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In sickness and in health

The race for the White House between 70-year-old Donald Trump and 69-year-old Hillary Clinton is the oldest Presidential election match-up in US history, so it is not surprising that their health has been an issue in the race, but an examination of previous presidencies suggests it may be more of a political distraction than a factor that should merit concern for voters.

Back in the 1960s, after all, President John F Kennedy, the youngest candidate ever elected to the White House at 43 years, had Addison’s disease but Americans didn’t know about it at the time and it probably made little difference to his presidency.

If voters had known about it, however, would they have had second thoughts and could it have tilted the election in favour of his Republican rival Richard Nixon? We will never know because it wasn’t until 30 years after Kennedy’s assassination that two pathologists at the autopsy finally broke their silence in the Journal of the American Medical Association (JAMA). They revealed in 1992 that Kennedy’s adrenal glands were found to be almost completely gone. The glands produce key regulatory hormones and their absence, if they are not replaced, can cause wasting and death. Kennedy’s chronically bad back was another one of his excruciating ailments.

Even before he secured the Democratic nomination in the 1960 race, Kennedy declared himself “the healthiest candidate for President in the country”. And he was famously able to exploit his perceived stamina and health compared to Nixon in the first ever televised US Presidential debate. When Nixon was shown perspiring and edgy in contrast to Kennedy’s cool demeanour, it was said to have cost the Republican the election.

However, during his time at the White House, Kennedy was under the care of an allergist, an endocrinologist, a gastroenterologist, an orthopaedist and a urologist. During the first six months of his term, he suffered stomach, colon and prostate problems, high fevers, occasional dehydration, abscesses, sleeplessness and high cholesterol, in addition to his back and adrenal ailments.

But Kennedy’s short presidency may also show that what can matter more than the age or state of health of a leader is their psychological attitude to their ailments and their natural temperament. Indeed, there’s a good reason why the temperamental differences between Trump and Clinton took centre stage in the current election.

It could be argued, for example, that despite his innumerable medical challenges, Kennedy showed extraordinary levels of courage and equanimity when faced with global problems like the Cuban missile crisis, during which a wrong move in his standoff with then Russian President Nikita Khrushchev could have set off a nuclear war.

What is essential, too, is that a country has in place a robust system of democratic succession, so that even if a President does die in office, as Kennedy did, it makes little difference to the running of the country because the Vice President takes over.

In any case, as with the three other assassinated US Presidents — Abraham Lincoln, James Garfield and William McKinley — Kennedy’s state of health had nothing to do with his untimely death.

Lincoln’s health up until middle age, for example, was fairly good for his day,  although he had malaria at least twice — in 1830 and 1835 — and he contracted smallpox shortly after delivering his famous Gettysburg address on the principles of democracy in November 1863, two years before his assassination.

Medical impact

The death in office of the second US President to be assassinated, James Garfield in 1881, ended up having a major impact on the improvement of medicine at the time because Garfield did not actually die of his would-be assassin’s bullet. He died of sepsis two months after his assassination because his surgeons did not believe in washing their instruments or their hands. At his trial, his assassin even said: “I shot him, but I didn’t kill him.”

The impact on medicine of Garfield’s death was the subject of a pertinent discussion in September at the Dittrick Museum of Medical History in Cleveland, in Garfield’s native Ohio, entitled ‘Presidents, public health, and pre-antiseptic medicine: Garfield’s death and its effect on antiseptic rhetoric’.

“We’re doing this partly because this is political season, and what happened to Garfield is one of those times in history that changed the public discussion about medicine,” Ms Brandy Schillace, Research Associate and Public Engagement Fellow, told The Plain Dealer newspaper. She said Garfield’s death led to a new consideration of germ theory and the importance of antiseptic. “It was such a high-profile case, it changed people’s thinking.”

But 20 years after Garfield’s death in 1901, then US President William McKinley was assassinated and his medical treatment was also found wanting. His death was due largely to gangrene brought on by his treatment under an incompetent physician and by the failure to remove the bullet which struck him.

The other four US Presidents who died in office all developed problems after their election, so an awareness of the condition of their health before their election would not have helped.

The first US President to die in office was William Henry Harrison. On March 26, 1841, he became ill with a cold. According to the prevailing medical understanding at that time, it was believed that his illness was directly caused by the bad weather at his inauguration. But Harrison’s illness did not arise until more than three weeks after the event. His cold worsened, rapidly turning into pneumonia and pleurisy.

His doctors tried various cures, applying opium, castor oil, leeches and Virginia snakeroot. But the treatments only made Harrison worse and he became delirious. He died after only 31 days in office, on April 4, 1841, of right lower lobe pneumonia, jaundice and overwhelming septicaemia.

Just nine years later, President Zachary Taylor died of bilious fever, typhoid fever and cholera morbus following heat stroke. President Warren Harding died in 1923 of a suspected heart attack and President Franklin D Roosevelt died in 1945 of a cerebral haemorrhage.

Health no impediment

Indeed, Roosevelt’s career from 1933 to 1945 shows that even if a President is ill while in office, their  attitude to the illness, like in Kennedy’s case, may be far more important in determining its impact on the presidency.

