How important is each candidate’s health in presidential elections? How do the candidates stack up?
The 2016 Presidential Campaign is nearing its end; in only two weeks American voters will decide who, most likely Hillary Clinton or Donald Trump, will sit in the Oval Office. The US presidency is a hard job, with grueling hours and the need to make critical decisions at any time, day or night. Campaigning for president is itself a tough physical endeavor, one that speaks loudly of the health of the candidates. This year has been especially bitter, with accusations and recriminations more appropriate to a college dorm than to the highest office in the land.
My primary work is as a family, preventive, and sports medicine physician. During this season, many people have asked me what I think of the health of the candidates. On one hand, I am not the personal physician of either candidate. I have never met either of them, much less taken a medical history or performed a physical. Any opinion that I render is dependent on publicly available medical information and observations that I have made from afar. On the other hand, the coverage does provide a great deal of data. For the sake of my friends and readers, who have asked me repeatedly, I will give an opinion.
An article on CNN dated 15 Sept 2016 states that Trump is 70 years old, stands 6’3” and weighs 236 lbs, giving him a body mass index of 29.5. By medical standards, he is overweight and therefore is at higher risk for diabetes, heart disease, and various types of cancer than Americans with a BMI between 21 and 25. A recent blood pressure was 116/70, remarkably good for a 70-year-old unless he is on medication, and is fasting blood sugar is 99 (normal is around 100). Trump takes Rosuvastatin for high cholesterol and triglycerides (the fat in his blood), and recent triglyceride results were 61, which is normal. He also takes a low dose aspirin for cardioprotection. Trump’s latest liver function tests, thyroid tests, electrocardiogram (ECG), and chest xray were normal. His colonoscopy (2013) and transthoracic echocardiogram (2014) were also normal. These results suggest that Donald Trump is in good health for a man his age, although I have not seen independent confirmation.
Observations are also important. The human gait changes over time, with stride length diminishing and pace slowing. Medical students are often taught that “gait is the signature of the nervous system.” Trump’s gait is essentially normal, comparable to those of other older presidential candidates such as Ronald Reagan and Bob Dole. His facial expressions and muscle movements are equal and fluid, suggesting a normal nervous system.
His posture is fair, but he rolls his shoulders in, as most people do. Thus Trump is at higher risk for shoulder weakness and chronic pain, although I was not able to find a picture of him without shirts or shoes on the internet. Given his age and weight, Trump is at high risk for arthritis of his weight bearing joints, especially his knees, hips, and spine.
Trump’s mental health has been the source of speculation and scorn for thousands of talking heads. His statements certainly come across as arrogant, but the same can be said for most billionaires, politicians, and otherwise prominent people. Some have suggested that arrogance is a prerequisite to run for president. Though a character flaw, arrogance is not a diagnosis. Narcissism, the excessive admiration of one’s own attributes, is a diagnosis that has been applied to Trump, but could equally well be applied to most rich, famous, and powerful people.
On 14 Sep 2016 Dr. Lisa Bardak, Hillary Clinton’s attending physician, states that the 68-year-old Clinton is “healthy and fit to serve as President of the United States.” It mentions her having sinusitis and a left ear infection in Jan 2016, for which she received a CT scan of the sinuses and brain as well as antibiotics and a myringotomy tube (ear tube). Clinton received antibiotics again for a “right middle lobe pneumonia” in Sep 2016. Bardak notes that she “felt dizzy” at a 9/11 commemoration event, and gradually improved. Clinton has hypothyroidism (treated with Armor Thyroid), Coumadin (which Bardak did not explain), and vitamin B12. Her other results are as follows:
“Of note, she has remained stable for many years on Armor thyroid to treat her hypothyroidism (a low T3 level). Her laboratory testing (vitamin D, CBC, fasting blood glucose, comprehensive metabolic panel, hemoglobin A1-C, vitamin B12) was normal, including cholesterol of 189, LDL of 103, HDL of 56 and triglycerides of 159. Her vital signs showed a blood pressure of 100/70, heart rate of 70, respiratory rate of 18, temperature of 97.8, and pulse-oximetry (oxygen dissolved in the blood) of 99%.”
Hillary’s publicly available health history includes the following:
Coughing fits can be due to many conditions, ranging from allergies to acid reflux to serious respiratory disease. Hillary has had several episodes of these fits. She also suffers from hoarseness, which can be related. Dr. Bardak states that Clinton has had allergies for many years and that they are controlled on Clarinex, an antihistamine.
Right elbow fracture
While serving as Secretary of State in 2009, Clinton fell and fractured her elbow in the basement of the State Department. The fracture had to be significant because she underwent surgery to fix it. A small, non-displaced fracture would likely have been treated non-operatively. White women are at high risk for osteopenia and osteoporosis (thin bones). Epidemiologically speaking she probably has both, and this may have contributed to the severity of the fracture. By contrast, in the 1996 campaign, for example, a 73-year-old Bob Dole leaned on a fake railing at a campaign event, which gave way. He fell three feet to the floor and hit his right side and arm but was not seriously injured.
Secretary Clinton is not thin, which lowers her risk for osteoporosis, but raises her risk for high blood pressure, diabetes, heart disease, and various types of cancer. Fortunately for her, the blood pressure and HgbA1C are normal.
