmonary embolism, had intense diaphragm spasm for a day, could not walk at all for 3 days, spent 45+ days when walking and sitting was a pain, have had bleedings all over my body, seen hospital roommates lose their memory and suffer a stroke, and I’ve lost my hair twice.

But! I am here, out of hospital, clinging to life. I am as passionate about crypto and biotech, if not more. And I continue to appreciate the school of blood cancer. Through this year, I have learnt how to cook, speak excellent German, learnt some Yoga and read a ton about biotech. I don’t feel any wiser. On the contrary, I am tired and prone to anger. At times, I feel sad and nostalgic. I find myself looking wistfully at my younger self in photos.

I have earned an MRD negative complete remission. In simple terms, no cancer cells are detected in my body within the limitations of modern methods. It also has implications on the probability of long-term survival. Perhaps 75% in my case. To keep those chances, I need to continue chemotherapy for another 2 years. But, it will be done majorly from home. If cancer does not re-appear, these survival odds will go higher. And if, by April 2024, I have not had cancer come back, then I will have survived it with high probability (>95%).

Today though, there’s that other 25% chance that hangs over me like a sword. If the coin lands this way, I have further battles-more complex battles-to fight for survival. Inside that 25% chance is also a chance, perhaps a 1 in 8 chance, that this is the sunset of my life. Death is, with a 1 in 8 probability, around the corner, even though this is the best I feel all this year.

I am grateful that I have received the best modern medicine can offer a patient of my age and condition. I was lucky to be in Basel at diagnosis. The University Hospital is full of competent doctors and nurses. Thank you Basel, and thank you Switzerland for everything done to save and rehabilitate me. I was also lucky to have a circle of family and friends helping me through this year. Several family members and friends visited. Thank you all — you know who you are!

So, what next? For one, the continuation of this chemodiary. I intend to detail my experiences of the year and steps I take for the future. The most important step, now that I have some energy, is to prepare for a sunset. That preparation will be the focus of this chemodiary. Cryonics incoming!

For another, I am back at Chorus One, the crypto company I co-founded. Surprisingly, I find it easy to adapt to crypto again. I also realize how much I love engineering cryptosystems. I thought I’ll work 2 hours a day, but the call of Chorus has me in front of the screen a lot more. I am anemic right now, but still able to contribute.

Finally, if I am granted enough time, I intend to use all the medical and biotech knowledge productively. I already have ideas in this direction, but find no point detailing them at the current moment. Maybe, the chemodiary will contain those experiments in the future — we shall see.

Until next time!

This is an update blog for my cancer treatment in the past one month. As you can imagine, I haven’t been doing physically as well as I was in the early part of my treatment. Otherwise, I would have blogged way more often! In this blog I will go through the progress I have made addressing the disease, the different side-effects I have encountered (and which have debilitated me), and my condition today.

I got diagnosed on 14 April, and it has been nearly 2 and a 1/2 months into my treatment. In the first month of chemotherapy, I had a decent amount of energy and all of my previous entries are from that time. The second month was a difficult and dark period. I have managed to go past that period and recover some of my earlier energy in the last couple of weeks. Strangely enough, that difficult second month brought news of the complete remission of my cancer in the body and bone marrow. The cancer can no longer be detected in the brain, central nervous system and bloodstream. In the bone marrow, it has shrunk such that it cannot be detected by flow cytometry and doctors need more advanced instruments (genetic sequencing) to be able to find and measure the cancer. Many patients, perhaps even the majority, that reach such a point are gifted with more than a decade of productive life thereafter. Assuming I am part of this lucky cohort, I will be able to make something positive from this experience. Life often poetically delivers the good and the bad news juxtaposed with each other. While me and my family were receiving this good news pertaining to my cancer, we were grappling with a few major effects of chemotherapy.

First and foremost, I faced an episode of Delirium between 26 and 28 May. It is hard to express what I went through during the delirium. My mind was seeing and believing things un-anchored to reality. I had to be rushed to hospital, lost 4 kg of weight during the episode, and was also unable to walk those couple of days. I bounced back from this episode due to efforts of doctors, immediate family, and my friend Dr. Pranav. This episode was likely triggered due to a mix of sleep deprivation, anxiety about the development of side-effects from chemotherapy and the effects of the chemotherapy itself.

One early and long-lasting (few months) side-effect of chemotherapy I encounter is peripheral neuropathy. I feel that my hands and feet have become less sensitive. It often feels that the blood flow to these organs is lower than usual (whereas in reality everything is fine). Peripheral neuropathy stems from the damage some chemotherapy agents, like Vincristine, do to the motor neurons in the body. Exercising affected organs helps alleviate some of the symptoms, and my exercise regime does improve my symptoms in the feet. I haven’t yet found a good regimen to improve the neuropathy in my hands.

Muscle wasting and strength loss has been a constant companion. From the start of chemotherapy, I lost 12 kg at peak, and am currently 5 kg lighter. I regained most of the weight loss, and some of the strength loss, thanks to the nutrition and strength building efforts from my close family. Chemotherapy sessions have, multiple times, left me bedridden. During these more acute days of chemo, I sleep 15 hours a day and am able to keep up with only the bare minimum. There are also issues such as haemorrhoids, internal bleeding, headaches, loss of appetite and general malaise. Finally, one of the recent rounds of chemo may have mildly damaged my kidney function, and I will need special care to recover normal functioning in the next one month.

Through all the above, I have kept a positive attitude. I am learning to address these challenges. Over time (several months or a year), my body will be back to an energetic state. Already, I walk 2 km everyday, do sukshma yoga and breathing exercises. I am also able to participate in social life around me, and have started keeping up with friends again. I feel confident, and am truly grateful that I am in complete remission.

The Simulation Hypothesis

The last 50 years brought us realistic computer games. Gamers find themselves lost in these virtual worlds. Physical objects in games can behave quite indistinguishably from the real world. Computer games have social interactions, quests, and opportunities to make money. They make us wonder: “Is this universe we inhabit itself like a computer game?” The Simulation Hypothesis posits that we’re players in a computer game of some sort. For the next 5 minutes, accept that we live in a game. What types of games could this Universe be, and what does it imply for how you should live? That’s what we delve into!

The most culturally familiar simulation is that this world is a prison — an idea so brilliantly explored in the Matrix movie series. Humanity has lost out to the machines. The machines have fashioned a mind prison — the Matrix — for their human captives. The game feels exactly like the world we find ourselves in — a world of objects, tasty food, hope, boredom, despair, careers, and corporations. Prisoners are born, live out their lives and die in the Matrix without perceiving it to be a prison. Some humans outside the prison even choose to give up their freedom and submit themselves fully to the Matrix. Life inside a prison can be better than the outside. Pablo Escobar, the brilliant Drug Lord, would have resonated; — he fashioned himself a prison, La Catedral, on similar grounds. A prison will have eternal detailed surveillance and guards to enforce order when prisoners break out of control. The clash between Matrix guards and humanity outside the prison forms the storyline of the Matrix.

What if this Universe we inhabit is a prison? We’ve been put here for incomprehensible reasons and probably, can never be free of it. Death in one form might be followed by rebirth in another since the prisoners must be kept entertained. There is eternal surveillance of what we do and thresholds we can’t cross. A critical threshold is to understand exactly how the prison is built and how to break free. Physics and science will stagnate before it approaches the point.

The prison can be not even entirely generated. Humanity has never sent a probe to the deep atmosphere of Jupiter. Well then, the prison builders haven’t worked out the details of its deep atmosphere either. They will do so when forced by us. There’s some part of Earth where paleontologists haven’t dug for dinosaur bones? The universe might generate new prehistoric animals when we do dig. Science won’t end up being consistent — theories will conflict with each other. Eerily, that’s what’s happening in physics — quantum mechanics and general relativity often produce wrong predictions when combined together. We’ve collectively spent 100 years trying to get them to synergize.

