Arteriosclerosis and other diseases in heads of government and its consequences for the population

Abstract

Heads of government with cerebrovascular arteriosclerosis and other diseases in key historical moments have led to decisions that have marked the destiny of countries not always in a beneficial direction. Severe diseases in political leaders in power have often been hidden from citiziens with the collaboration of personal physicians. The confidentiality of the patient-doctor relationship in special political circumstances should be re examined and subjected to debate. Legal provisions to ensure total transparency of medical information about the health of heads of government should be implemented. Transparency ensures the trust of citizens.

Resumen

La arteriosclerosis cerebrovascular y otras enfermedades de algunos líderes políticos en momentos históricos clave han facultado la toma de decisiones que han marcado el destino de sus países. Muchas enfermedades graves de líderes políticos, antes y durante su permanencia en el poder, se han ocultado a la población, y a ello han colaborado sus médicos personales presionados por su paciente. La confidencialidad de la relación médico-enfermo en circunstancias políticas especiales debe ser motivo de reflexión y debate. Sería deseable promulgar disposiciones que impidiesen la ocultación y garantizasen la total transparencia de los informes médicos sobre el estado de salud de los dirigentes mientras permanecen en el poder. La franqueza ayuda a conservar la confianza de la población.

Anyone who has meticulously observed the photograph which J.F. Toole’s book Cerebrovascular diseases¹ starts with will have probably suggested something similar to the title of this article. It is the famous photo (Fig. 1) of the Yalta conference, celebrated in February 1945, a few months before the end of the Second World War. The three allies who won a victory over Hitler are there and the reason for the conference was to establish the bases for peace, soon to come, and to decide on the division of territories in Eastern Europe, liberated from Hitler by the Red Army, the vanguard of which at the time was positioned just 60 km from Berlin.

Figure 1.

Yalta Conference (February 1945). The three leaders suffer from cerebrovascular arteriosclerosis.

Years later, the political outcome of the agreements made in Yalta contributed to the origins of the conflicts in Korea, Vietnam, Czechoslovakia, Poland, to the creation of the so-called “iron curtain” and the construction of the Berlin wall. Millions of citizens from Eastern Europe remained, until 1989 deprived of their freedom and subjected to communist dictatorships from which it was difficult to escape.

When they posed for the photograph in Yalta all three leaders suffered from advanced cerebrovascular diseases of arteriosclerosis aetiology and they had all survived at least one acute myocardial infarction, which had been kept absolutely secret.

In 1921, as governor of the state of New York, Franklin D. Roosevelt contracted polio at the age of 39 and was paralysed in both legs, having to use a wheelchair from that time onwards. He was no longer able to walk and was only able to stand for a few minutes with the help of casts on both legs. Despite this, he never felt incapacitated or wished to appear as an invalid and he fought against his impaired health, planning for the future and ignoring his disability. His outstanding willpower and huge political ambition won him the presidential election in 1932 and he set up a brilliant economic programme (The New Deal) which brought the country out of the great depression of 1929 and led to its economic recovery. His health appeared to be excellent during this period and his political management outstanding, with him being re-elected for his fourth mandate in 1944. Notwithstanding, his health began to deteriorate from 1942 onwards when a complete medical examination (the first he had had in 11 years) in the naval hospital of Bethesda revealed severely high blood pressure and cardiomegaly.² Dr. Howard Bruenn, who then became his personal physician, struggled in vain to treat the president’s high blood pressure, from 1943 onwards, which was approximately 220/110 mmHg. These severe blood pressure levels and signs of myocardial ischaemia in his electrocardiogram, maintained under the utmost secrecy, did not prevent him from presenting as the democrat candidate (against the advice of his physicians), winning the presidential elections for the fourth time in November 1944 and travelling to Yalta months later. On the night of 12^th April, whilst resting in Warm Springs (Georgia), he had a brain haemorrhage and Dr. Bruenn recorded, at the time of death, blood pressure levels of 300/190 mmHg. He was 63 years old. Considering the success of Roosevelt as president during his first three legislatures, despite his severe physical disability from polio sequelae, we could believe that the drive and stimulus which some diseases confer on certain people make them capable of surpassing major health limitations. Dealing with illness may change a person’s personality, sometimes for the better. This is something which George Pickering in an interesting book has called “creative malady”.³ Churchill’s struggle with his cerebral arteriosclerosis in the most dramatic moments of his leadership or the determination and drive of John F. Kennedy overcoming Addison’s disease he had suffered from since a very young age are other examples to consider.