A bigger question is why she fell. It could have been something as simple as tripping over a rug. Standing equilibrium decreases with age, as does vision, muscle strength, and many other factors that protect against falls. Past falls are a significant predictor of future falls.
Fainting and Traumatic Brain Injury
In late 2012, Clinton fainted and hit her head, sustaining what was then announced as a concussion. The State Department suggested that a stomach virus and subsequent dehydration caused the fall. She had chronic headaches after the fall and in December a follow up brain scan revealed the presence of a subdural hematoma, a collection of blood between the brain and the skull. This reveals that the blow to the brain was far more significant than originally thought. Her history is significant for a blood clot in her right leg in 1998, which means that she may have a genetic tendency to get blood clots easily. Clinton began taking Coumadin, a blood thinner which she continues today. Clinton’s head CT in January was probably a follow up on her brain injury in 2012.
In January 2013, observers noted that Clinton was wearing glasses with a Fresnel Prism, used to treat double vision. This was likely related to the fall in the previous December.
Pneumonia and Near Collapse
While getting into a black van after a 9/11 commemoration ceremony in Manhattan, Hillary nearly fell to the ground several times. Had she not been physically held up by supporters and Secret Service agents, she would have fallen. The video begins with Clinton leaning against a metal bollard with a woman holding Clinton. As Hillary moves she slumps, is caught by the Secret Service, and slumps twice more. Her head bobs several times. She lost a shoe while being whisked away. Common causes of such symptoms include dehydration, as in the earlier episode, heart conditions, and seizures. Dehydration is the most likely culprit, although Clinton’s history of brain injury elevates her risk of seizures, and her family history of heart disease is also concerning.
Sometimes Clinton’s upper body movement seems normal, and other times she seems to be supporting herself with a podium. Sometimes her step length seems normal, and other times it seems short and halting. Even at her best, such as during the second presidential debate, she looked repeatedly at her feet while walking. Each step was carefully placed. This suggests that her balance is poor and she needs visual cues to stay upright. She sat every time that she could while Trump stood without support during many intervals.
Some may argue that the president’s health is less important because a president has access to the best medical care in the world. Having worked with the White House Medical Unit on more than one occasion, I appreciate their dedication and professionalism; working long hours and traveling anywhere with little notice. The volume and variety of patients that they see is low compared to many primary care clinics, but their training is excellent.
Whether or not presidents have access to the best medical care in the world, they certainly have access to the most medical care in the world. Powerful people tend to want to stay powerful, and since their power is related to their work, they are impatient with the healing process. They want short cuts, usually in the form of more interventions, more drugs, and more procedures. To some extent this is true of everyone, but powerful people are able to get what they want. Often this is harmful.
Health care professionals wittingly or unwittingly collude to give presidents more health care than they need. Lincoln and Garfield might have survived had their physicians, in well-intentioned zeal, not probed to get the bullets that killed them. Even Bardak’s reassuring letter notes that Clinton got more care, not necessarily better care, than most people would for the same conditions. A single ear infection, even if it is persistent for a few weeks, is not an indication for a myringotomy tube. A sinus infection is not an indication for a brain CT scan, although it may have been done because of her prior subdural hematoma. Most people with pneumonia never get or need a CT scan, and a temperature of 99.4 is not indicative of a fever (100.4 is the generally accepted cut off for healthy patients). Clinton sustained the risks of relatively high medical doses of radiation and the risks of surgery, perhaps unnecessarily. More care does not equal better care.
This is not to blame Mrs. Clinton or her team; the pressures on a presidential candidate are extreme, especially in this era of inescapable public attention. High ranking generals, sports stars, and famous entertainers are also at high risk for getting more care, not necessarily better care. However well intended, this exposes them to risks that can be a detriment to good health.
As I mentioned above, I am not the physician for either Donald Trump or Hillary Clinton. I have never examined or even spoken to either. The information that I have reviewed is a small sample of all of the information available about these people. I am writing at the request of friends and readers. The question about the health of the presidential candidates is important.
Does Trump’s health disqualify him from being president? No. Does Hillary’s health disqualify her from being president? No. President William Henry Harrison caught pneumonia and died within 40 days of taking office, and it is unlikely that either Trump or Clinton will do the same. Franklin Delano Roosevelt was crippled from polio his entire presidency, a fact concealed by the media of his day, but he was an effective president. Nonetheless, just like an employer needs to know if the applicant sitting in front of her is physically capable of doing the job, voters need to know if their two applicants, Donald Trump and Hillary Clinton, are physically capable of doing the job.
Donald Trump shows no evidence of being physically unable to be the President of the United States. Voters can choose against him for a variety of reasons, but his physical health probably should not be one of them. He seems to be as healthy as past candidates of similar age, including Ronald Reagan and Bob Dole.
Hillary Clinton’s health is more concerning. She has many medical problems both past and present. Some of these are very serious. She has current symptoms possibly consistent with ongoing neurological impairment. She does not appear to be as healthy as past candidates of similar age. Voters will decide if Clinton is healthy enough to receive their vote.
Whichever candidate wins, time will tell if they were healthy enough to serve as president.