EDITOR'S PAGE
Presidential candidates and cardiovascular risk
Anthony N. DeMaria, MD, MACC*,1
* Address correspondence to: Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 400, San Diego, California 92122, USA.
Although we have barely passed the two-year mark of the current administration, the next presidential campaign is already getting underway. Each presidential election seems to bring with it an increasing attention to the health of the candidates. Given the propensity of cardiovascular disorders in our society, and the predominance of male candidates, it is not surprising there is a special attention to cardiac disease. This is likely to be particularly true in the forthcoming election in view of the well-documented history of coronary disease of Vice President Cheney and the recent combined valve and bypass surgery of Governor Bob Graham of Florida, a potential Democratic Party nominee for president. In addition, the recent emphasis on disease prevention and the publicity given to risk factors and their modification have focused attention on the high-risk coronary profile. In fact, in the 1996 presidential campaign, Senator Bob Dole was photographed on a treadmill and boasted that he had a lower weight, blood pressure, and cholesterol than President Clinton (1). These issues raise a number of important considerations, including: what role does health play in the qualifications of a candidate; how do we balance the candidates’ right to privacy with the legitimate needs of the electorate to know of conditions that may affect performance as president; and how and by whom should disease risk be assessed?
That the attention to health status is a valid concern is substantiated by the morbidity and mortality experienced by previous presidents. In his book "The Mortal Presidency: Illness and Anguish in the White House," Robert E. Gilbert points out that, despite being wealthier and better cared for than the general population, two-thirds of presidents have died younger than their life expectancy, yielding an average life span for all presidents of two years less than expected (2). Four presidents, nearly 10%, have died in office. A number of others, such as Woodrow Wilson, who had a stroke, have been virtually incapacitated while in office. Perhaps the most striking example of illness at a critical time was Franklin Roosevelt, who had hypertension, congestive failure, and evidence of cerebral vascular disease prior to negotiating the end of World War II at Yalta. Although the exact cause of the ill health of presidents is uncertain, Gilbert proposes—and intuition suggests—that it may be due to the stresses of the job. Certainly, several media sources have suggested that a look of fatigue and a more concerned countenance have been noticeable in President Bush as the military operation in Iraq has unfolded. If, therefore, the stress of the presidency is sufficient to predispose to illness, the health status of candidates would seem to be worthy of consideration.
The concern with the health status of prospective candidates has been accentuated by the frequent failure to fully disclose—and even the concealing of—serious illnesses by presidents and their physicians. Thus, a stroke and cardiac illness affecting presidents Wilson and Harding were described as nervous exhaustion and food poisoning, respectively. Franklin Roosevelt not only went to great lengths to hide his paralysis from polio but also did not make known his complications from hypertension. President Kennedy obscured the presence of Addison’s Disease, while Dwight Eisenhower and his physicians sought to minimize his coronary artery disease and myocardial infarctions. As a candidate, Senator Paul Tsongas claimed to have been cured of lymphoma after undergoing a bone marrow transplant, concealing the recurrence of disease a year later. During the last election, Senator Bill Bradley did not acknowledge a history of paroxysmal atrial fibrillation until he experienced several episodes during the campaign. Although the desire of candidates and presidents to withhold evidence of illness is understandable, it in fact may increase the perception of its significance: "It must be severe, or else why wouldn’t they want me to know?" In addition, the lack of candor is put forth as a reason that a more systematic and open assessment of health status is necessary, as is discussed in the following paragraphs.
If the presidency is such a stressful position that it predisposes to illness, and health status is therefore a significant factor in candidacy, who should be responsible for the evaluation of the "medical qualifications" of a candidate? It clearly cannot be the candidate’s physician, who is bound by the standard physician-patient confidentiality. The candidates themselves will usually be unable to speak authoritatively about medical issues. Some have suggested that an independent panel of medical experts should be established to review the records or generate an assessment of the health of each presidential candidate. This suggestion seems to me, however, to be without merit. Firstly, it would invade privacy to an undue degree and create another barrier to attracting excellent candidates. Secondly, the nature of the evaluation would have to be defined. Would it consist of a standard history and physical, or would a colonoscopy be included? Would standard chemistries be adequate or should one obtain a CRP ... a test for HIV? From the cardiovascular standpoint, should the candidate have an echo ... an electron beam computed tomography for coronary calcium ... a stress test? And who is to interpret the findings of this evaluation to the general public and assess risk in the context of the unique demands of the office. It is easy to imagine the folly of a presidential debate that touches on Framingham risk score, ejection fraction, time to ST depression, or non-sustained ventricular tachycardia.
Considering the history of debilitating illnesses among past presidents, and the frequent deception applied to hide or minimize its presence, it is clear that the health status of presidential candidates will continue to attract the strong interest of the media and the public. If anything, the stress associated with the position is likely to increase for the foreseeable future. However, the system for the disclosure of medical information, which has evolved over time, seems adequate and is probably superior to the other processes proposed. Although the release of medical records is currently "voluntary," it is hard to imagine any candidate withholding this information. Any such action surely would raise questions as to what was being hidden. In fact, when then candidate Bill Clinton refused to disclose his medical records in 1992, a critical article by Dr. Lawrence Altman of the New York Times caused him to abandon this position the next day. Moreover, the precision with which any medical data can predict the appearance or natural history of any disease is limited. Neither, for the most part, can any physician accurately predict how a disease state will affect the ability of an individual to govern. In light of this uncertainty, it seems to me that physicians should avoid the hubris of declaring the medical suitability of any candidate for the presidency of the U.S. or, for that matter, the equivalent position in any other country. Evaluating the risk of cardiovascular and other events serves several important purposes; selecting the best candidate for political leader of the country is not one of them.
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Footnotes
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1 Editor-in-Chief, Journal of the American College of Cardiology 
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References
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1. Annas JG. The Health of the President and Presidential Candidates—The Public’s Right to Know. N Engl J Med. 1995;333:945–949[Free Full Text]
2. Gilbert RE. The Mortal Presidency: Illness and Anguish in the White House. New York: Fordham University Press; 1998.
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