Roosevelt, who had polio, kept his paralysis hidden from the US public and it made no difference to the success and accomplishments of his four presidential terms, during which he steered America through the devastation of the Great Depression.

When Roosevelt took office in March 1933, there were 13 million unemployed Americans and hundreds of banks were closed. Roosevelt faced the greatest crisis in American history since the Civil War but he soon began to transform the social fabric of the country, lifting people out of grinding poverty with sweeping economic reforms, which he called the ‘New Deal’ and which his Republican opponents dubbed socialism. But it worked. Within three years, unemployment had dropped from 25 per cent to 14 per cent.

Roosevelt, who had polio, ran the country from his wheelchair but US voters did not know about his polio until after his death

His social programmes, including healthcare improvements, redefined the role of government in Americans’ lives, while internationally, his role during World War II established US leadership on the world stage. His 12 years in the White House set a precedent for the expansion of presidential power and redefined liberalism for generations to come with the revolutionary introduction of social security pensions and the creation of the Medicare health programme for the elderly and the Medicaid programme for the poor.

For most of his life, Roosevelt refused to accept that he was permanently paralysed. He tried a wide range of therapies, including hydrotherapy. In 1926, he purchased a resort at Warm Springs, Georgia, where he founded a hydrotherapy centre for the treatment of polio patients. He taught himself to walk short distances in his braces and was careful not to be seen in public using his wheelchair. In 1938, he founded the National Foundation for Infantile Paralysis, now known as the March of Dimes.

In more recent times, US Presidents have also managed to work away despite illnesses. In 1985, President Ronald Reagan underwent surgery to remove a cancerous polyp in his large intestine. Doctors also removed two feet of Reagan’s lower intestine. He was then aged 74 and the nation’s oldest serving President.

He chose not to invoke a clause in the 25th Amendment to the US Constitution for the transfer of presidential powers to the Vice President when the President becomes temporarily incapacitated. Instead, he spent a week convalescing at the hospital and continued working before returning to the White House.

By contrast, when President George W Bush had a colonoscopy in 2002, he invoked the clause, placing Vice President Dick Cheney in nominal charge for 20 minutes while Bush remained mildly sedated.

Europe

Neither did age nor ill-health prove insurmountable barriers to the presidency of another famous American — our own Éamon de Valera. During a political career spanning well over half a century, from 1917 to 1973, ‘Dev’ served several terms as head of government and head of state. He was 77 years old when he was inaugurated President of Ireland in 1959 and was aged 84 when he was re-elected in 1966.

By then he was growing more infirm and was suffering from severe visual problems that would leave him blind in his last years. But he was still active and did not shirk the activities of the office. At his retirement in 1973 at the age of 90, he was the oldest head of state in the world.

De Valera’s neighbour and nemesis Winston Churchill was another leader who managed to endure through illness and fulfil his duties as British Prime Minister. Churchill’s wife Clementine, his children and his closest confidantes managed to keep a series of increasingly damaging strokes a secret. In 1953, when Churchill was aged 78 years, but insistent he still had more to achieve in politics, he suffered a stroke during a dinner party, with Clementine and his son-in-law Christopher Soames tactfully moving him into private rooms before it was noticed.

A document sold at Christie’s auction house showed that after Churchill was injured in an accident in New York, his solicitous US physician, Dr OC Pickhardt, attested to the Prime Minister’s medicinal needs as follows: ‘This is to certify that the post-accident convalescence of the Hon Winston S Churchill necessitates the use of alcoholic spirits, especially at meal times’

Arguing it would not do to panic the country, potentially leaving them without a leader, the Prime Minister’s family persuaded London’s most powerful editors to collude with them to keep the story out of the British press.

Churchill also struggled with depression for most of his life, and his enjoyment of alcohol was widely known. Indeed, a document sold at Christie’s auction house showed that after Churchill was injured in an accident in New York in December 1931, his solicitous US physician, Dr OC Pickhardt, attested to the Prime Minister’s medicinal needs as follows: “This is to certify that the post-accident convalescence of the Hon Winston S Churchill necessitates the use of alcoholic spirits, especially at meal times. The quantity is naturally indefinite but the minimum requirements would be 250 cubic centimetres.”

Churchill’s physical health became more fragile during the war, as evidenced by a mild heart attack he suffered in December 1941 while visiting the White House and also in December 1943 when he contracted pneumonia. But there is no evidence that his ill-health while in office made him any less of a strong leader.

In more recent times, the Irish public’s right to know about the health of our politicians became a major controversy before the tragic death in 2011 of then Finance Minister Brian Lenihan.

On December 26, 2009, TV3 reported he had been diagnosed with pancreatic cancer, calling it a “news story of national importance”.

But there was never any suggestion that his illness impacted his work and many saw the TV report as an unnecessary intrusion and the timing of the story, just a day after Christmas, as insensitive. Former Minister for Health, now Minister for Social Protection Leo Varadkar, for example, said he thought it was “absolutely inappropriate” to broadcast details of Lenihan’s condition, particularly when the Minister had only received the initial diagnosis a few days earlier.