The prison, of all places, provides moral guidance. If this Universe is a prison, either eat, drink and be merry or escape prison. Things in between don’t make a lot of sense. To escape the prison, consider becoming a prisoner yourself — you need to understand the psychology, tactics and problems of a jailor!

The Libertarian Universe

Let’s journey to the opposite end of the spectrum. A universe as far away from prison as can be: The Libertarian Universe. A conceptual universe loved by scientists, rationalists, and many political philosophers. A set of rules (laws of physics) were set in motion or always have been in action, and this Universe moves forward by applying those rules mechanically. The unfulfilled quest to find those basic rules is physics. Most isolated systems we have studied — light, heat, computer science, spacetime etc. — have broken down into a basic set of self-consistent rules. So, there is hope that the overarching system — the Universe — will also yield it’s base rules to science.

The Libertarian Universe is probably entirely generated and self-consistent. A storm happened on a Pacific island with no resident humans? The patterns of falling trees, the effect on the animals, etc., are all worked out. We can go there and piece together much of what happened, like detectives. Is it hard to make quantum mechanics and general relativity work together? That’s because there is a deeper set of rules, as yet undiscovered, that will solve the inconsistency. Discovering those more profound rules will be a matter of time and effort. When we find out the final rules, we will wonder: “Why are these the rules, not others?” In the libertarian Universe, we might have an explanation for even that.

There is no external surveillance in the libertarian Universe — no more immense power interested in your life. It implies that no regime, beyond other people and me, can solve my blood cancer. The lack of a more significant being also means you’re utterly free beyond being subject to the laws of physics. You can be a saint, a nuclear warmonger, break the ten commandments every day, etc., without any judgment. Any morality is a self-imposition — you did it to make your life easier. Did you decide never to cheat on your spouse? It is your own volition — not a commandment by a God.

The Libertarian Universe is brutal to accept as a belief system for most people. Grasping it requires an appreciation of physics and of scientific falsification. The lack of external moral compass and purpose gnaws at people. Acceptance of old age and death is also challenging since the end is final. Events (incl. my cancer) have to be accepted as a probability always there in the background, being played out. No wonder the libertarian Universe is the refuge of rational, scientific minds.

The Middle Paths

Between the prison and the libertarian Universe lie an enormous class of directed universes. The Universe is created by some entity (God), and that entity retains some interests and capabilities. It is a humongous class since all religions fall under it. Think of the Christian Universe as an illustration.

God has struck a good balance between free will and moral guidance in the Christian Universe. We are mostly free to pursue our lives. God encourages us to help other people and achieve things. God imposes some acceptable limitations — like the commandments. God watches over everyone, i.e., complete surveillance, and uses that knowledge to judge our actions. Judgment determines our course beyond this world. This shared belief system has, at times, assisted societies to push the boundaries of construction, exploration, and knowledge. Other directed universes — that of Islam, Judaism, and Hinduism — have found their own unique combinations to architect functioning societies. Let’s now move on to a second example of a directed universe, which also breaks the association that they are only religious in nature.

In the space of possible directed universes, this is a gem. I call it The Catalog Universe. Imagine that this world is a great game, and the purpose of the game is to find capable bits of intelligence. We are the agent(s)/intelligence(s)/AI(s) playing the game. The Universe is surveilled, and an external entity is building an immense catalog of intelligence with different capabilities. Albert Einstein figured out the nature of spacetime? The entity notes that and stores the code (neural patterns) running Einstein’s mind. Elon Musk built an empire in the industry? The entity noted and stored the code. Your father held together with your family exceptionally and brought up great children? The entity noted and stored the code. Mahatma Gandhi provided actionable moral guidance to millions of people? Noted and stored. Osama bin Laden terrorized a generation? Noted and stored. Your friend’s mother not only brought up her children but supported hundreds of orphans through their childhood? Noted and stored. We’re all assisting the entity in building this giant catalog. All you need to do to make the catalog is distinguish yourself. Be original since the catalog has little need for unimaginative clones. Distinguishing yourself does not need to be about public achievement. Unremarked monks who found inner peace are in the catalog.

But, what is the purpose of this catalog? To what use will the entity put the code of these different people/bits of intelligence? We can only guess. Perhaps, the entity is a corporation that will sell these bits of intelligence to other corporations to solve their problems. Maybe, the entity is building a museum of intelligences that children in another universe can play with. Perhaps, the entity is facing some issue of its own. It needs some of our intelligence to breakthrough.

So, how would you live life if you believed in the Catalog Universe?

My answer: I will wake up, seize each day, and attempt to distinguish myself creatively. Carpe Diem!!

I am 15 days into my first chemo. My immune system is down to near zero, making me pregnable to infectious agents (bacteria, viruses, fungi). If they take root, they have been known to end lives in a matter of a few hours. Being without an immune system is not a widely shared experience, and it is 10X as neurotic as Corona’s defence. This post covers how I design and execute my infection defence. A general reader will know how to manage a future pandemic much worse than Covid. Please show this blog to your doctor before adopting rules from it.

The Five Holes

The body is well wrapped up and does not present entry points to invaders easily. Evolution made 5 holes so that material from outside can come in and vice versa. It is with this material flow into and from the body that infectious agents can get in. Diminishing this flow of harmful agents into our holes is the central principle underlying this blog. The holes are Mouth, Nose, Ears, Anus, and the Engineer Hole. For men, the Engineer hole combines urination and sensory pleasure into one and is a tribute to evolution. If you cut yourself during chemo, that’s a sixth hole requiring vigorous defense. Get material flow into holes as safe as you can, and you’ll cut infection risk dramatically, making chemo easier. Sanitize your hands with alcohol before and after you use any hole — that has to become an instinct.

The mouth comes first. Eat and drink will go in here. Our stomachs have a defense unless it has been eradicated by antibiotics. The bad news is that food is complex in the type of infectious agents it can introduce. Two small rules help. The first is to ensure you eat only cooked food heated to high temperatures (80c) during cooking. Out goes the Sushi, the skinned apple, kale salad from your favorite bar, and the yogurt that’s sitting in a supply chain for 2 months before it comes to your plate. The second rule is to eat foods that your gut is used to — now is not the time for experimentation. Disregard new diets you’re unused to like keto, carnivore, paleolithic, Atkins, intermittent fasting, etc., for your first chemotherapy experiences. The creators of these diets produced benefits for humanity, but chemonauts weren’t on their minds.

One final addendum: minimize processed food. It is designed to sell by appealing to taste but is usually not nutritious (capitalism!), made in a factory under bulk cooking conditions, and sits in supply chains for weeks. This rule is hard, and I break it every day by indulging in Dark Chocolate.

For the nose, wear a clean medical-grade mask. Do not interact with maskless people and keep social distance, even with primary relatives. For now, assume you do it 24 hours in the day. We will relax this rule later in the article. Do not clean your nose by hand — use medical cotton and sanitizing liquids as needed.

Heat can be used as a defense for the mouth and nose. Hot water with salt can be drunk and steamed water can be inhaled. Critters are sensitive to heat, which is why our bodies have evolved fever to make a temporary heat shield. Use that shield — the times call for it.

There’s less to be done for ears. Cover them with clothing or buds when you go out. Do not itch or play with them with your hands. Itches and discomfort in the ears need to be referred to your doctor.

Solid excretion is a high-risk activity — you’re usually sharing a seat that multiple other people use, and their bacteria can quickly enter. You will manically clean everything that will come in touch with any region near your body part — back of the seat, the weight support, etc. Invest in high-quality cleaning paper both for equipment cleaning as well as your body part.

