How does a President’s health affect their ability to lead? Do Presidential candidates deserve any privacy in terms of their medical history? How do we define what health issues ‘matter’ for a role as all-encompassing as President of the United States?

On this episode Sarah looks for answers with the help of Watson Professor Rose McDermott. McDermott’s 2010 book ‘Presidential Leadership, Illness, and Decision Making,’ explores the history of health issues faced by US Presidents, and the effects they’ve had on the country and the world. As we prepare for the inauguration of a 78-year-old President amidst a global pandemic, there’s no better time to understand the complex relationship between a President’s health and health of the nation.

You can learn more about and purchase Rose McDermott's book here.

You can learn more about Watson’s other podcasts here.

[MUSIC PLAYING] SARAH BALDWIN: From the Watson Institute at Brown University, this is Trending Globally. I'm Sarah Baldwin. In ways that were totally predictable--

REPORTER: 77-year-old Joe Biden will be the oldest first-term president.

JOE BIDEN: Can I still run up the steps of Air Force Two? Am I still in good shape? I think it's totally legitimate people ask those questions.

SARAH BALDWIN: --and in ways that were absolutely not--

REPORTER: The President of the United States and the First Lady have both tested positive for the coronavirus.

SARAH BALDWIN: --questions of health and of physical and mental fitness for office became a central topic in US politics this year. These issues were weaponized by both sides during their campaigns, but underneath the attack ads and headlines were genuinely important questions. What details of a president's health does the public deserve to know? What details should a president or candidate be allowed to keep private? How do we even define what health issues matter in a role as all encompassing as President of the United States?

These are questions, which, as a country, we don't have very good answers for. On this episode, I looked for answers with Watson professor, Rose McDermott. Her Twenty-Ten book, Presidential Leadership, Illness, and Decision Making, explores the history of health issues faced by US presidents and the effects they had on the country and the world. We talked about a few of these issues in addition to how health factored into the Twenty-Twenty race and what history can teach us about how to approach presidential health going forward.

I had some technical issues from my office slash recording studio. So, for the last few questions, I had to use my backup audio, and it sounds a little fuzzy, just a heads up. I started by asking Rose how she's been thinking about presidential health lately. Here's Rose.

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ROSE MCDERMOTT: Obviously, it's a really salient issue now because of the COVID pandemic and because of President Trump getting diagnosed with COVID and, obviously, recovering and everything. I wrote a piece for Politics and Life Sciences about his treatment. And several members of the board actually resigned, saying that they couldn't believe that I was being such advocate or whatever. So partisan I think was the word.

And I was sort of shocked because I started working on this book and working on this issue long before Donald Trump was even a candidate, before he was-- long before he was president. And there is a long history of other scholars looking at these topics too. And the reason it's important is because, as we all know from our own personal lives-- just hold up the mirror of introspection-- when you're sick, and you don't feel well, for whatever reason, it's very, very hard to make the best decisions about anything, about what you're going to eat or what you're going to wear, much less things related to big national policies.

And there's all kinds of reasons for that, having to do with energy levels and distraction and so on. But, in foreign policy, it's particularly problematic because the president, typically, has more leeway and license to do what he wants to do without as much congressional constraint as he does in domestic policy.

So, in domestic policy, Congress has a lot more to say, not just with the power of the purse, but, also, with local legislatures and state legislatures. And there's lots of other kinds of constraint. But, with foreign policy, usually, presidents have a lot more leeway, and so they have a lot more ability to influence larger aspects of policy for longer periods of time just on their own personal proclivities. And so if they're not feeling well, if they are not operating on all cylinders--

SARAH BALDWIN: Or if they're medicated?

ROSE MCDERMOTT: If they're medicated, for sure. And there's lots of history of leaders being on all kinds of drugs, Kennedy being a classic example of this, but lots of other presidents on lots of other medication that is known to affect cognitive abilities and competencies. And so those kinds of things really can affect how leaders behave and have an impact on larger policy.