Stalin was a hypertensive alcoholic, as was discovered years after his death when Gorbachov rose to power and was granted access to numerous documents which had remained secret. Since 1940 Stalin had suffered from chest angina attacks and it is known that in 1944 he suffered from an acute myocardial infarction and a transient cerebral vascular accident. What is most striking about his mental constitution, according to witness accounts provided by David Owen in his book,⁴ was his extreme paranoia, which led him for years to order systematic executions to keep himself in power. In 1950 he accused Prof. Etinger, a prestigious Jewish physician, of having criticized him and ordered his arrest, after which he was tortured to death. This was the beginning of the so-called “conspiracy of doctors”, with the arrest and death of five more physicians, including his old doctor and friend Prof. Vladimir Vinogradov, accused of conspiring against Stalin. These facts led Stalin to refuse to be treated by any doctor as he was convinced they wished to poison him and when he died, due to the same causes as that of Roosevelt, on 5th March 1953, at the age of 72, 12 hours passed by until Beria and Molotov dared to make the news public or to call a doctor. The autopsy showed a massive brain haemorrhage.

When he went to Yalta, Churchill, who was 70 years of age, had suffered from a myocardial infarction in 1941 and several recurring attacks of transient cerebral ischemia and cerebral thrombosis. He also suffered from a bipolar disorder (manic-depressive) alternating between periods of euphoria and depression, which he referred to as “black dog days”. After the war ended h1e lost the elections celebrated in July 1945 to Clement Attlee, of the labour party, but was re-elected as prime minister in 1951. In June 1953 he suffered from a hemiplegia with aphasia, which was kept in utmost secrecy, and he was incapable of governing for several weeks. The media was told that the prime minister had flu. His son-in-law, who was a conservative MP, acted in his place and had to falsify his signature on repeated occasions. Against all odds, Churchill, with his extraordinary resilience, was able to recover, but he was forced to stand down in 1955 for health reasons. Churchill never gave up, he said he did not know how to die.⁵ In strict justice, it has to be recognized that as a strategist and politician in key moments, Churchill displayed his genius and was a key figure in the eradication of fascism. From a health viewpoint, the last decade of his life was bleak, with recurrent failure of brain circulation which made him comment about his situation that “this is not life, only a weak substitute for it”. He no longer knew hardly anyone and when President J.F. Kennedy, visited him on the Onassis yacht, he mistook him for the waiter. He died aged 91 at his residence in Hyde Park on 24th January 1965 from a brain haemorrhage, as described by his personal physician, Lord Moran, in his memoirs published in 1966.⁶ There followed controversies and criticism by his family, condemning the publication of the book by Lord Moran as a breach of confidentiality governing physician-patient relations. Lord Moran’s comments on his illustrious patient were published a posteriori and with great editorial success. Much time has passed and from today’s viewpoint we could add that in the case of political leaders in power certain information on their health should be made public at the time. Doubtless Lord Moran may be criticised for his deceitful public declarations on Churchill’s health in 1953.

Lord Moran was a good clinician and was president of the Royal College of Physicians. It is interesting to reproduce the comment which he recorded in Yalta in his diary regarding Roosevelt: “to a doctor’s eyes, the president seems to be a severely ill man. He was sitting looking fixedly ahead, with his mouth open as if he were absent. He participated very little in the discussions, his acumen had disappeared without a trace and he appeared physically consumed. He has all the symptoms of a serious hardening of the cerebral arteries and I would not give him more than another two months to live”. It has been much discussed afterwards whether the illness and deterioration of president Franklin D. Roosevelt, diagnosed by Lord Moran and obvious in the photo, allowed Stalin to go forward with all of his territorial occupation plans, faced with a fatigued and isolated septuagenarian Winston Churchill who was unable to put up much opposition.

Numerous clinical data exist and, in the case of Stalin, also an autopsy, made by their personal physicians who confirm, without a shadow of a doubt, the existence of coronary and cerebral arteriosclerosis in these three major political leaders during the Yalta conference and their subsequent deaths as a result of them.

