The Probabilities of Living
Life is a matter of probabilities. Ask any cancer patient.
Having treated many types of cancers and hematological diseases over the course of his career, Prof. Heinz Ludwig from Vienna, Austria, is used to getting the question “How long do I have?” immediately after diagnosing people with a cancer. Ludwig does “not think much of giving concrete information about expected survival time. These are average values that say little about an individual patient’s prognosis.” But he understands wanting to know is a normal human reaction.
“If patients do not ask, then I do not mention any concrete figures…Instead, I tell them about cases in which people have coped particularly well with their illness,” wrote Ludwig in Live Right, Live Longer: 5 things we can do to stay healthy. “If, however, they insist and want an answer to the question, I draw a survival curve that shows how different the course can be. It shows that there is an average, but that some patients die very early and others survive unexpectedly long.”
Ludwig is the longtime director of Vienna’s Wilhelminen Hospital Cancer Research Institute and director emeritus of its Center for Oncology, Hematology, and Palliative Care. And he’s one of the world’s foremost authorities on myeloma, having received the Robert A. Kyle Lifetime Achievement award in 2007. He became a pioneer in patient-centered approaches to medical care while treating the full range of diseases seen in his department.
Patient-centric has become an overused marketing term in recent years, but for Ludwig it’s been a part of his outlook since his days as a medical student. Imagine being able to spend a few hours alone with Ludwig to talk about the lessons he’s learned and what it all means – or more precisely, what the probabilities tell us they might mean. You can actually do that, sort of, by downloading the audiobook (see bottom of article).
Live Right, Live Longer is a summation of Ludwig’s ideas about what people can do to improve the odds of experiencing a life lived well. And with life – as with disease – there are no guarantees or absolutes, only probabilities. Some do better than the average, some worse, and most are somewhere in between.
Ludwig writes “not with the purpose of producing a book of advice that will guarantee a healthy life to everyone who follows it blindly.” His views are centered around principles that “are fundamental to our humanity, they pervade our entire life, and they influence our physical as well as our mental health.” People should live their lives, not just survive.
If central casting put out a call for a Viennese professor, few would fit the bill better than Heinz Ludwig. Seen from a distance, he can seem as intimidating as the stereotype implies. Upon closer inspection, however, it’s immediately obvious that’s all wrong…sort of. He’s definitely refined; tall, a quiet baritone voice, reflective. But in no way stuffy or aloof.
Ludwig’s intensity isn’t intimidating; it comforts. His explanations are simple and illuminating. His approach is collaborative; when he says patients are partners, he means it. This conviction also led him to forge a very different path to becoming a noted myeloma specialist, one very different than followed by everyone else of his stature: he did it outside of traditional academia.
Coming out of medical school, Ludwig studied for three years at the University of Vienna’s Institute of Immunology, making him a sought-after candidate for internal medicine training at two of Vienna’s universities. He chose the “less prestigious” one because of its emphasis on “the interpersonal aspect,” they focused more on patient need than publishing scientific papers. Following his internal medicine fellowship, Ludwig decided to work in one of Vienna’s large city hospitals.
In Europe, medical universities form the backbone of national health systems, as we saw in previous articles about France. Ludwig is an exception to the rule. He established the top myeloma research and treatment clinic in the nation while leading a comprehensive department with a reputation for patient-centered care.
Live Right, Live Longer helps explain why. The evidence he presents is empirical, based on personal clinical experience and an incredibly eclectic range of studies. And he does it in plain language meant for regular people, not in the scientific jargon of scientific papers.
Ludwig opens with anecdotes about two patients that helped him to conceptualize the book. Martha had a breast cancer diagnosis that had an average of two-to-four-years survival. She wanted to live long enough to see her twelve-year-old daughter graduate from school. In six years. Not only did she live to see her daughter graduate, she got to see her get married and held her grandson before succumbing to the disease.
