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Fighting "Mad Leader Disease"

Rebecca Sloan Slotnick

A potentially devastating condition that has affected hundreds of thousands of people, and even altered the course of world history, remains unchecked, President James F. Toole warned in his opening remarks to the World Congress of Neurology in London last June. He urged members of the international community of neurologists to take action.

The threat? A condition he called "mad leader disease." Mental competence in world leaders is often taken for granted, said Toole, a stroke expert and director of the Cerebrovascular Research Center at Wake Forest University. But he doesn't think it should be. The world community must work to develop methods for the identification and treatment of mental illness in world leaders, he said.

"Never forget that war begins in the minds of men," he told the audience. Leaders are granted unparalleled powers over resources, including weapons of mass destruction, and their influence on public citizens cannot be overestimated, he said.

Throughout history, leaders have been afflicted with a variety of mental and behavioral disorders. In the 18th century, King George III of England suffered bouts of insanity, impairing his decision-making abilities and losing him valuable colonies, including those that would become the United States.

U.S. President Woodrow Wilson (<em>right</em>) . . .Click to Enlarge Image

More recently, U.S. President Woodrow Wilson sustained a stroke in October of 1919, which left him incapacitated during several crucial months as the Treaty of Versailles awaited ratification in the Senate. Chairman Mao Zedong of the People's Republic of China was diagnosed with congestive heart failure in 1972; few were aware of the extent of his physical deterioration, and he remained in a position of power until his death in 1976. The degree to which leaders' deficits have been concealed from the public is a topic of great concern, Toole said in an interview.

People are entitled to the privacy of their medical records, but leaders "hold too much power to be given the right to hide disabilities from their publics," agrees Robert Dallek, a presidential historian and professor of history at Boston University.

In the United States, the 25th amendment to the Constitution, ratified in February of 1967, provides for a transfer of power to the vice president should the president become incapacitated. However, as Toole pointed out in an article published in 1994 in the Journal of the American Medical Association, the disability amendment has been invoked only once: One morning in July of 1985 Ronald Reagan underwent surgery to remove a malignant tumor and signed a letter turning power over to the vice president. Later that day, following the surgery and while he was still medicated, Reagan's advisers allowed him to sign a second letter reclaiming presidential power.

Mental incapacitation or deterioration is difficult to define because "there is little agreement even among experts about the line separating normality from insanity," says Kendrick Clements, a biographer of Wilson and history professor at the University of South Carolina.

To better inform decisions regarding mental competence, Toole proposes adding mental examinations to the annual physical exam required of American presidents. Although mental illness can occur at any age, incidence of cognitive impairment increases with age. Therefore, at 60 years and older, world leaders should submit to an annual magnetic-resonance imaging scan and mini–mental status exam, said Toole, who is 76 and recently co-edited a book, Presidential Disability, issued by the Working Group on Presidential Disability.

The international community's response to an unsatisfactory exam will require careful consideration of both political and medical consequences. And although he admits it will be difficult to gain compliance from certain countries, Toole hopes that encouraging discussion at an international and nonpolitical level, among meetings such as the World Congress of Neurology, will precipitate change and allow the threat of mad leader disease to be subdued with a minimum of casualties.—Rebecca Sloan Slotnick

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