Furthermore, to these three leaders could be added a striking list of other important political leaders who suffered from cerebral arteriosclerosis and who died because of it. Stalin’s mentor, Vladimir Lenin, suffered a stroke in 1923, and became hemiplegic and aphasic. He died from a brain haemorrhage one year later, at the age of 53. Also, when the American president Woodrow Wilson attended the Paris Peace Conference in Versailles in 1919 to sign the Treaty after the First World War he had already suffered from a stroke from which he had partially recovered and he died from cerebral thrombosis at the age of 67, not long afterwards. Similarly to what occurred later with Roosevelt in Yalta, Wilson’s delicate state of health helped to clinch the tough conditions imposed by Georges Clemenceau and Lloyd George on the defeated Germany, which was the seed of Hitler’s rise to power a decade later.

The problem of changes to behaviour, memory and behaviour as a consequence of cerebral vascular diseases affects many people in the world from a certain age and is a major cause of death or prolonged disability. Political leaders are naturally exposed to the same diseases which affect the general population. It is possible that the stress and pressure they are subjected to during their mandate play an aetiological role in the earlier development of arteriosclerosis and arterial hypertension. Obviously, when this disease affects political leaders who have risen to the peak of their power it is reasonable to question to what extent they are in a condition to continue making important decisions and when it is time to stand down. This should be the responsibility of their personal physicians, but there are numerous examples that their advice was kept secret, and was rejected by the leaders who wished to hold onto power.

Unfortunately, reduction in mental capacity and the inability to take the right decisions may condition the future and the lives of millions of people. What is more worrying is that these serious diseases with neurocognitive impairment in most cases were kept secret and systematically hidden from the general population. It should also be noted that mental changes are not always the consequence of cerebral arteriosclerosis, but may also be due to certain drugs. The case of Anthony Eden, successor to Churchill in 1955, is a good example. A brilliant and extremely popular politician, appointed minister of foreign affairs at the age of 35, he remained in the shadow of Churchill, who never found the time to stand down, waiting to be prime minister. He was an expert politician, affable and with exquisite manners.⁷ He won an absolute majority in the elections of May 1955 and at the age of 55 he was predicted to have a successful future. Unfortunately this was not to be. Previously, in 1953 after several episodes of jaundice and abdominal pain he was diagnosed with gall stones and a cholecystectomy was performed, but the operation was disastrous. The bile duct was accidentally severed and ligation of the left hepatic artery was performed. He was operated on three more times, one of them in Boston, but without success. At the end of 1954 he suffered from the first bout of cholangitis and had a high fever, from which he recovered well and was able to present and win the elections previously mentioned. However, months later he again suffered from cholangitis, high fever, shivering attacks and strong abdominal pains. It was later known that he began to take morphine derivatives, barbiturates to sleep and amphetamines to raise his mood, all at progressively higher doses and it was said he lived thanks to Benzedrine. His sudden mood changes, insomnia and growing irritability in debates in the Chamber of Commons and cabinet meetings where he shouted at his ministers, unheard of in him, increased, but his disease and the drugs he was consuming were kept under a veil of the utmost secrecy. Against this backdrop, Nasser nationalised the Suez Canal in July 1956, forcing an ever more frayed Eden to take a series of erroneous decisions, obfuscated in bringing down Nasser and ordering the bombardment of Egypt to recover the canal, without achieving this. For most historians, his illness and the drugs were a relevant factor in the catastrophic decision-making of Eden and contributed to the Suez Canal debacle. Eden was forced to stand down at the end of 1956 by his own government. He was the last prime minister to believe that Great Britain was a great power and the first to confront a crisis which proved that it no longer was.

It is also right to accept there are several exceptions to what has previously been stated, with leaders who have been exemplary regarding information about their health. President Eisenhower was the first American leader to break the cycle of secretiveness and concealment. One year after his first mandate he was diagnosed with high blood pressure. He continued to be a heavy smoker and one year later suffered a myocardial infarction, which he informed the whole country about with total transparency. In 1957, during his second mandate he suffered from a transient cerebral ischaemic attack, remained aphasic and partially hemiplegic, from which he recovered after 48 hours. He informed his country of all of this, including the outbreaks of terminal ileitis which he was operated on for. He created a special committee to transfer power to the vice-president if a president was too ill to take the correct decisions. His model of fewer secrets and greater frankness helped to sustain the population’s trust.