Robert was a successful Austrian business man in the United States who returned to Vienna after a metastasizing colon cancer diagnosis, in part because of American health care costs. He lived the life he wanted, but it left him alone, without a support network of family and friends. Instead of setting a goal to live, he wanted to die; but the euthanasia for which he hoped was illegal in Austria. As his case worsened, Ludwig put him in palliative care for a few days before he died. Alone.
Martha set goals and outlived the odds, dying peacefully among her loved ones. Robert felt his life had been lived as he wanted and he wasn’t living for anyone else. Each was on the opposite side of their respective survival curves; one lived longer or the other died sooner averages indicated. Perhaps there was more to it than medicine alone, Ludwig concluded.
Martha and Robert represent thousands of patients Ludwig has cared for in his career, leading him to ask fundamental questions, "what it is that makes us the persons we are. How important are our genetic makeup, our life experiences, our surroundings?” On the one hand, the latter two have nothing to do with medicine as such. On the other, they have as much or more to do with patients’ diseases and the treatments as any medical fact.
Ludwig distills his thoughts into what he calls five L-concepts: loving, laughter, learning, lifelong fitness, and lighter eating. Much like diversity medicine, the concepts intersect differently in each person.
Loving is an expansive and all-inclusive concept, encompassing everything from individual passion to familial bonds to community engagement. The key is to make an effort to be connected and engaged, to bond with others. Ludwig explains various studies confirming linkages between poor health and disease to individual isolation or, more importantly, the opposite: health benefits come with social connections.
One study demonstrating remarkable health outcomes in the close, socially cohesive community of Roseto, Pennsylvania, noted “loneliness is exactly as harmful as smoking 15 cigarettes a day.” A lack of loving bonds – family, intimate relationships, pets, colleagues, friends – adds to stress, which is known to exacerbate the effects of harmful bacteria in the stomach as well as “pain [which] can also be triggered by psychic factors alone.”
Methods to foster love include making active, consistent efforts to be involved with the important people in your life and finding passion in the activities you find most interesting. Physical contact ranging from casual handshakes and hugs to the sexuality of intimate relationships have been shown in studies to have beneficial effects. Our connections and interactions matter greatly to our health.
Ludwig cites studies showing how laughter is healthy for the heart and circulatory system, reduces stress, changes biochemical processes, and improves oxygen distribution.
If we succeed in making humor a part of our lives, this will contribute to our health…it provides medical benefits similar to those of positive social contacts, which are, in brief: Our blood pressure and our heart rate decline, which is good for, among other things, our arteries and our heart, and the cortisol level also decreases. Our immune system can therefore do its work more effectively and proceed against a great variety of disease-producing microorganisms – such as bacteria, viruses, parasites, molds – or tumor cells.
One should never mistake that authenticity of laughter to morph into “the harmful dogma of positive thinking” to obscure or crowd out realism. That could be “seriously naïve and, worse yet, extremely counterproductive.” Humor should never obscure the truth, and can often confirm it. And a true appreciation of humor requires a certain amount of knowledge.
Unfortunately, the speed and pace of modern life have complicated learning. “Some five hundred years ago,” Ludwig writes, “a person was born into approximately the same world as that in which he died. And his grandparents and grandchildren lived much as he did.” An average myeloma patient today has lived through times going from rotary dials to touchtone phones to faxes to the internet to social media.
Change has become an expected part of modern life. But that, according to Ludwig, doesn’t change their behavior as one might think, “I have come to know many people who did not start to look inward until they suffered a serious health crisis…And so they wanted to determine whether and what they might have done wrong up to that point and what they could do better in the future.”
Regardless of how cancer patients learn, a certain amount of education is required in order to have constructive discussions about with their physicians. That doesn’t mean they need to become experts. They should know enough to ask questions and request explanations when they don’t understand. Patients who do so generally do better in the long run.
As important as knowing about their disease is, Ludwig emphasizes, learning – about anything – is more of a life activity, one that keeps the brain active. Exercising the brain, is as important as physical exercise.