SARAH BALDWIN: You brought up John F. Kennedy, and I had no idea how sick John Kennedy was. He had a bad back. He had digestive ailments. He had Addison's disease maybe. He was taking painkillers, anti-anxiety meds, stimulants, sleeping pills, hormones. And, yet, I don't think people think of him as infirm. And so I wonder if that sort of functioning in spite of and not sharing, is that-- did that make him deceptive or stoic?

ROSE MCDERMOTT: I think the answer is both. Kennedy is such a great example because he actually projected this image of being exactly the opposite of what he was, which was he was kind of the soul of youth and health. And he was so tan, and he looked so much better in the debates against Nixon who was sweating like a pig. But the tan was actually one of the side effects of Addison's disease, right? And so it actually was an indicator of his underlying lack of health, but it appeared that he was healthy and robust.

And, when I originally started reading a lot of this stuff, I had the response you had about he was being deceptive. And how could he have lied to the public? And, by the end, I just ended up having so much admiration for his ability to get out of bed in the morning because what he was up against, physically and medically, was just phenomenal and what he was able to overcome through just kind of like will was really impressive.

SARAH BALDWIN: Are there examples that you can point to of how his condition affected US foreign policy? Or did he not let it, as far as you can tell? And is it even worth thinking about, wondering, how might a healthy man have acted differently?

ROSE MCDERMOTT: The case that I look at in the book, actually, had to do with the Nineteen-Sixty-One Vienna conference with Khrushchev. He went in being quite arrogant about his ability to kind of take Khrushchev, verbally and rhetorically, but he was having a lot of back pain, which was not uncommon. To make it very simple, he took a lot of painkillers that would sedate him. He'd spend hours and hours and hours, actually, in Vienna in a bathtub, a hot bathtub, to kind of make his back feel better. So him and Winston Churchill had that in common, spent a lot of time in bathtubs.

But then painkillers are quite sedating. So he'd have to go in and meet with Khrushchev, and he'd basically take a lot of speed. He had a doctor, Max Jacobson, who was known as Dr. Feelgood who would give him these injections of sort of steroids and amphetamines. He went into those meetings both sedated and hyped up. And Khrushchev made mincemeat of him really.

And two really important things came out of that. The first was that Khrushchev left thinking this guy can be taken, and he starts putting in place the plan to put missiles in Cuba because he really thinks that this is a young, untested, really fragile guy who he can take. And that really sets up what becomes the iconic aspects of his administration, the Cuban Missile Crisis and then the Bay of Pigs.

Kennedy comes out of the meeting, and he feels chastened. He, basically, decided he wasn't going to let Khrushchev take him, right? So they both sort of were set up in this particular way where Khrushchev was like this guy is an easy target. And Kennedy was like you got me once. You're not going to get me twice. And I think, if somebody had been healthier in that situation, they would have been both less vulnerable to second judging their own bad performance, but they also would have come across as less fragile.

SARAH BALDWIN: Yeah, that's such a good point that it kind of teed up what became one of the almost worst crises of the 20th century.

ROSE MCDERMOTT: Right, and I think a lot of people don't necessarily peg the origin of that to the meeting in Vienna in Nineteen-Sixty-One, but I do think that that was the origin of the meeting. And there's a quite interesting series of quotes that Kennedy gives to James Reston who was the main writer for The New York Times at the time right when he comes out of those meetings, and he's feeling attacked and everything. And it's the first time you see Kennedy making a statement to the press about the importance of pushing back in Vietnam. And so you also see the origins of the Vietnamese policy. I'm not going to let him take me, right?

And, of course, the back pain came and went. The drug use came and went. And so, had it happened at a different point in time, it could have turned out differently.

SARAH BALDWIN: So what is the situation regarding the health of the leader in other countries?

ROSE MCDERMOTT: Well, it's a big deal everywhere, right? And part of the reason it's a big deal is that most leaders are old. And a lot of chronic illnesses are a function of aging, right?

So you think about cardiovascular disease, but, much more importantly, dementia. It's something that usually happens when people age, and there's an upside of older leaders, which is that there's a lot of experience. There also is a downside, which is that there's a higher risk of all kinds of chronic illnesses.

