Just over a year after the death of Sir Winston Churchill in 1965, his personal physician, Lord Moran, published Winston Churchill: the Struggle for Survival 1940 – 1960. Moran’s 800 page book was based on the diaries he had kept. Moran was vilified and excoriated for this; not only had be betrayed confidences, but he had broken the sacred bond of doctor-patient confidentiality. Some month later, when his critics had read the book, they saw that Churchill had been severely ill for periods during WWII with pneumonia, and had had significant episodes of depression, the ‘black dog’, and that is to set aside Churchill’s alcohol consumption; we would say today that Churchill was at times ‘not fit for purpose’. Moran also revealed that Churchill had had a major stroke in 1953, from which he made a slow and incomplete recovery. At this time a cabal of press barons conspired to prevent the news reaching the attention of the public. Is such secrecy acceptable today? Alarmingly, does it still happen?
Following Moran’s revelations, Dr Hugh L’Etang published The Pathology of Leadership in 1969, referring particularly to the health of Presidents of America and British Prime Ministers. L’Etang noted, in the period up to the publication of the book,
…since 1908 eleven out of thirteen British Premiers and six out of ten American Presidents have had illnesses while in office which have incapacitated them to some degree.
For instance, L’Etang described how Woodrow Wilson was an inflexible person, though his first term as President was largely uneventful. In his second term, Wilson attended the Peace conference at Versailles, where his mental rigidity was much more marked. Wilson had a severe stroke in 1919 after a number of prodromal episodes. He remained incapacitated, and for the remainder of his term of office, his duties were sustained by a triumvirate of the First Lady, Wilson’s physician and secretary.
Franklin Roosevelt is the only American to have won four presidential elections. By the start of his fourth term he was mortally ill from severe hypertension (raised blood pressure) and heart and kidney failure. At the Yalta peace conference in February 1945, when he, Stalin and Churchill were redrawing the map of post-war Europe, Roosevelt was easily outmanoeuvred by Stalin, while Churchill was strangely passive. Roosevelt died two months later; the severity of his illness had been kept hidden from the American public.
L’Etang continued his theme with Fit to Lead? published in 1980, which expanded on the material in his previous book, but included evidence of psychological stress and downright psychiatric illness.
A third book, Ailing Leaders in Power 1914-1994, was published in 1995. This is orientated more to a medical than a general audience, and discusses ‘top generals’ and others, with a distinct American slant. The release of medical information is now de rigeur in the US for senior positions, including Presidential candidates.
Anthony Eden, Churchill’s successor as Prime Minister in 1955 had had an operation to remove the gallbladder (cholecystectomy) in 1953. During this operation, Eden’s bile duct, the tube that drains bile from the liver to the bowel, was damaged. A second operation a couple of weeks later did not successfully repair the damage; Eden then went to the Lahey Clinic in Boston, the world centre for the repair of such problems. Despite a third operation, Eden suffered recurring episodes of infection in the bile ducts (ascending cholangitis) or Charcot’s Fever, typified by abdominal pain, fever and jaundice. During the Suez Crisis, Eden had such attacks, though between times he sustained himself with heavy doses of ‘benzedrine’, an amphetamine.
His successor, Harold Macmillan, noted in the last few months of his Premiership ‘a strange lethargy’. Macmillan had an enlarged prostate gland, and this produced back pressure changes in the kidneys, with a degree of kidney failure or uraemia, hence the dimming of his mentation. Macmillan then had an acute retention of urine due to his prostate, and underwent an emergency operation. Though always presenting an outward picture of unflappability, Macmillan could be very emotional in private. Thinking, wrongly, that he was dying he resigned office.
Ted Heath was diagnosed with hypothyroidism, underactivity of the thyroid gland, some years after he had left No 10. Often the onset of this is quite insidious, and the gradual changes in personality and mental ability can go unnoticed by those in close contact to the sufferer. It’s not clear if hypothyroidism was present during Heath’s Premiership.
Harold Wilson most unexpectedly announced his resignation as Prime Minister in 1976 when he was 60. It is very unusual for a premier to leave office entirely voluntarily. Wilson may have been influenced by his wife, who was disgusted with politics. But Wilson had noticed that his once very retentive memory was failing; those close to him noticed a significant reduction in his abilities. Though his family always denied it, it is clear that Wilson then had early onset dementia.
Margaret Thatcher was 62 when she won the 1987 general election. Her third term as Prime Minister wasn’t a success. The ‘iron lady’ who wasn’t for turning showed increasing rigidity in her thinking; she was contemptuous and rude to her ministers, would brook no dissent, and was apparently unaware of the great public dissatisfaction with the Poll Tax. Her daughter, Carole, confirmed her mother’s dementia in 2005; from the description it was then very severe. Whether she was so afflicted during her final premiership is uncertain.