Liquid excretion behaves differently for different sexes. For those who urinate the same way as they defecate, all precautions are duplicated. As a man, I do something gross: urinate in a standing position and clean the seat for other users. I am avoiding bringing my orifice near dirty places unless necessary — the times call for it.

Finally, let’s discuss the pleasure orifice =). Chemo will be stressful. We lose physical cuddles and other displays of affection for months on end. Self-stimulation might be the only thing we do. I’ll dedicate a blog to this because men and women are pretty different. Overall, you want to sanitize your hands before and after, and dispose of resulting secretions carefully. Do not let the secretions become a nutrition source for critters right outside your pleasure hole! Sanitize places where secretions had lain.

Did you open up the sixth hole by cutting yourself? Show to the doctor immediately. The situation is out of your control.

The Sanctum

I am sure readers realize the difficulty of following all these rules all the time. I break them by scratching my nose, eating food from outside the plate, forgetting to wipe the toilet seat, etc. Adapting to discipline takes time.

Hence, a second major hack: Define your clean Sanctum. It is a small space in your home (for home-chemo) or around your bed in the hospital. The Sanctum contains all you need for 95% of your activities — rest, meals, exercise, relaxation, connection, and work. You, and your caregivers, make an effort to keep the Sanctum clean. Sheets are changed every day, floors and surfaces wiped down, possessions sanitized etc. The Sanctum also contains a nearby (ideally single-user) toilet and bath. The highest hygiene standards are applied to those. This sacred place is meant only for the chemonaut — mask-bearing family members come in to help with the cleaning but leave quickly. The Sanctum is your temple/church, and you are the Priest.

When the Sanctum is immaculately kept, risks arising from you breaking some earlier rules reduce. Did you pick your nose in the Sanctum? Undesirable, but might be okay: your hand was touching something else in the Sanctum, and that other thing is clean. Did you pick food off the plate in the Sanctum? Not good, but the Sanctum provides you some additional protection. See the logic?

Critically, you can be without a mask in this place. Everyone else wears a mask and gloves to enter the Sanctum, but you’re exempt. We need this freedom to keep ourselves sane.

Venturing out of the Sanctum

Chemonauts will venture out of their Sanctum to gardens, lakes, trails, and other comforting locations. These ventures are necessary and will be designed for. The critical mental image: venture out dressed as tanks in the outside world. Medical grade masks, gloves, correct eyeglasses, sanitary ear covers, clean underwear, a scarf, full clothing covering every part of skin below the neck, stable shoes, warm socks, and warm overwear are worn. Chemonauts may not look cool. They realize they are on the path to be cancer survivors, one of the sturdier breeds of people in the Western World. Coolness is a sacrifice they find easy to make.

There is an implication — a chemonaut requires a protocol to wear external clothes without contaminating the Sanctum on onward journey. In return, they need a different protocol to ensure critters stuck on outer clothing do not enter the Sanctum. Let’s call the first the tanking procedure and the second the de-tanking procedure.

Tanking must be performed either at the edge or just outside the Sanctum. Sanitize your hands, wear gloves, remove sanctum clothing while storing it properly, and then put on each piece of clothing for the external venture. Once tanked, there is no fleeting return to the Sanctum, for instance, to collect a mobile. Remember: Agents on outer clothes are to be kept away from the Sanctum.

De-tanking is the opposite. Just outside the Sanctum, every piece of external clothing is taken off, gloves last, a quick shower is taken, and fresh clothes are worn for the Sanctum. Outer garments are then either stored for later use or washed depending on the duration and location of the venture.

That’s the lifestyle I am getting used to ward off infections. I am a beginner. I am wondering about questions such as:

• How can a mobile road vehicle be built with an inner Sanctum so that people with compromised immune systems can travel?
• Can tanking and de-tanking be simplified? Can we augment personal transport vehicles, like cycles or electric boards, with bio-containment capabilities to make them Sanctum-like?

Until next time chemonauts!

Early adopter cyborgs live among us today. They are humans, living primarily inside hospitals, needing to be monitored and connected to some machine(s) to keep alive. Plug them away from the devices, and take them out of hospitals, and they will die. I am one of them, and I am a special kind. I am a blood cyborg at the University Hospital Basel, a sanctum where Steve Jobs sought treatment for his cancer. This post covers the insane capabilities we possess for the sustenance and upgrade of blood cyborgs. You will get a sneak peek into the future potential for blood cyborgs. You might want to end up becoming one. There are other classes of cyborg; it’s just I was fortunately admitted to being the coolest type.

A blood cyborg is born when the standard machinery for producing blood in their body malfunctions in some significant way. Imagine blood like a river coursing through our bodies. It contains ships (cells), signals, and building materials. Ships perform various kinds of work in different parts of the body. We’ll focus on 3 types of ships — repair ships (thrombocytes), transport ships (erythrocytes) and warships (leukocytes). By sensing and keeping the numbers of these ships and building materials under control, the hospital keeps blood cyborgs alive. This is 95% of their job in treating my cancer. The chemotherapy itself constitutes a much smaller active part.

When a blood cyborg is admitted, the first thing the hospital does is open a cyborg port. The cyborg port is the connection between the machines and the blood. They opened the port in a large vein on my bicep, put in a tube from my bicep to near the heart, and sealed off the port to the outside world to prevent infection. External lines so the machines can access the port were attached to the port. The port comprises multiple terminals, where entry and exit of material can be done in parallel. Just like a large airport has many terminals, my cyborg port has numerous terminals. The machines can draw blood and send in a wide variety of substances in parallel through the cyborg port.

The doctors and machines are constantly at work managing my blood. Consider the aspect of repair first. In my disease, the number of repair ships in blood has sunk to minuscule levels. This is due to cancer itself eating up repair ship production capacity and chemotherapy shutting down the construction of repair ships. Hence, I am vulnerable to injury — cuts and internal injuries are significant threats. Beyond accidental cuts, doctors themselves need to periodically open up minor cuts to either take samples deep from within or deliver chemo cocktails to unique places. I can’t handle cuts, but the doctors need to make cuts. Catch 22.

They have come up with an ingenious solution. A couple of hours before they make a cut, the machines deploy (infuse) extra repair ships and extra repair concrete into my blood. The surgery is done and bandaged up. With this boost, I’ve usually closed surgical wounds in 1 day. A few days back, I started bleeding from my gastrointestinal system — blood in the stool. The doctors acted immediately — extra repair concrete was deployed. Today is the first day I haven’t bled the same way. Notice the pattern? They modulate my blood according to the life circumstances I am going through.

Everyone has oxygen transporter ships that get loaded with cargo in the lungs and then dispose of that cargo in the organs and muscles. Before diagnosis, cancer had cut the number of these ships to a third of my usual number. That, in turn, led my heart rate to double on average. I fainted on the street once and had headaches. These external signs led me to my doctors and diagnosis. So, you can imagine that the doctors keep a close watch on these transport ships. They keep me operating at half the number of ships an average person — no more. Transport ships are measured every day, and if low, I get reinforcement ships in the blood that day. These ships are red (blood-colored) and, I must admit, there is no purer nourishment I have known in life. I feel uplifted, funny, focused without any side effects like stupor.

A final aspect of my blood is that my warships are near zero. A special kind of battleship caused my cancer when it went berserk and duplicated itself beyond control. In its quest to destroy those murderous battleships, chemotherapy has basically killed off all the warships — even the good ones. As a result, I am deadly vulnerable to infections — bacteria, viruses, and fungi. If any of those critters take hold anywhere in the body, it could be game over quickly. So, the machines put various drugs — anti-bacterial, antifungal, and antiviral into my system regularly. My guess is, if a severe infection were to ever happen, the doctors would roll out a substitute navy, with warships of different designs, into my blood in an instant. They are prepared for every eventuality.