And, certainly, in totalitarian or authoritarian or autocratic regimes, it can be even more influential because those leaders have fewer constraints. And so their illness can play out on a larger scale with even fewer constraints. Of course, it's going to be more secret in regimes where there's more secrecy writ large, but I think that, to me, the telling part of that story is that kind of information is much more secret, even in democracies, than we're aware. And, sometimes, we don't know it until years later.

I mean, my mother, who's 97, worshipped Roosevelt, grew up with him, never knew until after the war that he was in a wheelchair, right? So she lived through that whole period, and I've gone through all the archives. There's like thousands and thousands and thousands of pictures of Roosevelt. There's only 12 of him in a wheelchair. People did not know that he really couldn't walk at all.

And they would come up with elaborate things of having him lean very heavily on two people with braces so that it looked like he was walking, even though he wasn't, or propping him up against a very, very steady lectern so that he could lean on it. And those things were just kept very hidden.

And, obviously, with Kennedy, the extent of his medication and drug use-- he was on antipsychotics at times and, again, not publicly known until years later. And so I think that the bottom line story is, even in democracies, this information is held much more closely and kept much more secret than people would like to believe, even in the modern age of social media.

SARAH BALDWIN: Just, to go back to Roosevelt for a second, I think I read having polio actually sensitized him to other people's problems. And that must have affected his domestic policy.

ROSE MCDERMOTT: Oh, for sure, there's no question about it. And I thought about that, actually, when Trump got COVID because I wondered if him getting sick would make him more compassionate. Obviously, that did not happen. It seems to have had the opposite effect. But, in Roosevelt's case, it really worked.

So what was interesting with him is, when he was young, he was understood to be kind of an arrogant jerk. People thought he was haughty. He was elitist. He was definitely wealthy. He went to the best schools, and he was understood to be aloof, understood to be haughty, understood to be somebody who did not have any interest or compassion for other people, and then got polio and, as he put it, spent two years in bed trying to learn how to move his toe.

He never could learn how to move his toe. He never was able to get movement back in the lower part of his body, but it did make him unbelievably compassionate for other people's pain and directly led to what we think of as the most progressive social policies probably ever-- Social Security, the whole New Deal, the things that really provided some social support for people in the country who were not just sick, but poor.

And everybody says he just changed. He really became a much more empathic, connected person. And I think it was part of what the country responded to in Joe Biden. He was very and has been very compassionate for people who've lost family members to COVID or who've been sick with COVID.

And it's clear that he comes from a place of understanding exactly what that's like because he's not just lost one son to brain cancer, but he lost an earlier son to a car accident. He lost a wife. He understands what loss is like. Clearly, a lot of people in the moment of the pandemic, 75 million people, responded to that in a particular kind of way.

I did really wonder if Trump would-- when he got COVID, there was one moment where he was like, well, we'll see how this turns out. And you could almost see vulnerability. But then, of course, immediately, it turned into doubling down on this is no big deal. I got over it. Everybody else can too. And that I think just reflects underlying differences in personality structure.

SARAH BALDWIN: Let's stay with Trump and Biden for a second. And I'm just interested in different attitudes and approaches to age and health. Trump, I think, dictated his own letter of health, whereas Biden released a three-page report, and he's like all about transparency. So that made me think, is presidential health on an honor system kind of showing your tax returns?

ROSE MCDERMOTT: I think so, yeah. And the question is how much do you reveal.

SARAH BALDWIN: How much do you reveal? And then, who is in a position to judge your health and to deem you competent? I think there's representative Raskin and Pelosi are trying to suggest that we need an independent commission to assess presidential health. Do you think that's a good idea?

ROSE MCDERMOTT: There have been a lot of discussions about these independent commissions, on and off, for really a long time, really since the 25th Amendment, right? So Birch Bayh writes the 25th Amendment on a legal pad on a plane coming back from Kennedy's assassination, right? But he wrote the 25th Amendment in response to the recognition that Kennedy had been assassinated.

And what do we do under these kinds of circumstances? What if Kennedy hadn't immediately died and was just kind of like a vegetable? Like what would you have done under that kind of circumstance?