Lifelong fitness is easier said than done. It’s hard for a myeloma patient who has been physically inactive to start an exercise routine. It is, however, common knowledge now that a fitter patient will have more options and, on average, better outcomes than one who is not. For example, myeloma expert Jens Hillengass from Roswell Park Comprehensive Cancer Center in Buffalo, New York is studying how exercise and fitness impact cancer incidence and treatment.
When it comes to exercise for patients, Ludwig has “a simple rule of thumb…exercise should be carried out for half an hour at least three times a week” reach pulse rates of “180 minus the age of the patient, which for a 50-year-old would mean 130 beats per minute…it would be preferable to do a bit more rather than a bit less.”
Indeed, Ludwig “recommend[s] almost all of my patients to consider physical training as one of the most effective drugs, with the least side effects and also among the most reasonable in cost, and to ‘consume’ this drug several times a week” to boost the immune system.
With this mindset, food could also be considered a drug. Lighter eating, historically speaking, was a normal part of the human condition.
In the history of mankind a regular feeling of hunger was the normal condition for very long periods of time. This actually helped people survive because they were compelled to stock up to be better prepared for periods when access to food was extremely limited, such as during extreme drought or long, cold winters. It is not surprising that, with this adaptation, which evolved early in the history of man, our body is still so organized as to want to put on reserves. In our present-day culture this is, of course, not only not necessary, it is out and out harmful.
His insights on food and nutrition align very closely to research currently being conducted by Urvi Shah at Memorial Sloan Kettering Cancer Center in New York. Less meat, especially red meat, more fruits and vegetables, less processed food, more whole grains, less sugar. Eat less. Not so often. Drink more water. Don’t use supplements as substitutes for real food.
For many of us, as obvious as it seems, this is not an easy transition. Not only do decades-long habits die hard, according to Ludwig, advertising makes it harder still:
Modern food trends, such as light products or power foods, are not really much more than clever sales arguments of the industry, with which it turns to profit our hopes for an alternative to self-control. It allows us to cherish the hope that we could change something about ourselves without having to make an effort. We buy “light” products whose advertising suggests that we could lose weight just by eating them. We gladly pay a bit more for that. If it then turns out that it doesn’t work, we don’t blame the manufacturer of the product, we blame ourselves. Then we have simply not eaten enough of it or have once again indulged too often or both.
Most importantly, Ludwig writes, “We should be orienting ourselves on ourselves. We should always start from where we are; otherwise the danger is too great that after a few days on a new nutritional plan we just give up.” That’s wise advice to be applied, in my view, to the first four L-concepts as well.
Live Right, Live Longer largely discusses universal themes. One Ludwig mentions is “economic security. To have to fight every day for our livelihood is an enormous burden.” It’s hard to do anything about the five L-concepts if you’re worried about basic economic needs. But starting here, the American context is quite different from that in Europe.
Medical bankruptcies don’t exist in western Europe as in the United States, where it is a real fear for perhaps a majority of Americans, whether they are cancer patients or not . And while European patients may not have access to the latest cutting edge drugs outside of clinical trials, they do get effective treatments and their survival curves are similar and, in some cases, slightly better than those in the United States.
“It’s up to us,” concludes Ludwig. That alone makes the idea of personal change so difficult. But then again, cancer is difficult.
As I reflect on the book, though, I think the intended audience of cancer patients and older adults who want to do something about disease should pick up a copy, read it, and pass it on to their children and grandchildren. Or at least get copies to them.
These are lessons and suggestions that are more easily learned and adopted at a young age, preferably long before the possibility of disease. And while doing something about the five L-concepts will increase the range of probabilities for many patients, the real goal of adopting them is to stop the onset of disease in the first place – to prevent it from ever occurring.
The odds that reading this book will cure anyone of disease is not realistic. But it would greatly increase the probabilities of living longer, and, if not living right, living better.
An audiobook of Live Right, Live Longer is available at Amazon Music, Spotify, and Everand.