While I am keeping good spirits and eating hearty meals, some chemotherapy patients stop eating altogether. For such cases, the doctors and machines can airdrop everything — energy, vitamins, general building materials — directly into the blood! In the form of a hospital, humanity has built a blood monitoring, stabilizing, and augmenting device. It’s a wonder one can only perceive when one becomes a blood cyborg.

A blood cyborg realizes that half the things the body does are to just stabilize the blood. Stomach and gastrointestinal system? Exist to pump energy and building materials into the blood. Pancreas? Existing to control the amount of energy flowing in the blood. Kidneys? Exist to purify the blood. Breathing and lungs? Exist to have enough oxygen cargo on transporter ships. What you, as a person — the senses, the brain, the muscles, the sexual system really needs — is good blood.

That ushers in the imagination of late adopter blood cyborgs. The hospital will be shrunk into a blood monitoring and modulating device worn inside the body. Or they will have such a unit at home to which they plug themselves every night. Whatever the system, these blood cyborgs will have optimized blood. They won’t suffer obesity since excess energy is never pumped into their blood. They won’t suffer from diabetes because of similar reasons. Their wounds will heal in an hour or two since they are fortified with repair ships exactly when needed. Their warships will be augmented when they travel to a foreign country. They will climb Everest quickly by boosting the number of transport ships. And maybe, just maybe, they won’t age since the signals for aging are carried, alas, in the blood. Here beckons blood cyborg humanity!

Until seven weeks ago, I was enjoying my beach. I had just learned surfing on the challenging, but rewarding, waves of being Chorus CTO and a father. I was on the lookout for a third wave that I could gently learn on. I seldom paused to look at other people’s beaches. In an instant, my beach transformed — the tsunami of blood cancer hit and made the landscape alien. It brought two significant facets — daily vicissitudes of the body and the prospect of a shorter life. I haven’t slept well the last 17 days since one of the medications has this effect on me. Severe anemia, headaches, fainting episodes, constipation, anal bleeding, skin rashes, and minor surgeries are constant companions. I have probably become infertile for life and stand to lose my hair. Pondering an earlier end to the game of life is a more abstract exploration. There are insights brought by thinking about the game tree in that direction, but that’s not my focus here.

When my tsunami hit, my instinctual reaction was: I will learn to surf this beast. Extract helpful energy from it and build something with it. On the ten-minute tram journey from the doctor’s clinic to the hospital, I averted my wife’s eyes since I could not hide my smile at improved prospects for growth. This blog pens down a realization on how useful energy can be extracted from the tsunami. My thoughts, words and conduct may sometimes have increased the capability to send some tsunami energy to other people. Hence, they mount their new waves with confidence. This capability exists for everyone — the tsunami merely laid it bare for me.

When my tsunami hit, my instinctual reaction was: I will learn to surf this beast. Extract helpful energy from it and build something with it.

Conduct in the face of physical discomfort and death has always had the power to inspire others’ thoughts and actions in the face of doubt. Two stories illuminate beautifully- one of physical pain from the world of non-violence and another of graceful acceptance of death in the theater of violence.

The early years of Gandhi in South Africa were marked by a pattern of civil disobedience. He and his followers would disobey, individually or in groups, some civil law they found unjust. Brown people were not allowed to walk on pavements, partake in certain clubs, travel in some train classes, assemble in public, and were required to pay additional taxes. These rules were legally clear but morally unjust. There existed a pragmatic legal question of whether British subjects, such as brown Indians, could be discriminated against in another British province.

The Gandhian approach simply refused to follow the rule — for instance, walk on the pavement normally. This would bring out the neighborhood ruffians, who would progressively escalate from verbal slurs to stone-throwing to beating the errants. Under such physical discomfort, the Gandhians would either gracefully accept the punishment or offer a different part of their body for further punishment. This conduct made the difference — it led some of the oppressors to doubt the justness of their approach. Is continually hitting the meek their calling? That doubt would often de-escalate the physical confrontation and move the discussion to diplomacy, where the justness of the rule itself would become the centerpiece. This approach, ahimsa, leverages conduct during physical discomfort to sow doubt.

Transplanted from South Africa to India and scaled up through the political organization, ahimsa became a critical method by which India achieved its independence from England. At scaled-up levels, ahimsa led to questions in the minds of the ordinary British people. Was taxing commodities heavily, forcing trade one way, barring people from service, etc. the fitting reflection of their society? That inward reflection, inspired by certain conduct, was the critical one.

Now, onto an incident where the conduct in the face of probable death inspired action. We revisit the legendary battle of Troy — the Trojans are besieged by the Greek army, who have come to reclaim one of their princesses. On the Greek side, we have the hero Achilles, the greatest of the Greek warriors and invulnerable all over his body except the heel. On the Trojan side, the lead character is Hector, the crown prince. Dutiful, responsible, a good warrior, Hector led the military charge for the Trojans. In one of the military sorties led by Hector against the encamped Greeks, Hector succeeds in personally killing the best friend of Achilles. Achilles himself was otherwise predisposed during this sortie and did not take part. News of his friend’s demise drives Achilles fervent, and he swears personal revenge for Hector.

The next day, Achilles drives his chariot to the walls of Troy alone and challenges Hector to a one-on-one duel. Hector and his family are aghast. Hector faces a decision. If he declines, he will forever be marked a coward. It will temporarily save his life, but make it much harder to order men into battle and their potential deaths. He instinctively knew that Troy would lose and death must be faced more widely in his society. How would his wife, the princess, be a source of comfort to other grieving wives if he was saved by a decision to decline?

Hector stoically accepts his fate and takes the challenge. Rides outside the gates of Troy and fights with honor. But alas, he is squared against an invulnerable demi-god, and he does meet his end. In fulfilling his destiny with calm, he inspires Troy to defend bravely and accept their defeat in the future. For that sacrifice, Hector is the greater hero of the story. Conduct during the possibility of death often allows other people to re-evaluate their own priorities and approach to life.

Conduct in the face of physical discomfort and death has always had the power to inspire others’ thoughts and actions in the face of doubt…the way we tell our story, approach our bodily fights, find positivity, and put the ideas into words, can have more energy than usual.

I or my circle of friends are no Hectors or Gandhis. Other cancer patients aren’t either. However, the way we tell our story, approach our bodily fights, find positivity, and put the ideas into words, can have more energy than usual. And sometimes, just by chance, we can succeed in bringing positive change that allows someone to ride their wave. I realized this when a friend of mine told me he would learn all about cryptocurrency and finally make a career switch. It’s a decision he knew to be correct for the past couple of years, yet the magnitude of change felt too large. Possibly, the transience of life he now perceives makes it easier — I don’t really know.

That, in turn, made me realize — it’s time to reach beyond my own challenges. Understand other people’s beaches and the waves that paralyze them. Some of them have more enormous tsunamis than mine. Others have gentle waves, but so numerous of them that they make navigation difficult. Still, more have good beaches, but some internal thought pattern prevents them from making the best out of them. I can listen to them and ponder about how I can supply some of my tsunami energy constructively. It won’t work most of the time, but who knows, there are people somewhere that do need my tsunami energy. I have more of it than I could make use of. I will listen as much as my bodily energy allows.

And, if there is a tsunami on your beach, perhaps you can try the same. If you do, by chance, manage to channel and supply this energy positively in your circle, your tsunami will look less scary. More controllable. And maybe, just maybe, even a friend.

Living with, surmounting, and bouncing back bigger from cancer is a team sport. Teams of people need inspiring, uplifting stories to propel them forward and distort reality in their favor… The story need not be grand, but it needs to connect, inspire and uplift. I cover the story of my cancer and then why I chose this story.