There are many, many more examples of illness in leaders, not just locally but abroad. Common features include sociopathic or even psychopathic tendencies, severe mood swings, dementia, physical illness and decrepitude, and the ‘usual suspects’ of gluttony, tobacco, alcohol, medication and even syphilis. Further, many of the leaders were elderly. Though Blair, Cameron and Obama were young, more recent leaders in the UK and the US are distinctly older. Relative youth isn’t a guarantee that stupid mistakes won’t occur.
L’Etang wrote that the ill-health and incapacity of Presidents and Prime Ministers was ’horrifying’.
It’s well appreciated today that a gradual decline in mental abilities accompanies ageing. This can include increasing rigidity of attitude, the reduced ability to comprehend new information and to process it and some memory loss. For most of us this normal ageing process is accepted and unremarkable; but then, most of us aren’t Prime Ministers. We may have the destiny of, at most, a few people in our sphere of activities. Prime Ministers and Presidents have not only the destiny of their countries to think about, if they have the ‘nuclear button’ at hand, potentially the future of the world. (President Pompidou of France, a very unwell man, was unable to remember the 6-digit code, the ‘PIN’, for the nuclear option; he had to have it marked on a tag which he wore round his neck.)
In the British Civil Service, even ‘top mandarins’ are required to retire at 60. Their function is to advise ministers; it is the function of ministers to make decisions as executives, with the Prime Minister being the ‘chief executive’. There is no mandatory retirement age for ministers, for MPs or for Presidents.
If we can accept that the mental and physical prowess of our leaders is something of which we and they must be aware, what can we do about it? What is ‘best practice’ elsewhere?
Commercial aviation is often cited as having ‘best practice’. To become a pilot, the applicant must pass a stringent medical examination. His or her competence and fitness is then regularly assessed, yearly if below 40, and six-monthly if older. Fitness is assessed through medical examination, competence is assessed using a simulator.
Further, such pilots will be required to retire once they reach a certain age. For British Airways, this used to be 55. This has been increased to 60, and may be increased to 65. This change is not a reflection of better medical care or better health, rather it is driven by competitive pressures from a relative lack of pilots, and the usual pension deficits. The point though is not a quibble about an appropriate age, it is the recognition that beyond a certain point and age, any pilot’s critical faculties will fall short of what should be expected; and that this is an entirely normal feature of ageing, no matter how much we all may rail against it. We must all simply accept that for those in positions of executive power, there is an age at which they become a liability; they might well remain, but only in an advisory role. The House of Lords is the prime example of this, where the wisdom of the agèd can be of considerable benefit, for the members no longer have executive functions to sully their minds, and can therefore express a more considered opinion. (The composition of the Lords is another question entirely.)
‘Pilot error’ is held to be a cause of airline disasters. The ‘instance’ case is the crash of United Airlines Flight 173. The pilots noted that the sensors indicated that the landing gear had not properly deployed, though they had, and the sensors were faulty. While the pilots discussed how to manage this, the flight engineer told them repeatedly that the plane was running out of fuel; the pilots ignored this warning, and the plane crashed.
The particular significance of this, and the Tenerife disaster in 1977, the worst to date in aviation history, is that the pilots concentrated on what they thought was the job in hand and completely ignored warnings from other staff. After all, like Prime Ministers, pilots were at the apex of the command structure and didn’t need to heed what impertinent underlings said.
These two incidents provoked a major change in attitude, away from the adversarial and corrosive ‘blame game’, and to what’s called ‘crew resource management’. Now, if any member of a cabin crew is concerned that something is awry, he or she knows the ‘trigger words’ that will cause the pilot to stop and reconsider.
If only this had applied to Prime Ministers and Presidents in the past. Those around such people when their faculties were declining saw changes in personality and ability, even if they ‘saw but did not observe’. They discussed with others, and wrote in their diaries, and did nothing. Such important leaders, even today, are likely to surround themselves with sycophants, and people whose livelihood depends on ‘loyalty’. Who then will speak ‘truth to power’, or even tell the Emperor that he is bollock-naked? Who will speak out and risk being thought to be ‘unfit for their positions, stupid, or incompetent?’ Who will tell the king two days before their coronation that without an operation he will go to his own funeral instead?
For this requires a significant culture change, a change away from the idea the the leader can, through force of will or personality, overcome illness, stupidity and handicaps in a way that mere mortals cannot. Who will even recognise that a change in ‘culture’, the way we do things here, is necessary?
If things, people will say, were good enough for my grandfather, why do we need to change them? Perhaps: if Sir Edward Grey was your grandfather, a lazy man who despite Winchester and Balliol had very limited intellectual powers; a man whose blindness made it difficult for him to read state papers, a man who after the death of his wife had no interest in the future, a man who spoke no foreign language, perhaps if he hadn’t been Foreign Secretary at the outbreak of the Great War, that war could have been averted. Or, if you are American, perhaps your grandfather was Cordell Hull. He was known to be in poor health in 1941, and had diabetes and arteriosclerosis and liked his office kept at 90ºF (32ºC). He was American Secretary of State at the time of Pearl Harbour, and was then 69. He was ‘worn out’ by his exertions trying to reach a settlement with the Japanese.
Robert Campbell is a retired surgeon.