2016 US election

Likewise, in the 2016 battle for the White House, reporting on the health of the two main candidates has sometimes been seen as insensitive but it has, nevertheless, become a heated topic. It reached a climax when Clinton appeared to collapse after having to leave a 9/11 commemoration in New York. A frenzy of media speculation quietened only after her doctor issued a statement saying the Democratic candidate had been diagnosed with pneumonia and needed rest. Soon, Trump moved from wishing her well to questioning her fitness to run for the White House.

But then the spotlight turned on him, with demands that he release his own medical records. He countered that he was in excellent health and produced a bizarre letter from his physician, Dr Harold Bornstein, which said Trump “will be the healthiest individual ever elected to the presidency”.

But hard facts to back this up were not forthcoming, either from the candidate or from his doctor. In contrast, Clinton’s physician, Dr Lisa Bardack, released detailed notes on the Democratic candidate to back-up her statement that Clinton was “healthy and fit enough to serve as President”.

During the candidates’ first televised debate, when Trump again argued that Clinton “doesn’t have the stamina” to be President, the former US Secretary of State was well armed with a response.

Looking directly at the cameras and beyond them to the 11 million Americans watching, she declared: “As soon as he travels to 112 countries and negotiates a peace deal, a ceasefire, a release of dissidents, an opening of new opportunities in nations around the world, or even spends 11 hours testifying in front of a congressional committee, he can talk to me about stamina.”

Since then, polls showed the issue fading from voters’ minds. Instead, with election day this week, voters are far more concerned about their own healthcare costs. The Kaiser Family Foundation, which focuses on healthcare issues, found that two-thirds of voters say that the affordability of healthcare, rather than hearing about the candidates’ own state of health, is the real issue on which they should be focusing.

In the US, the top five causes of death among people aged 65 years and older are heart disease, malignant cancers, respiratory diseases, strokes and Alzheimer’s disease, according to a 2014 report from the Centres for Disease Control and Prevention (CDC). However, more people are living to at least age 65 years than in the past. In the 1970s, about 10 per cent of the US population was aged 65 years or older, according to the US Census Bureau. In 2010, this age group made up 13 per cent of the total population and is projected to constitute 20 per cent by 2030, according to a CDC report.

Thus, in modern times health issues in older people, regardless of their profession, are far less threatening than in previous decades because better treatments have emerged and illnesses that were once seen as fatal can now be well managed. This also means that age is far less of a barrier to election than it once might have been.

So the fact that Clinton and Trump are the oldest candidates ever in an election for the White House is testament both to better medical treatments and more enlightened thinking about growing older, according to Dr Liam Twomey, a former TD and Senator for Fine Gael.

He pointed out in an interview with the Medical Independent (MI) that enduring the sheer length of a US presidential campaign, which is often run over as many as 18 months, is testament in itself to the stamina of the candidates. “At the end of it, you’ve proven you have the physical stamina to be President,” he said.

“It’s an incredibly demanding campaign, physically and psychologically. They, literally, don’t have a moment to themselves, and if they can manage to survive that, I don’t think people have to be concerned.

“I think voters know exactly the sort of temperament and personality that they’re getting in a candidate. To endure months of this type of campaigning as they do, and this one is particularly robust, their ages don’t really matter if they can withstand that sort of pressure.”

It is also testament to the fact that healthy older people now have more opportunities to pursue their ambitions. “I’m always amazed at this time of the year, when we do the flu vaccinations in our surgery, at the number of people in their 80s and 90s who are in incredible physical shape. So there are a lot people out there who are in their 70s and even in their 80s and 90s who are very healthy, both mentally and physically.”

Ms Stella O’Leary, President of the Irish-American Democrats lobby group, who has been close to Hillary Clinton for decades, insisted that US voters have “nothing at all to worry about” as regards Clinton’s health. “I am very confident about that,” Ms O’Leary told MI.

“I think her pneumonia makes her more relatable to people. Illnesses are things that we all have to deal with from time to time. And she’s no different.”

Bad for voter health

But this volatile election has also raised issues beyond the health of both candidates. It is having a negative impact on the psychological health of some US office workers, leading to increased stress and isolation, according to a recent survey by the American Psychological Association (APA).

More than one-in-four younger employees reported feeling stressed out because of political discussions at work about Clinton and Trump, and more than twice as many men as women said political talk was making them less productive, according to the survey.

Men were more likely than women, and younger workers (ages 18-34 years) were more likely than older generations, to have experienced negative consequences of political discussions at work during this election, the survey found. This includes having difficulty getting work done, producing lower-quality work and being less productive overall.

Similarly, these groups were more likely to have said that because of political discussions at work, they feel more isolated from their colleagues, have a more negative view of them and have experienced an increase in workplace hostility.

Republican or Democrat, liberal or conservative, the survey found few differences across political party or philosophy when it comes to how the 2016 election has affected the psychological wellbeing of US workers.

The sooner this particular election is over, the better, it seems, not just for the candidates themselves but for the health and wellbeing of American voters.

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