Presidential Illness: Give the People What They Want

Even presidents get sick. This should come as no surprise, given the circumstances.

First of all, despite the energetic arm waving and sweet campaign jams (whether endorsed by the artists or not) US presidents are− by and large− old. The average age of a president at election is nearly 55. That may not sound old, but bear in mind that’s the average from 1789 to 2008; for most of that period, life expectancy was well below 55. As recently as 1900, the overall (male and female) life expectancy was about 49.8 The current life expectancy for American men is around 76.4 (When we finally elect a female president, she’ll have until 81.4) Add the long hours, extended travel and stress of being Commander-in-Chief, and you have the perfect recipe for ailment.

Acute (sudden and severe) illness has cut several presidencies short; four presidents have died from sickness while in office. Many more have suffered in silence, laboring with the burden of chronic (long-lasting, non-infectious) disease. With one exception (I’m looking at you, Woodrow), illness did not affect the president’s cognitive or leadership abilities, but was concealed nonetheless. At times, extreme measures were taken to minimize the appearance of illness, sometimes covering it up entirely.

Calling in sick to the (oval) office

At least two presidents have had major medical procedures to treat chronic illness while in office: Grover Cleveland and Dwight D. Eisenhower.

In what has to be one of the most amazing medical maneuvers of all time, Grover Cleveland underwent a clandestine surgery to treat mouth cancer near the beginning of his second term in 1893. To pull it off, he arranged for his surgery to take place on a friend’s yacht in Long Island Sound, using the cover story of a month-long fishing trip. The surgery took place in the refurbished saloon of the boat, where he had several teeth and part of his jaw removed. To ensure there was no noticeable difference in either his appearance or speech, he was fitted with a prosthesis and continued to cultivate his trademark mustache. He never relapsed and the surgery was not officially acknowledged until 1917, nine years after Cleveland’s death.1,5

Dwight D. “Ike” Eisenhower had a massive heart attack in 1955, about midway through his first term. It was likely the result of chronic heart disease; it may not have been his first, or even his first as president. The public was informed, but the severity of his condition was substantially downplayed. In fact, efforts to keep Ike’s condition secret may have actually endangered his life: his doctor waited a full day to seek outside medical assistance, for fear of political repercussions. Ike also suffered chronic gastrointestinal issues throughout his military and political career. Intense intestinal pain brought Eisenhower back for a second surgery in 1956. The public was told that the results were normal, but that was far from true. The surgery revealed adhesions suggestive of Crohn’s or inflammatory bowel disease.3

Two of the most beloved (and boldly initialed) American presidents, FDR and JFK, also suffered from serious chronic illness that they attempted to conceal. JFK had a slew of troublesome medical conditions that he publically denied, including Addison’s disease, colitis, ulcers, and a degenerative back issue.2 Roosevelt contracted polio in 1921, and the disease left him paraplegic. He initially tried to hide his condition, but it was eventually leaked to the press. In response, the president underwent a medical exam to dispel fears about his health. Despite the fact that his condition had become public knowledge, FDR never allowed media photographers to take his picture while he was in his wheelchair. Instead, photo ops and public events were carefully planned so that he used a seat that was not reminiscent of his condition, like his iconic convertible7.

fdr disease
What. A. Boss.

Patient-in-Chief

Everybody gets sick, so why all the secrecy and subterfuge?

Well, it’s politics. Image is everything, and any display of vulnerability is an invitation for an attack. Illness− even when it is chronic and does not affect job performance− can be seen as weakness and weakness is fatal in politics. No president has wanted to be viewed, either at home or abroad, as a Patient-in-Chief− a sick old man past his prime.

But the shows of vigorous good health were not just for fellow politicians. In all of these cases, it was thought that admitting the complex reality of the President’s health would not only minimize the effectiveness of the president, but also destabilize the country. It was taken as given that the admission of chronic disease would inspire uncertainty in the public, that the people would also see illness as weakness and reject it.