Humans are the only species that can cooperate flexibly and in vast numbers. A city of 10 million people is orchestrated action that can survive hundreds of years. This is unparalleled in the animal kingdom. We can do this because we invent and collectively believe in stories¹. Everything from nation-states to corporations to football teams to human rights to religions to liberty to money itself is fiction. These concepts have no basis in physical matter or the tangible — they belong to the ethereal world of storytelling.

What is the American Dream? A story that diverse disenfranchised people can come to America, where other people value certain ideals (democracy, rights, liberty, and equality) and get an opportunity to be successful. As long as enough people believe in, nay hallucinate the fiction, talented immigrants arrive, work hard and provide each other the opportunity they were seeking.

What is SpaceX? A story that we can travel to and live on Mars, with as yet unbuilt/unknown technologies, and that a group of maverick nerds led by Elon Musk will accomplish that goal. If enough maverick nerds hallucinate the fiction and dedicate their lives to it, coordinating tirelessly, it will actually happen.

What are human rights? If you dissect a human, you’ll see lungs, hearts, kidneys but no rights. These are fictions that every person ought to have — the right to a fair trial, protection against enslavement, etc. As long as we all believe in them and support causes to protect them, then the average person’s life improves materially.

A cancer patient, and the community around them, needs a story of their cancer and their recovery from it. The story need not be as grand as the ones we’ve covered, but it needs to connect, inspire and uplift. I cover the story of my cancer and then why I chose this story.

The story of my blood cancer

How odd is it that a successful biotechnologist crypto-entrepreneur, with a fascination for life extension, is placed as a cancer patient?

This universe behaves as a training ground for me. My initial assignment was to give me good birth in a developing nation. I trained and performed really well from that starting point. I got into the best university possible, did well in student leadership, learned basic chemical engineering and biotechnology. Then, I worked for a pharmaceutical giant, lived in five different nations, started a family, made the maverick decision to switch into cryptocurrency, did well as an entrepreneur in that alien field, and accumulated capital. I dreamt of building a life extension company and personally living to 150. I was grinding away at a theory of human aging to base that effort. We hold together as a loving family, and I have a supportive network of friends. My business partner is fantastic, and I adore the crypto community.

So, this intelligent universe decided to test me and simultaneously allow me to grow way beyond where I would have tread in the ordinary course. It’s test: A carefully considered form of blood cancer. This is the second assignment in my training.

How odd is it that a successful biotechnologist crypto-entrepreneur, with a fascination for life extension, is placed as a cancer patient? For pre-cancer Meher at 32, life extension was a distant desire. For post-cancer Meher at 33, life extension is the need of the hour. It accelerates everything I was already headed towards and gives me razor-sharp focus. It provides me with a perspective few other young people have — that of being an early-adopter cyborg, of being dependent on machines to survive the day in day out. It gives me a visceral empathy for the suffering that life extension seeks to solve. It is the perfect testing and training module for me at age 33.

I will make the best of this training module. Soak up knowledge of everything consequential around similar patient cancers. I will use this shock, this magnificent bolt of energy, to engage in creation: some creation, probably this chemo diary, to improve the lives of everyone in my shoes.

Why this story?

There are two main types of responses possible for any sizeable external shock: Either focus on dissipating the damage produced by surprise or concentrate on altering your identity in a way that you can leverage the shock to emerge stronger.

Your partner of 2 years left you for another person? You can focus on preserving your ego. You will erect barriers against other people in the future because that defense mechanism is needed to contain the damage produced by the shock.

The alternative is to mutate radically and yet gracefully: change in calculated ways that make it easier to attract and retain partners. Mutation requires casting aside old beliefs, habits, friends and may lead to an overhaul of identity. The correct modifications allow you to perceive the shock not as a shock, but as an opportunity.

Your society is beset with Covid and had to bring economic activity to a halt? The leadership can focus on printing money to keep festering companies, institutions, and old money afloat. Or it can totally change tack, accept that a significant structural mutation must happen, and invest in UBI, remote work/university/X, and biotech research. People, marriages, companies, cities, institutions, ideas, religions, and crypto networks face similar choices in the face of shock.

A cancer diagnosis is a substantial shock. When I think about my prognosis, I break it down into the fortunate case, the battle of attrition case, and the transcendent case. In the fortunate case, chemo will work on my body over the next 2 years and give me a 10–20 years life extension without any additional continual procedures. I will use these years to find or invent an insurance therapy against my own cancer and go on for more. The battle of attrition case is when chemo works short term (2 years), then cancer returns, and I am back to square one and so on. It’s multiple life-death struggles that must be borne by the body and mind one by one until maybe a targeted therapy clicks. And then, there is the transcendent case where death must be greeted like an old friend early. I don’t know the odds of either of these cases — that data will materialize over the following months when the impact of chemotherapy on my cancer is better understood.

My response, the only possible response I know how to have, is to regress. Become a child and a teenager. Look at the world with wonder, go forth in it with curiosity, make myself plastic, ever ready for calculated mutations. The belief system most aligned with such regression is to think of the universe itself as a university and cancer merely a test assignment. And in that innocence and willingness to soak knowledge, I will find the genius to convert this shock into usable energy and engage in a burst of creation.

And thus, at age 33, I herewith become a teenager studying at the School of Blood Cancer. But it won’t be just study — I will write up every nugget of trustable research insight I find into how to handle chemotherapy gracefully, alleviate graft versus host disease and other practical matters touching the lives of cancer patients. My first homework assignment is to improve our collective experience as cancer patients.

¹ The importance of storytelling for humanity’s progress is from Yuval Noah Harari’s book Sapiens.

Events raced in my blood cancer. I was diagnosed and admitted to the hospital on a Wednesday, put through various scans Thursday and Friday, started with steroid therapy on Friday, and started with chemotherapy on the Friday of the following week. My current chemotherapy lasts one month and puts four cocktails of drugs in my body at different times during the month. I got a list of medicines in these cocktails and scanned the side effects of these drugs on the internet.

It was a shock. The total breadth of side effects is massive. It covers short-term side effects (felt during the therapy) to long-term side effects (encountered years and decades beyond). Short-term effects range from nausea, vomiting, drying skin and skin problems, loss or alteration of taste, loss of head hair, blood during urination, diarrhea, susceptibility to infections, etc. For all of these effects, the doctors have defenses — other drugs they could give, if the side effects were felt, to stabilize me. The doctors can’t predict which patient would develop what short-term impact. So, I quickly stopped thinking or worrying about these effects. They are beyond my locus of control, and the experts can handle them.

Want to read this story later? Save it in Journal.

Then comes the long-term side effects. My hospital roommate is suffering long-term side effects from his treatment in another blood cancer. He has difficulty with German word lookups and searches for a word for a concept he knows. He finds it difficult to correctly pay attention to the material information while ignoring the noise and focus for more than 1 hour on any task. He feels pain in moving muscles of his ankle in specific directions and issues maintaining muscle mass. Every chemotherapy patient has such a distinctive mix of long-term problems.

The doctors disclose such long-term side effects for my particular therapy via an official paper. They include everything from the whimsical to the tolerable to the materially impactful to the grave. A whimsical effect is that some chemo patients lose all of their head hair, and it grows back later much curlier than earlier. So, a curly-headed Meher is in the offing :). A tolerable effect is the permanent loss of fertility. The doctors bought me insurance against that by storing my sperm samples before initiating chemo. I would class my roommate’s attention and lookup issues as material. There is a colloquial term called “chemobrain” that is a superset of similar brain issues. Grave issues of my cocktail are future increased risk of other unrelated cancers, increased risk of diabetes, weak bones, and the body finding it hard to seal cuts. All these side effects are happening because our current chemotherapy technology is not targeted enough. It kills the cancer cells, but it also kills other healthy cells performing perfectly well. Imagine a city with a few criminals loose. The mayor brought in the army to destroy the criminals. The army killed the criminals and indiscriminately blew up the science museum, damaged the water treatment facility, and took down a few schools. That’s state of the art in chemotherapy today.