There have been a lot of commissions on having commissions on presidential health, and there have been a number of these scholars who have looked at this, doctors and social science scholars. There have been a lot of proposals, and, basically, they just haven't been adopted.

And, basically, these attempts at commissions always falter on the partisan issue, right? OK, do you have three Republicans? Do you have three Democrats? Who's the tie vote?

Should they be doctors? Should they be not doctors? Should it be a combination of both? If it's doctors, how much are they precluded from sharing medical information that the patient doesn't want shared?

And you can imagine particular political complications for this. And I think about this along a couple of different dimensions. There are things that are medical issues that could become political that would have no effect on somebody's ability to lead.

So, for example, if there was a female candidate for president, and she had had an abortion, that would have zero impact on her ability to lead, but it would have a million percent impact on the political complications of that debate. And so, if a doctor who examined her knew this, should he or she be required to reveal it? Or is that an OK thing to keep hidden? What does transparency mean?

That's slightly different than the tax issue. But how do you decide what needs to be disclosed? And there have been lots of debates, and they have not been-- they've not been resolved. They're complicated and hard and, honestly, I think will take another huge medical disaster, like an assassination of President Kennedy, to lead to any kind of fundamental change. And I'm not even sure that would do it.

SARAH BALDWIN: In the Constitution, there's a minimum age for becoming president. Do you think there should be a maximum age?

ROSE MCDERMOTT: There's been a lot of discussion about that. And it has not been, obviously, put in place, I think, partly because, when the founders did the Constitution, no one lived to be that old. And so it really wasn't an issue.

I think it's a good idea. The question is what age would you put that at. Do you make it the average life expectancy? So the average male life expectancy in the United States right now is 78. So, if you made it at 78, that would mean Joe Biden couldn't be president. It would also mean that Donald Trump is getting pretty close to not being able to be president, certainly, wouldn't be able to run again in Twenty-Twenty-Four if that was put in place.

SARAH BALDWIN: To me, they're both men in their 70s, but I noticed that there must be some psychological dividing line between being under 75 and being over 75 because people talked about Biden and his age. And he's not that much older than Donald Trump.

ROSE MCDERMOTT: No, he's not that much older, and he's in much better physical shape, right? And so people have a real big difference in terms of individual genetic variability in how old they live to and what kind of shape they're in. I mean, there's incredible individual variation in that. And so how somebody handles age is very variant. And so I think that's what's also hard about putting an age limit on somebody.

SARAH BALDWIN: I agree, and I think age and health get conflated.

ROSE MCDERMOTT: Well, and age is also a function of race, right? So white people live longer than minorities, and that's an unfortunate reflection of all kinds of things, including health disparities. But the other thing is longevity is a huge function of education. So people who have a college education live, on average, 12 years longer than people who don't.

That's actually, to me, a public health issue that nobody really talks about. There are individual differences around those kinds of things. But how would you decide that no one could run for president after they're what, 75, 80? Women live a lot longer. So would you say women can be president until they're 85, but men can only be president until they're 80? I don't know how you make those kinds of decisions.

And, basically, people have decided not to decide, to let the voters decide what too old is. And, obviously, Trump wanted to make that an issue with Biden, but it was hilarious to me because he was like-- he's not that much younger, and he's in way worse physical shape.

SARAH BALDWIN: Does it just come down to transparency? If Americans wanted to elect a 90-year-old, should they be allowed to?

ROSE MCDERMOTT: Well, that was a lot of the discussion about Roosevelt, right? Like Roosevelt was in very, very, very bad shape when he ran for his fourth term. And, in fact, the fact that he had four terms and died in his fourth term was a big part of why we've got laws that you can only be president for two terms.

I'm not going to second guess the voters there. They were not wrong, but he didn't last very long. You can say leave it to the voters. But then what does that mean about the floor, not just the ceiling? Is it OK to change the law so we elect a 20-year-old?

Now, obviously, that would require a constitutional amendment, and so that's a different thing. There have been a lot of these age limit proposals put through, and I support them in general, but I think they're unlikely to go through.