We, the People

It’s reasonable to be concerned about an ill president’s capacity to perform the duties of the office. However, in the history of the American presidency only one president has been incapacitated by illness, Woodrow Wilson. Wilson had a major stroke that left him bedridden and unable to sign his own name, but neither Congress nor the American people were informed of his condition. For the next 17 months, until Wilson left office, essentially no one was allowed to see the president, and nearly all communication was relayed through his wife, Edith.6 Disconcerting, to say the least. But, in an era with TV and Twitter, repeating this maneuver would never work. (I know, never say never, but seriously: never). Not only that, there are now procedures in place for passing presidential duties on to the Vice President in such circumstances, thanks to the 25th Amendment (passed by Eisenhower, BTW).6

Instead, the evidence actually shows the opposite: chronic disease and disability do not make a person incapable of meeting the demands of the presidency. Collectively, the presidents mentioned here successfully led America through some of its most trying times: financial crises, WWI, the Great Depression, WWII, and the Cuban Missile Crisis. They were taken seriously by their peers, both nationally and internationally, and they handled some seriously challenging situations with nothing short of grace. Three (FDR, Eisenhower, and JFK) routinely rank in the top ten greatest presidents.

While it is certainly not commendable that these men concealed their health issues, it is understandable. They were combatting their own fears of disgrace and disgust by attempting (albeit misguidedly) to give the people what they (might have) wanted. They were striving to fit an unrealistic ideal of youthful experience. However, I’d like to think that their concerns too were unfounded. We will never know if honesty would have damaged or ended their careers, but I hope not. Maybe Americans would have seen the bravery and endurance these men evinced. And, when a candidate finally runs for office openly admitting a chronic condition, maybe they will see strength in his or her suffering and admire it, knowing that there is− as FDR famously said− nothing to fear but fear itself.

References

  1. Cashman, EC, & C. Timon. 2011. Otolaryngology and the American presidency: a medical legacy. ORL, 73:105-109.
  1. Dallack, R. The medical ordeals of JFK. The Atlantic, Special Issue. Web. 4 September 2015.
  1. Gilbert, RE. 2008. Eisenhower’s 1955 heart attack: medical treatment, political effects, and the “behind the scenes” leadership style. Politics and the Life Sciences, 27: 2-21.
  1. Life expectancy. Centers for Disease Control and Prevention. 20 January 2015. Web. 4 September 2015.
  1. Maloney, W. 2010. Surreptitious surgery on Long Island Sound: the oral cancer surgeries of President Grover Cleveland. New York State Dental Journal, 76:42-5.
  1. Menger, RP, CM Storey, B Guthikonda, S Missios, A Nanda, & JM Cooper. 2015. Woodrow Wilson’s hidden stroke of 1919: the impact of patient-physician confidentiality on United States foreign policy. Neurosurgical Focus, 39:E6.
  1. Meschia, J, BE Safirstein, & J Biller. 1997. Stroke and the American presidency. Journal of Stroke and Cerebrovascular Disease, 6: 141-143.
  1. Rosner, M. 2015. Life expectancy. OurWorldinData.org. Web. 4 September 2015.

Image source: Creative Commons, https://en.wikipedia.org/wiki/History_of_segregation_in_the_United_States_Armed_Forces

Cancer: The Big C

Aliases: cancer

Cancer is an obvious choice for this month’s theme (economics); its costs are so great, they almost need no introduction. As the second leading cause of death in the US1, it has touched the lives of nearly every American. Obviously, the cost of cancer is incalculably high for the patient, but it does not stop there. The painful challenge of this disease extends outward, from family and friends to the medical professionals charged with combatting it.

While the emotional toll on doctors and nurses that work with cancer patients is impossible to measure, there are other, more quantifiable costs associated with their work. One is malpractice. Radiologists, who use imaging technologies (i.e. X-ray) to diagnose and treat illnesses such as cancer, have a high rate of malpractice claims, both in the US and abroad, and it’s increasing. This leap in litigation reflects both the inherent difficulties of radiology, and the rise in its use5. The majority of these suits are related to cancer cases; in Italy, over half of the diagnostic radiology claims between 1993 and 2005 concerned breast cancers and mammographic technique. The predicted rate of litigation against Italian radiologists is 10.5/1,000, which amounts to 1 claim per radiologists per 10 years of work4.