How do I respond? How does any prospective chemotherapy patient respond? This article is my answer, and from it flows a plan for my (every) day at the hospital.

Dreams of Churchill

I dreamt I was old, wizened, battle-scarred, obstinate, determined Winston Churchill on the eve of the Battle of Britain. Once Hitler had consolidated his hold over Europe in 1940, Germany set its eyes to bombing and subsequently invading Britain. I saw myself in Churchill’s shoes scanning over a massive hologram of Britain — people, factories, weapons, the palace, and hamlets. I saw it all, and I realized I will need to choose who and what to try to save. I woke up feverish from the insight and knew how to think.

Churchill was faced with an unpredictable enemy strategy. He could not have known where Hitler would bomb and invade… Churchill also knew that no matter his efforts, the future contained a changed Britain with the loss of many people — destruction itself was outside his control. He did have something in control — prioritization of what to save during the Battle of Britain… I believe I also have that same element of control — prioritization of what to preserve from the ravages of chemotherapy.

Churchill was faced with an unpredictable enemy strategy. He could not have known where Hitler would bomb and invade. The indiscriminate chemo is similar — I cannot tell what healthy part of me will affect, save the definitely known side effects like hair loss. Churchill also knew that no matter his efforts, the future contained a changed Britain with the loss of many people — destruction itself was outside his control. He did have something in control — prioritization of what to save during the Battle of Britain. There are examples where Britain chose to let the German war effort destroy elements even though they had intelligence of upcoming attacks to prioritize the more critical features. I believe I also have that same element of control — prioritization of what to preserve from the ravages of chemotherapy.

You see, we all can make a catalog of all the capabilities we individually possess. On the dimension of the body, we can inspect the body muscle by muscle and joint by joint and articulate the range of motions these elements can do. In the dimension of the mind, mental capabilities can be broken down into classes — short term memory retention, long term memory retention, attention targeting (paying attention to the correct piece of information and ignoring the rest), word lookups, language construction, visual shape manipulation, facial recognition, arithmetic calculations, etc. A catalog is easy to make.

With this catalog, the next problem comes into view: How to prioritize what to save? This is where each chemotherapy patient will diverge in their preferences — they must decide what matters to them. For me, the answer is breadth-first prioritization — I want to save some capability in every element of the catalog, even if I lose the peak performance in that capability. Some examples clarify.

I am good at mental math and can add or multiply relatively large numbers in my head. I am OK to lose much of this ability as long as I retain the essential knowledge to add small numbers. I am great at high-intensity running at a heart rate of 190, and it’s acceptable to lose that ability as long I can simply run. I am poor at word lookup (scrabble is difficult). Therefore it is highly critical that I retain whatever capability I do have in word lookups. My thigh muscle is stiff and doesn’t articulate well, so I must preserve what I have there. On the high level, I want to walk away with at least small or medium levels of ability across all catalog elements, even if that means sacrificing what differentiates me as an individual. After chemotherapy, I will again train and develop some parts of the catalog to a high level of performance. Make sense?

That leads us to the final problem: How do we tell our body what to preserve. What’s the preservation signal? It’s blindingly obvious.

Our intelligent bodies operate on a use-it-or-lose-it basis… The use of any capacity in our body is not just a physical or mental work — it doubles down as a signal for the future development priorities of the body… If true, I, the Winston Churchill of my body, can signal my preservation priorities simply by using capabilities in the catalog during my entire month of chemotherapy on a breadth-first basis.

Our intelligent bodies operate on a use-it-or-lose-it basis. Whatever part of the catalog of abilities is used to its limit develops further. Powers seldom used shrivel to free up space for other things. The use of any capacity in our body is not just a physical or mental work — it doubles down as a signal for the future development priorities of the body. I suspect the body uses sleep to aggregate these signals and build structures according to the development priorities laid down by actions in the day.

If true, I, the Winston Churchill of my body, can signal my preservation priorities simply by using capabilities in the catalog during my entire month of chemotherapy on a breadth-first basis. That’s the protocol my wife, Apoorv Tiwari, and I have minimally designed and are iterating on further. The two prominent execution elements are Sukshma-Yoga and Lumosity.

Sukshma-Yoga or Subtle Yoga

This is an ancient practice of Indian yoga that my wife has learned and is further specializing in for me. Yoga is associated with complicated postures, hot temperatures, and balance exercises. Sukshma Yoga is very different from the commonly held conception of Yoga in the West.

In Sukshma Yoga, there are no complicated postures or even a need to get out of bed. Instead, a session goes through joint by joint and muscle by muscle making subtle, slow movements across the entire articulated range of the body part. Slight movements are accompanied by different types of breathing — single nostril breathing, dual nostril breathing, throat muscle-based breathing, and stomach-based breathing. Glands are exercised via massages. A 1-hour session of Sukshma Yoga is feather-light on energy requirements since all of the movements are subtle. The low energy need is an exquisite property to have in chemotherapy. I, or any other patient, won’t be at their peak energy during chemotherapy.

Sukshma Yoga is my method of sending a breadth-first preservation priority signal to my body.

Lumosity

Apoorv researched the catalog of brain abilities and searched for solutions to the prioritization signaling problem. He settled on Lumosity, an application containing around 50 simple mental games. These games exercise different aspects of brain function such as information lookups, short-term memory storage, flexibility, arithmetic, shape manipulation, logical problem solving, and speed. I play different games on Lumosity every day and make sure to spend 10–15 minutes on each part of the catalog. I don’t try to do well on any of the games or look at the scores of other people on the same games. This is not a competition or training; it is a preservation signal!

Dissatisfaction

I was proud of this 2-day hacked-together protocol until a significant doubt crept into my mind. When I scan my entire life and all of the successes I have been blessed with, I associate them significantly with an ability to plan and strategize for the long term. In my post-cancer life, my ability to address future cancer is a problem where long-term strategizing and planning are a material determinant of success. There is nothing to practice long-term strategizing of the kind needed in the real world in Lumosity. I thought of the natural variant: strategy games like Age of Empires. I downloaded the latest and greatest on the iPad and was busy learning the rules.

And then, another flash of inspiration struck! The best preservation signal for long-term strategizing ability is not some software game but a blog. The blog would cover my recovery plan from blood cancer in the short and long term. It will force me to think strategically every day. As a side effect, send a preservation signal for my strategic mind. That digital manifestation of the tool is this chemo-diary you’re reading.

In effect, I am breaking my earlier rule of breadth-first preservation to make one depth-first exception: long-term strategic ability. This is the only ability in the catalog I will exercise intensely every day.

Design of my day

I wake up at 07:00, groom myself and give my blood measurements until 08:00. The following 1–2 hours are engrossed in Lumosity. After that, follow some doctor appointments and then 1 hour of Sukshma Yoga. Then, I break for lunch. Post lunch, I work on the blog as much as my energy permits. I have video calls with family, friends and walk in the park during breaks in blog writing.

One final thing: I interact socially with everyone who comes into the hospital room: nurses, janitors, caterers, doctors, etc. I remember their names and get to know their stories. It improves the vibe on my floor, and it doubles down as a social intelligence preservation signal.

What do you think? Send me feedback, questions, likes, comments. Don’t shy away thinking a cancer patient needs his rest. On the contrary, I am Winston Churchill, and I am fighting a war for preservation.

📝 Save this story in Journal.

I feel great today, especially after the sukshma-yoga done with Kiran*. Sleep eluded me last night, mainly on account of night infusion.

