It is selfish of a leader of a nation to drop dead during office. Jawaharlal Nehru, India’s first prime minister, died suddenly at 74, apparently from a ruptured aneurysm. His aneurysm, allegedly, had something to do with Edwina Mountbatten – the wife of Lord Mountbatten, the last Viceroy of India. Shortly after Nehru’s death, Pakistan attacked India. Nehru’s replacement, Lal Bahadur Shastri, died mysteriously in Tashkent two years after Nehru’s death, and was succeeded by Indira, Nehru’s daughter. India’s future was forever changed by a burst aneurysm or, if rumors are to be believed, by a flagellating spirochaete which left the Raj in bliss.
Clearly, the death of a leader creates turmoil for a republic. So it is understandable that a nation obsessed with health is obsessed with the health of its presidential runners. Mr. Trump’s doctor declared he’s the healthiest presidential candidate ever. Mr. Trump has drawn attention to his super health by pointing to the size of his hands – by Mr. Trump’s standards a rather decorous allusion. It matters not what has hypertrophied Mr. Trump’s hands, what matters is that Mr. Trump’s large hands signal vigor and imagination. The American Psychiatric Association, to their credit, in ruling out a new diagnostic code for Mr. Trump’s colorful soundbites in the next edition of their Diagnostic and Statistical Manual, ended all hopes of banning Mr. Trump from the presidential race on health grounds.
We hold our presidential candidates to moral standards higher than saints, even though they often have moral standards lower than men on a bachelor night. Bush Jr was fried for driving under influence, Obama for hanging out with socialists (who else are you supposed to hang out with in college?), and Romney for inventing Obamacare. Since health is the new morality, and we want proof of scruples, candidates must go to extraordinary extents to prove they’re in good health.
In healthcare, what’s good for the gander isn’t necessarily what’s good for the goose. Mr. Trump, against the advice given to the proletariat by the United States Preventive Services Taskforce (USPSTF), had his PSA checked. Mrs. Clinton had a mammogram, likely without the shared decision making about the dangers of anxiety from a false positive mammogram. For good measure, Mrs. Clinton also had a coronary calcium CT. She doesn’t have coronary calcification. I won’t alarm you by saying that a negative coronary calcium scan doesn’t rule out non-calcified vulnerable plaque, which is far more dangerous than calcified plaque. As a radiologist, I know that the pit of “can’t be ruled out” is as bottomless as Health McCarthyism, a new obsessiveness in the republic.
It is Mrs. Clinton who is in the crossfire of Health McCarthyites. Many have diagnosed her ill health merely by looking at her. This is an extraordinary feat by the lay public, which physicians can’t achieve even after years of training. Perhaps I’m not staring at her intently enough, but I can’t detect pallor or icterus in Mrs. Clinton. I do detect boredom in her. Rather than the vigor I expect to see in her in the last lap of becoming the first female president, Mrs. Clinton’s physiognomy is of a runner who has hit the wall at mile 17 of a marathon.
Mrs. Clinton fainted last Sunday. Her syncope kick started the conspiracy theorists. In all fairness, the differential diagnosis for syncope is broad and includes stroke, pulmonary embolism, poisoning by Russians (theory advanced by Dr. Bennett Omalu of Concussion fame) and, as it seems to be the case with Mrs. Clinton, pneumonia. We should, at this moment, spare a thought for our colleagues in emergency medicine when they order a battery of tests in a patient with syncope, particularly as they have to rule out poisoning by Russians.
It is unclear how Mrs. Clinton’s diagnosis of pneumonia was made – radiologists often overcall atelectasis, which looks awfully like pneumonia. Assuming it is pneumonia, the fact-checkers might wonder what the organism tells us about Mrs. Clinton. A lot, actually. If the organism is Mycobacterium Avium-Intracellulare, it tells us that Mrs. Clinton has been suppressing her cough for too long, and like the puritanical Lady Windermere, she must speak more forcefully, not just to her husband. If Legionella, someone needs to clean her air conditioner. Can a president who can’t look after her air conditioner be trusted to police the Straits of Hormuz? If the organism is Chlamydia psittaci, Mrs. Clinton has been ignoring a sick parrot, and if Mrs. Clinton ignores her parrots, what does that mean for Europe? If pneumococcus, then evidently Mrs. Clinton has not been vaccinated. Does she believe vaccines causes autism? Or has she ignored the advice of physicians? And if she ignores the advice of physicians who else might she ignore? Economists?