Another example could be the British Labour Prime Minister Harold Wilson, who was elected for his first mandate from 1964 to 1970. He skilfully governed during a difficult period due to the poor economic situation of his country and won the referendum in favour of the continuity of Great Britain in the European Economic Community. He had a tremendous photographic memory and was particularly skilful in meetings and debates in the Chamber of Commons. He was re-elected in 1974. From then onwards his short-term memory began to rapidly decline, he found it difficult to express himself and began to speak very slowly which was a hard blow for his self-esteem. Aware of his problem, with no pressure from his party and totally unexpectedly, he voluntarily stood down at the beginning 1976, being the only prime minister to voluntarily do this. Some years after his death, in 1995, he was diagnosed with Alzheimer’s.

Without a doubt, the health and mental capacity of political leaders is a tremendously delicate and difficult issue to cover, but this should not make it irresolvable. The power setting that surrounds them leads to secretiveness and isolation, partly facilitated by the inevitable security services. As a result, it is not uncommon for some leaders, throughout their mandate to metamorphose, developing the so-called hubris syndrome (from the Greek hubris), characterised, according to Owen,⁴ by unbridled arrogance and self-confidence, lack of reflection, impulsiveness, the need to be admired, fearful contempt for others, loss of contact with reality with a tendency to talk about themselves in the third person, repeated predisposition to lying and narcissistic traits. Many of these characteristics are part of the diagnosis of a psychopath, with personality changes that psychiatrists have called “the dark triad”: (1) lack of empathy and remorse, (2) Machiavellianism and conceited narcissism, (3) fantasies of unlimited power. When governing, this set of traits leads to incompetence, because excessive confidence makes the leader ignore the practical aspects of a political directive, denying recognition of errors and failing to change their stance. Drunk on power. We may recall the phrase of Margaret Thatcher “The lady’s not for turning” or that of Blair, who joked he had no reverse gear. Meanwhile, it is the country and its citizens who pay the price. Theodore Roosevelt, Adolf Hitler, Richard Nixon, the Shah of Persia, Margaret Thatcher, George W. Bush, Tony Blair and Donald Trump are all examples of the hubris syndrome, to name just a few from a much longer list of leaders. Generally, as the Greeks showed us and current history corroborates, all hubris end up being punished by their nemesis, or find retributive justice, i.e. the return to reality because in the end the gods demand humility. The examples of Hitler and Nixon are paradigmatic.

Armed forces recruits, commercial aviation pilots, senior executives of large companies and football players, among other professions, are all subject to rigorous medical examinations for acceptance. However, there does not appear to be the same degree of exigency regarding the health of political leaders, in whose hands the fate of millions of citizens lies.⁸ Naturally, the level of health involvement must be assessed since it is not logical to demand perfect physical and mental health from leaders, as this is almost impossible in any person after a certain age. But limits should be imposed on their decisions in extreme cases of illness, or the hubris syndrome and the doctors play a major role here, with heavy responsibility. The deliberate concealment of severe health complications has determined the course of many political careers, changing the course of history and being the cause of many problems for its citizens.

Serious health problems of politicians in power are obviously an issue pending resolution, difficult to cover but unavoidable as essential defence of democracy. Independent media information transparency appears to be an absolutely essential requirement, together with the guarantee that the physician’s report is not censored by the politicians. The doctors, together with the legislators, are requested to participate in the resolution of these issues. It would be fitting if democratic nations took measures to safeguard the physical and mental capacity of their leaders and society could protect itself from the consequences of these diseases and psychopathies suffered by their rulers.

In a democratic society citizens have the right to be informed about the health of their leaders and to be aware of the results of an independent medical assessment prior to their presentation at elections for the nation’s top-ranking position. The collaboration of a general internal physician and a neurologist as the supervisor of the medical examination, in addition to the personal physician of the politician in question could be a solution, as noted by Owen.⁴ It would be recommendable for laws to be passed to guarantee public information of medical health status appraisal, including mental health, of the candidates for head of state or government prior to elections taking place and for these appraisals to be made annually whilst they remain in power. In sum,⁸ procedures need to be made available to ensure that the leaders’ decisions are supported by the electorate’s vote of confidence.

Conflict of interests

There is no conflict of interests.