Friends

I am grinning since I got a remarkable gift: A personal message from Grand Maester Pycelle from the Game of Thrones. Julian Glover, who plays the character, was also the voice of Aragog in Harry Potter. The video goes into how his character was developed subtly in the series and found his identity.

It struck a chord since I am also searching for my new identity: https://youtu.be/r-ey_LVjp0w

This gift comes from the fabulous team at Solana. They have built the most performant live crypto network with trailblazing new financial capabilities such as an open-source exchange. Raj, Dominic, and Anatoly, cheers!

I am also grateful to have Rishabh in Basel. He flew down from the US to get us through the first chemo push and filled in some of my fatherly roles for Zubi**. His connections to doctors from different research institutes broaden our network of advisors that we can consult during my illness. He is a budding Biotech VC, so reach out to him if you invest in that area.

Chemoplan

Yesterday, I took the systemic chemotherapy cocktail consisting of three drugs — Vincristine (C1), Daunorubicin (C2), and Cyclophosphamide (C3). They plugged in some additional C2 into my cyborg port today and will do so tomorrow as well.

The three drugs are primarily administered to stop cells from dividing and thereby creating new cells. My leukemia blasts have a constant need to divide and proliferate. They have infested most of my bone marrow (90% of all cells in bone marrow were blasts) and a large portion of my blood. Of course, the need for cell division is also a feature of many healthy parts of the body, such as my reproductive system, hair follicles, intestinal linings, and so on. The fact that cell division is both an essential feature of the blasts and one of the normal bodily processes leads to the potent curative effects and side effects of chemotherapy.

Cell division is a complex process with 5–6 sub-steps. The three agents interfere with the different sub-steps in cell division and are therefore able to affect the division of the blasts. It is as if we’re attacking the blasts and normal dividing cells with weapons that work in three different ways — a knife, a pistol, and a rocket launcher.

Consider Vincristine (C1). Its mechanism of action is to disrupt the formation of microtubules in dividing cells. Just like our bodies have a skeleton to provide structure and stiffness, cells have microtubules to provide physical structure and move cells. Microtubules for both daughter cells must be formed during cell division, and these structures then pull the two cells apart. Microtubules are molecular machines for structural support and pulling cells apart. Vincristine stops the formation of proper microtubule structures required for cell division.

Onto Daunorubicin (C2) targets a specific molecular machine, called Topo-Isomerase, working during DNA duplication. DNA is the long-term memory of every cell, and it stores instructions to make a wide range of cell components. Division requires the entire DNA of a cell to be duplicated. One of the wonders of DNA is how it is folded compactly in the cell. Origami is used to fold 3 meters long human DNA into compact structures called chromosomes whose dimensions are in the deca-nanometer range. Whenever operations (reading, copying, maintenance) need to be performed on DNA, the origami on that operated piece of DNA must be undone. Structures near the opened piece of DNA develop stresses that must be resolved. Topo-Isomerases are molecular machines that rectify the mechanical stresses resulting from the undoing of origami during the duplication of DNA. Daunorubicin impairs the functionality of one of these machines, thereby bringing DNA replication to a halt.

The third Cyclophosphamide (C3) majorly works by disrupting the chemical structure of the DNA itself. DNA structure uses two types of glues for its formation — strong glues (covalent bonds) and weak glues (hydrogen bonds). Certain parts of DNA are only weakly glued together as these structures need to be periodically separated and then brought together again during normal operations (reading, copying). Cyclophosphamide works by strongly gluing parts of DNA that should typically be only weekly glued. This inhibits DNA replication and leads to cell death.

Chemicals like C1, C2, and C3 have many more effects than the ones described. We’ve covered here the main known mechanisms by which these agents work to halt the spread of leukemia. It is fair to say that humanity doesn’t know everything about what these agents do in-depth. Now, onto my thoughts for the day.

Withholding judgment in grand strategy

You are in the office. The boss walks by your cubicle and winks at one of your coworkers. This hasn’t happened before. Possibilities swell in your mind — budding friendship (?), commemoration, or something else. A short pause, you judge it immaterial. One is in a computer game. A shadowy figure enters, far in your visual perception. Is that an ally or an enemy? You must make a judgment and act.

In routine affairs, most of our interactions deal with short periods — seconds, minutes, hours, and days. Events happen, and we must judge those events’ value — whether they’re good or bad, and what may be the magnitude of the impact on us. Our brains make such judgments continuously, to the extent that, sometimes, we may not even realize decisions already made.

Some events are so unusual that it is necessary, nay critical, to abstain from making any quick judgments about them. The development of my leukemia is one such event. It’s tempting to judge it as an adverse event, but I must resist that temptation.

It is pretty fascinating that artificial intelligence researchers have needed to put “judgment modules” in their intelligence as well. These modules assess the state of affairs in any game the AI is playing. For instance, there is this famous AI called Alphago that bested the top human (Lee Sedol) in the ancient game of Go in 2017. This particular event was covered in an excellent documentary which I highly recommend. Inside the architecture of AlphaGo, there is a module called “the value network,” which is responsible for making quick judgments on the quality of the position AlphaGo finds itself in. The value network outputs a probability of winning from that particular position in the Go game.

This convergence of humans that naturally judge events and AIs that need judgment models to function in complex environments indicates the centrality of the judgement process to intelligence.

Some events are so unusual that it is necessary, nay critical, to abstain from making any quick judgments about them.This is especially important in grand strategy, where we’re trying to plan actions for much longer time horizons — years, decades, even centuries. Some events whose influences percolate down these longer time horizons cannot be assessed without much more data. And sometimes, they cannot be evaluated since the data to evaluate them won’t exist in this universe altogether. In grand strategy, the ability to withhold judgment is a crucial skill to master.

One feature that marks such events is that the potential advantages and potential pitfalls produced are glaringly heterogenous on two different time scales. The origin story of humanity provides us with a graphic illustration.

We diverged from our common ancestor with chimpanzees sometime around 7 million years ago. It is a matter of great interest as to what triggered our ancestors to separate physically and behaviorally from this common ancestor. There are many hypotheses, and I cover the most interesting one.

Our common ancestors lived in trees and ate fruits. In some parts of Africa, 7 million years ago, climate change happened very rapidly (over hundreds of years). The amount of forest shrunk and was replaced by dry grassland. This was the trigger for our divergence for chimpanzees. When change is gradual, populations of a species can adjust to the changing circumstances by altering population numbers over generations. If change is rapid, gradual adjustment of numbers is arduous, and other mechanisms come to play.

When trees were replaced by grasslands, some chimpanzees were forced to go and live in the grasslands. Most likely, the physically dominant chimpanzees continued to live in the trees, and the weaker ones were left to fend for themselves in the savanna. Our ancestors had a precarious situation: their strategies to get food, stay safe from predators, and their bodies were out-moded. It must have been a gut-wrenching experience to be kicked out of trees in which their ancestors, in turn, had lived for more than 10 million years.

However, this massive downfall possessed the seeds of long-term growth. Our ancestors were able to find niches where a small number of trees were surrounded by grassland. They learned to scavenge for food in the plain while using the trees for hiding. This modified lifestyle led them to travel more on the ground and learn to scavenge. Since they were scavenging from animals much more physically powerful than themselves, social coordination assumed much greater importance. We have evidence that our first tools were rough stones used to break bones left behind by larger animals after eating their meal. It points to how mental capacity developed to adapt to this new lifestyle. The need to travel more on the ground slowly gave way to more upright stances in successive generations. A couple of millions of years later, we have evidence of our ancestors becoming completely vertical to prioritize running on the ground over moving or hiding in trees. We also developed sweat glands and lost all our hair to run for a longer time without overheating. This opened up the strategy of chasing down prey in a marathon by tiring it out.

