Monday, October 20, 2008

McCain's Health

Today's Pew Research findings indicate increasing concerns about John McCain's age, behavior and judgment. All of these may be related to health. The physical and cognitive functioning of the person holding, arguably, the most important position on Earth is certainly relevant to the very essentials of the Presidency, such as decision-making, ability to attend to multiple and constantly shifting events, scenarios and possibilities, ability to persist and to remain both strong and flexible under stress, and the abilities to handle staff capabilities, demands, and agendas, to name but a few key areas--but the public has not seemed to be quite ready to deal with the question of McCain's health. It has been regarded either in categorical terms, or in humor regarding his age--such as listing the number of jobs he would be ineligible to hold at his age (Judgeships, commercial airline pilot, etc.), the AP noting that "six-packs, automatic transmissions and the American Express card were all introduced after he was born", a site devoted entirely to McCain's age entitled "John McCain. Old. Really Old"; the Harvard Satyrical Press noting that he "voted for the Articles of Confederation before he voted against them" and so on. Others have simply avoided the issue entirely (except, often, for the right-wing, which argued strenuously and extensively that McCain was "too old" in multiple publications during the primary fight, publications that have now grown curiously silent on the issue).

In the current situation--a nation beset by financial crisis; the existence of multiple unstable foreign policy arenas as well as critical future decisions with regard to the stabilization of others; and the essential need to steadily recover from eight years of a largely disastrous domestic and foreign policies, has combined with evidence--the choice of a largely unqualified Vice Presidential candidate, and the impulsive, reactive, and often shifting decision-making, based largely on the needs and contingencies of the moment, that a McCain Presidency would lack the steady, broad, persistent and flexible intellectual and functional foundations necessary at this critical time. The reasons for the reactions and decision-making seen thus far are legion. However, one important contributing factor--and one that, by actuarial standards, would be likely to grow worse during a McCain Presidency--is the candidate's health. Of course, it is important to be careful in making conclusions about health without a physician's examination and report; nevertheless, it is also important to make reasonable inferences about functioning that are made from the data, given the potential significance of the information to our decision. This is information that any citizen can find and use to educate themselves about questions about McCain's health, just as journalists do or wish to do. It's important to be aware like any good citizen of the health of their nation's President.

Physically, Senator McCain has shown an admirable vigor on the campaign trail that certainly a minority of 72-year old men could match. He is driven like few men of his age towards such a demanding goal.

However, in terms of physical functioning, he has also suffered from four episodes of one of the most serious forms of skin cancer melanoma, including two malignant melanomas removed from his arm and temple during a six-hour operation in 2000--which also included removal of his salivary gland and multiple lymph nodes in his neck, as well as the removal in 2002 of a melanoma on his nose. This puts into stark contrast his choice of a Vice Presidential candidate who has struggled to discuss basic aspects of domestic and foreign policy at a time of vital demands in both areas. Yet, as we will see below, the McCain campaign has fought to keep access to his voluminous medical records from the scrutiny necessary to accurately determine current and past functioning, and likely prognoses. Indeed, as we will see, in May 2008, the McCain campaign limited access to these records to one local newspaper and one national newspaper who were allowed to observe the records for a limited period; they did not allow photocopying and did not release the records. Moreover, records were only provided for the previous eight years, leaving out thousands of pages of McCain's medical history from all of those prior years.

Cognitively, in terms of emotional functioning and intelligence, McCain often displays a canny sense of the moment and readily moves towards certain forms of humor. He is not unintelligent--surely more intelligent than his predecessor it is sad but true to say, and has shown growth and development in certain ways that represent admirable, if in part perhaps politically opportunistic, changes.

At the same time, the core individual is emotionally shot through with a persistent anger than burns through even his most humorous moment--noted even in the largely hagiographic biography by Bob Timberg. The resentment, the need to prove, the anger at what has occurred--both during Hanoi and long before--is always there, driving him on as a prime referent, shaping his reactions to events, his positions and inflexibility on what is right, even the wryness of his humor as compared to his sense of rage, drawing everything in his orbit to that central point, in a way that is even more fundamental than Bush's familial resentments--far more willing, in movement from that central point, to make the impulsive, "What the hell" gesture, far less burdened by the momentary, quickly covered self doubt.

If the key emotion is an impulsive, reactive rage shot through by the long and hard learned bare container of tactics--there are many moments when you can see him actually engaging in the suppressive act of not exploding--the cognitive concerns are of more recent origin, but also now highly relevant. As the journal Annals of Internal Medicine noted in Prevalence of Cognitive Impairment without Dementia in the United States (2008), nearly one-quarter of adults who are age 71 or above suffer from the disorder known as Mild Cognitive Impairment (MCI). Other estimates of the disorder among the elderly have ranged from 17-34%. MCI is often a precursor to Alzheimer's Dementia--that is, those who are diagnosed with MCI often progress to this more serious disorder of memory and functioning as they continue to age. Indeed, in comparison to elderly persons who are healthy, who develop dementia at a rate of 1-2% per year, those who have MCI have been estimated to progress to dementia at a rate of 10-15% per year. The Mayo Alzheimer Disease Center has found that, for those who have MCI, the progression to Alzheimer's rated as high as 80% in MCI populations studied for 6 years.

During the 2000 election campaign, McCain's cognitive function--his memory, his tendency to make notable and cognitively revealing slips--was not at issue. The emotional factors--impulsivity, rage--were clear, if somewhat better controlled (this issue of decreased control due to cognitive impairment is another issue to be discussed in the next section). However, there was no evidence, for example of memory impairment.

Occasional errors of memory and verbal slips are common for all of us. However, during the 2008 campaign, McCain has shown repeated errors of memory and misstatements that are at the very least suggestive of MCI; for example: not once, but repeatedly referring to the existence of Czechoslovakia, a nation that does not exist--suggesting not only the original error of memory, but the forgetting of the error consistent with an impairment in the ability to remember later-learned information characteristic of MCI; the confusion of among the nations of Iraq, Afghanistan and Pakistan, and which nations border one another; the inability to remember his own voting record on major/substantive issues, such as contraception; inability recalling his stance on discussions with Spain, or the nation's Prime Minister, referring to Vladimir Putin as the "President of Germany", and forgetting a question that he had just been asked in Panama City--seemingly unable to focus on or follow the words that had just been said, although clearly audible and sensible content.

In distinguishing between ordinary memory loss and MCI, it is important to realize that MCI occurs across multiple areas or domains of cognition. Thus, in addition to showing memory loss, those with MCI also show word-finding difficulty and other language disturbances, as well as difficulties with attention, such as focusing on and following other people's speech. As the initial presentation of these is mild, and the individual is otherwise able to function, they may deny such difficulties. The importance here is the disturbance in multiple areas of cognition. While certainly deserving of greater study, it is significant to note that there is evidence of each of these in the examples above.

To Follow: McCain's Health: Part II