One survey of radiologists across three American states found that about half had a previous malpractice claim. The same study showed that malpractice suits have a negative psychological impact on the doctors involved; about 81% of respondents described the claim as very or extremely stressful. Nearly 1/3 (35.3%) had considered withdrawing from mammogram interpretation entirely because of malpractice concerns. The effects of these experiences spilled over into their practice. More than ¾ (76.4%) were concerned about the impact of claims on mammography practice, and over half (58.5%) indicated that their concern moderately to greatly increased their recommendations for breast biopsies (sampling cells or tissues), a more invasive diagnostic procedure. Yet, their fears may be overblown: the responding radiologists’ estimate of their future malpractice risk was much higher than the actual historical risk. And there doesn’t seem to be a downside for patients, as medical malpractice experience and concerns were not associated greater false-positive rates in cancer diagnosis3. Nonetheless, malpractice claims add another cost to cancer’s tally: the price of human error.

cancer
To err is human.

Cause: Although we think of cancer as one illness, it is really a category of ailment that encompasses a whole suite of diseases. But while there are a wide range of cancers, the fundamentals are the same. Cancer is caused by the development of uncontrollably dividing cells that can infiltrate and destroy normal body tissue. These abnormal cells are caused by a DNA mutation, which can be genetic (inherited), stimulated by the environmental (i.e. smoking or radiation), or a combination of the two. Cancer can spread throughout the body, but it takes time to develop, which is why most people are diagnosed after age 651. Men are most commonly affected by prostate cancer (128.3/10,000 men contract it), breast cancer is the most common type in women (122/10,000), and lung cancer has the highest fatality rate in both men (57.9/10,000) and women (37/10,000)2.

Consequence: Because there are so many forms of cancer, there are myriad symptoms, and they largely depend on the part of the body that is affected. Many are also symptoms of other less serious conditions. Some common symptoms include: a lump or area of thickening that can be felt under the skin, unexplained weight change, skin change, persistent cough, unexplained muscle or joint pain, fevers or night sweats, or indigestion or discomfort after eating1.

Cure: While there is no hard and fast cure, there are extensive treatment options. Treatments can be broken down into three types: primary (treatments that remove or kill cancer cells, i.e. surgery), adjuvant (treatments that kill cancer cells that might remain after primary treatment; i.e. chemotherapy or radiation), and palliative (treatments that relieve the side effects of other treatments or the cancer itself). Treatment options include surgery, chemotherapy (which uses drugs to kill cancerous cells), radiation therapy (which uses radiation, such as X-rays, to target cancerous cells), and hormone therapy, among others. Unfortunately, many cancer treatments have significant side effects, including: pain, fatigue, nausea, weight loss, diarrhea or constipation, and neurological or hormonal changes or issues. Palliative treatments include alternative medicine options, such as acupuncture or massage, which may offer some relief. As ever, prevention is key, and there are an abundance of screenings tests for cancer, ranging from physical to imaging to biopsy1.

References

  1. Cancer. Mayo Clinic. 2 January 2014. Web. 12 April 2015.
  1. Cancer prevention and control. Centers for Disease Control and Prevention. 6 April 2015. Web. 12 April 2015.
  1. Elmore, J.G., W.E. Barlow, G.R. Cutter, C.J. D’Orsi, R.E. Hendrick, L.A. Abraham, J.S. Fosse, & P.A. Carney. 2005. Does litigation influence medical practice? The influence of community radiologists’ medical malpractice perceptions and experience on screening mammography. Radiology, 236:37-46.
  1. Fileni, A., N. Magnavita, & L. Pescarini. 2009. Analysis of malpractice claims in mammography: a complex issue. La Radiologia Medica, 114:636-644.
  1. Magnavita, N., A. Fileni, P. Mirk, G. Magnavita, S. Ricci, & A. Cotroneo. 2013. Malpractice claims in interventional radiology: frequency, characteristics and protective measures. La Radiologia Medica, 118:504-517.

Image source: Creative Commons, http://www.bbc.com/news/health-29920157