That event, that gut-wrenching event, of being kicked out from trees had glaringly different pitfalls and hidden advantages on two different time scales. The true meaning, or appreciation, of the event can only be seen in a grand time. Such events do happen in our lives, even though we are dealing with much smaller time scales (only decades) than the development of humanity itself.

The development of my leukemia is one such event. It’s tempting to judge it as an adverse event, but I must resist that temptation.It is that rare event for which judgment must be withheld. We will, I will need 10–20 years to begin to judge this event.

*Kiran- My classmate, colleague and now wife. We’ve been married for almost 5 years.
**Zubi (Zubin)- My two-year-old son.

Today begins my chemotherapy. I will endeavor to keep a diary of the procedure, how I feel, and my overall thoughts/learnings. Today was full of infusions and the regular daily routine.

Prednisone

I’ve been taking this steroid as tablets for the last week, which produces an interesting psychological effect. I feel in “fight or flight” mode as if there is some threat, and the body must be in an active state. There is a brain fog that dissipates in the evening. I take Prednisone (120 mg) in the morning typically.

Prednisone makes my beard grow faster. I have needed to shave every day the last week, which is unusual for me. The final effect of Prednisone is that it elevates blood sugar during the day. It takes a few hours for this effect to kick in, which is harder to handle for people with diabetes. My body has dealt with this well, only spiking blood sugar to 7.5 units at peak in the afternoon. My roommate, Eric, is not so lucky — his sugar is hiking to 15, and he must take insulin to handle Prednisone. The keto diet I have put myself on helps with glucose control.

Gameplan

Today, they will give me the first big hit of chemo. This first hit comprises many chemicals, and I will provide an overview to make sense of the mix.

We can break down the chemotherapy chemicals into five groups:

1. Systemic cocktail: This is chemo put into the body through infusion, and it will go everywhere. My cocktail has three agents — C1, C2, and C3. Their respective names are Vincristine (C1), Daunorubicin (C2), and Cyclophosphamide (C3). They have their beautiful stories we will get into later. Infusions are sent into a vein in the arm, and it lands right next to the heart. There is a catheter inserted to enable this.
2. Neuro cocktail: Cancer can be in the central nervous system. All scans indicate otherwise, but, for safety, I am given a neuro cocktail against cancer in the central nervous system. This cocktail also has two agents — C4 and C5. Their respective names are Methotrexate (C4) and Cytarabine (C5). This cocktail also has dexamethasone, is a steroid, to help alleviate some of the Adverse Events caused by C4 and C5. Nurses administer the Neuro cocktail via some lumbar injection.
3. Antagonists: This is an exciting class of drugs. They act against some of the chemo elements, dulling some of the effects and preserving their other products. Antagonists are usually supplied two days after the chemo cocktails. One example of an antagonist used in my chemo is called Folinic acid (A1). The second is Dexamethasone (A2), an antagonist against C4 (Methotrexate). These are the only two antagonists in my chemo regime for the next four weeks.
4. Defense elements: Chemotherapy has a long history. Perhaps one of the hardest things for the medical system has been to get patients to stick to the regimen. Some side effects develop and cause the patient to drop out. Therefore, they give some defensive drugs against the most common uncomfortable side effects of this therapy. I’m receiving three drugs in this class — D1 (Emend), D2 (Palonosetron), and D3 (Uromitexan). D1 and D2 act against the sensation of nausea or vomiting. D3 helps the kidney metabolize by-products of the chemo elements and prevents urinary tract disorders.
5. Regeneration signal: To understand this class, let’s realize that many of these drugs will plummet the production of normal cells from my bone marrow, also called Bone Marrow Suppression. Bone marrow suppression is needed so that cancer cell production is suppressed. Once the chemo is far enough along, and enough battles are done, the protocol gives one substance called GCSF (Granulocyte Colony Stimulating Factor) to tell the bone marrow to start regenerating and produce blood. As you can imagine, this signal will come later in the cycle. As an aside, I was in the production facility for GCSF for Intas in Ahmedabad as an intern way back. I am seeing this molecule from the user side now.

Now, what did they do today? They gave me the systemic cocktail (C1, C2, C3) as an infusion. They also gave me defense elements D1 and D2 as tablets and infusion, respectively. We will start D3 shortly, and it will take the form of injections for 6 hours all the next three days. Pretty simple, I feel like a cyborg!

The neuro cocktail will follow in a day or two.

How I feel

Pretty much the same. My urine has turned pink, but that is an expected side effect.

Thought of the day

As I go through the journey, many new thoughts will take shape in my mind, and I will cast them here. Thought for today is that humanity has the tools to gather information about the cancer enemy, but not the means to leverage that information effectively against that enemy.

For my disease, they have collected bone marrow samples. We can visualize the blasts (cancer cells) under a microscope and stain them (K1 = Knowledge 1). We can do flow cytometry to understand what different kinds of proteins are present on the surface of these blasts (K2). We can do a panel of limited genetic tests that indicate the most critical mutations in the blasts (K3). If we go further, we can do a whole-genome sequence of these cells to determine how their genome behaves (K4). And if I pursue it doggedly, I might be able to do some epigenetic map of my blasts as well (K5). All this knowledge is there to be plucked at a relatively low cost. K1, K2, K3 are already being run in parallel. K4 will cost a few thousand dollars out of pocket. K5, perhaps 10X more. We can understand every blast element — how it differs from the rest of the cells, how to recognize it from the outside and what it is producing inside.

The chemo plan, however, is entirely independent of this knowledge. The particular cocktail I indicated earlier would be given to any T-ALL patient, no matter what the intelligence gathered from the enemy. There could be two of us with cancers very different but in the same cell type, and we’ll go through the same cocktail and protocol.

Why? It’s down to the limitations of manipulating biological matter. We don’t have accurate toolsets to take in this information and intelligently evolve a remedy that hits the enemy based on this intelligence. Lacking this capability, doctors mostly ignore much of the surveillance of cancer itself. The only use of intelligence is to get some estimate of how “risky” leukemia is. They know from history that cancers with a particular type of mutation usually return at higher rates than others. They use this epidemiological data to tell the patient what to expect of their disease (how frequently it might return) after chemotherapy.

The opening battles of World War II provide an analogy. In the early war, Germany defeated France handily. We take this fact as a given today, but it was a massive surprise when it came. France had the larger army, with experience from World War 1. They had also invested in building massive defenses against Germany for the last 20 years, given the previous war experiences. Why did it happen?

It happened because France was fighting the previous war mentally. In World War 1, both armies dug trenches where soldiers would hide, and they would shoot at each other in a battle of attrition. Months and years would pass with no gain or loss of territory on either of the two sides. The nature of the word was a static battlefront. The French expected the German attack in World War 2 to be similar — a static battlefront and war of attrition.

But something significant had shifted — tanks and airplanes had been perfected from 1917–1938. Inside a battalion of tanks, armies can move fast. With airpower, they can hit strategic targets behind the enemy’s line. These two inventions re-introduced mobility into war. The Germans had realized this potential and developed a strategy of Blitzkrieg, which focused majorly on mobility. There are many examples where they sacrificed materials and land to gain mobility because they saw the value of this new method of warfare.

So were the French defeated. They were committed to a defense plan assuming Hitler’s armies would behave like World War 1 German armies. No intelligence about the enemy changed their mind and made them revisit their strategy. The French saw the Blitzkrieg in action across Eastern Europe before they were invaded, but they missed this intelligence to devise a counter. They were fighting the last war, not the current conflict.

My doctors at UniSpital Basel, and humanity more broadly, are like the French in early World War 2. Just like one could see the Blitzkrieg in action in Eastern Europe, we can gather a lot of intelligence on my cancer. But, our minds are committed to this cocktail. Intelligence about the enemy does not matter in the cocktail design — yet!