Of life’s infinite wonders, if looking at Mrs. Clinton’s serum biochemistry floats your boat, fair enough. But if you want to make a truly informed decision about the true health of the candidates you need to extract relevant information. And there’s a lot of relevant information to be extracted. Let’s take blood pressure. As this helpful guide to analyzing the health records of presidential candidates from Stat News explains about blood pressure:
“All these measurements change with time, and it’s not as though doctors look for a candidate’s blood pressure to hit an ideal mark. But the information can be used to rule out or at least minimize the risk factors for certain conditions. “We’re asking for a snapshot of your current status and a look in the past,” said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University. “You would like to know, for example, that a patient’s blood pressure was within a range.”
To Dr. Schaffner’s excellent point about knowing the range of candidate’s blood pressures, I’d add that you must know if the blood pressure of the presidential candidate was recorded by an automated device or measured manually, and if the physician was in the room when the blood pressure was taken, and if the physician in attendance was wearing a white coat. To understand why read about the controversy of measuring blood pressure in the SPRINT trial.
Should we inquire about the candidate’s biometrics, too? Notwithstanding Mr. Trump’s eagerness to disclose his biometrics, the same helpful guide from Stat News encourages us to seek, but also cautions us from seeking, biometrics.
““You might want to go so far as [body mass index], but that’s a very touchy subject,” said Dr. Michael Coates, a family medicine doctor at Wake Forest.
Touchy? We’re talking about the president of the most powerful country in the world, not some college safe-space-seeking precious dumpling. And body mass index is hardly a secret. Take a look at William Taft, the 27th president. Google image him. He looks like he’s deciding between imploding, exploding, or rising above the ground in a helium-like defiance of gravity.
May be one-day precision medicine will lead to precision voting. Perhaps presidential candidates will have to be approved by the FDA – after all presidents can be a safety issue for the public, just like a new drug or device. Perhaps bioethicists will have the first word on suitability of the candidate for presidency, bioethicists are always looking for things to do. Perhaps USPSTF will list “must have” screening tests for presidential candidates, including screening for chronic traumatic encephalopathy, intracranial vascular disease, patent foramen ovale (you never know – presidents could have a sudden stroke), and Alzheimer’s disease.
Talking about screening for neurocognitive disorders, I’m reminded of Ronald Reagan’s reaction to USS Vincennes gunning down Iran Air Flight 655, a passenger flight from Tehran to Dubai. He was unapologetic and indifferent without even an accidental whiff of contrition. Perhaps his hearing aid wasn’t working or maybe it was the first sign of impending Alzheimer’s. I was at school at the time and I remember muttering “ducking tosser.” Mrs. Thatcher, the British prime minister at the time, sounded indifferent and unapologetic as well. Thatcher and Reagan had been buddies in the global domination of free market. Curiously, Mrs. Thatcher, too, developed Alzheimer’s.
Recently, a chap in a solemn tone said “I’m really worried about Hillary’s health. We’re not talking about a hospital administrator. We’re talking about the commander-in-chief.” He had perfected an affect which exuded copious sincerity and hid subtle disingenuity – if you blinked you’d miss the disingenuity. But I knew him, I knew he wasn’t terribly fond of Mrs. Clinton, and that he was full of shit (it takes one to know one). There’s nothing wrong with not liking Mrs. Clinton. Many people didn’t like Mitt Romney or the constipated-looking John Kerry, or his slimy running mate, John Edwards. That’s fine because voting for a president is a primal instinct, and will remain so for the foreseeable future. What I can’t abide is the pretense of objectivity, which is, not just bullshit, it is Bullshit Squared.
Concern about a candidate’s health is the latest of objective, data-driven, façades where prejudice peacefully thrives. It is a circus show which distracts us from the main issue, which is that neither candidate offers a bold economic platform for the future. In America’s strangest election till date, the public are grasping the last bastions of objectivity. They’re grasping at straws and behaving very strangely. It is a clownish effort befitting a clownish election.