SARAH BALDWIN: The physician of the president, you have noted, is, usually-- his patient is his boss, right? Because he's usually from the armed services. So explain why that's problematic. And, also, I don't even know. Does the president choose his or her own physician?

ROSE MCDERMOTT: Some of them do. Some of them don't. So they have a choice, but, oftentimes, they take whoever is assigned within the military forces. They don't have to have a military physician. Clinton didn't have a military physician, but most of them do have a military physician.

And the problem is that, if you're in the military, the commander in chief who's the president is your boss. And so you're in his chain of command, which means, if he doesn't like what you say, he can fire you. And that means you're less likely to be honest, not just with the public, but with him about what kind of treatment he needs or what kind of drugs he should take or so on and so forth.

You actually saw this with Kennedy, right? Like his physician completely colluded with-- his original physician completely colluded with him, Janet Travell. She ended up losing her medical license over her treatment of him because she would inject him in the spine with lidocaine. And the problem is, if you hit the wrong place, it can make you paralyzed. And he would insist, and she would do it.

And then a military guy came in and, basically, was like I'm taking over. You have to start exercising. You have to start doing physical therapy. And he got a lot better. He got a lot stronger. His back improved. Like there was no question that was the right thing to do.

Sometimes, the military guys can do the right thing. They certainly did in the case of Roosevelt. It was one military doctor taking over for another military doctor who was a hack-- the first one was a hack, not the second one. So you don't have to have a military guy, but the problem is is that then they may not actually tell you the truth about the right kind of treatment. They'll do what you want, rather than what's best for you.

And that can compromise things like your ability to survive a really serious illness or injury or other kinds of treatment. I actually don't think it's a good idea for the military to be the physician for the president. I think it should be an independent person of great stature who can, basically, say, if you tell me to do something I think is medically wrong, I'm going to quit.

SARAH BALDWIN: Like taking a joy ride as a COVID-19 patient, riding around in a closed car with other people, like I can only imagine that that's because your boss is also your patient, and you're afraid to say no.

ROSE MCDERMOTT: Trump's doctor, when he went out on the steps-- and the other thing is you could see the other, potentially, problematic thing. The guy has got 24 doctors, right? He's got like a specialist for every subfield, subspecialty.

And, sometimes, that's fine. It can be helpful. But, sometimes, having a lot of high-profile doctors just means you get a lot of disagreement. And that can actually make your treatment worse, rather than better.

And there is a very well-documented VIP problem where VIPs often die where regular patients would be fine because of these doctors disagreeing with themselves-- President Garfield, who got shot, and all the doctors put their fingers in the wound, trying to get the bullet out. He didn't die of the bullet. He died of all the infections from everybody's dirty fingers in the wounds. That can be a problem.

But, with Trump's doctor, he won't answer some questions, like how much oxygen was he on and for how long and how much and so on. And then he also said things where he later admitted that he had a more positive presentation because he didn't want the president watching on TV to be depressed hearing that the prognosis wasn't so good.

That kind of stuff is ridiculous. I mean, it's contrary to what you would expect for good medical treatment of the leader. Forget the information that goes to the public. I think that a self-confident physician who had a job independent of the military, where it's not just losing your job, but your pension, who's like, yeah, I can go back and be head of surgery at this big deal hospital-- I need this like I need a hole in the head-- I'm going to quit unless you do what I want-- means that that person is much more likely to actually get good medical care.

But I think the idea is that you have a military person to keep them quiet, that they'll be loyal, and they won't reveal any medical information, not just because of the way they're socialized, but, also, because their job will be on the line in a really different kind of way.

SARAH BALDWIN: Well, it'll be interesting to see who becomes the physician to the president next January. And I hope that we don't get to know him or her. I hope that that's a very low-profile position.

ROSE MCDERMOTT: I really hope so too.

SARAH BALDWIN: Thank you so much for coming on today.

ROSE MCDERMOTT: Thanks for doing this, Sarah. I really appreciate it.

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SARAH BALDWIN: This episode was produced by Dan Richards and Alina Kulman. Our theme music is by Henry Bloomfield. I'm Sarah Baldwin.

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