The Health of the First Ladies: Medical Histories from Martha Washington to Michelle Obama
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Barbara Bush (1989–1993)
“George is very healthy, and I always questioned the press’ right to know things about his body that had nothing to do with his ability to govern.”1
Barbara Pierce Bush remains an outspoken and universally admired mother and grandmother. She is the wife to a two-term vice president (1981–1989) and one-term president (1989–1993). Barbara Pierce married navy pilot George H. W. Bush on January 6, 1945.2 Their marriage has lasted for 68 years and counting. Barbara Bush had six successful pregnancies between 1946 and 1959, giving birth to four sons and two daughters.3 However, the Bush’s oldest daughter, Robin, died from leukemia seven months after the diagnosis. The child was one month shy of her fourth birthday.4
Mrs. Bush’s health had always been robust. In the 18 months leading up to her husband’s presidential inauguration in 1989, she never had felt better and was very pleased that she was losing weight, a reduction of eighteen pounds. However, during the week before George Bush’s January 1989 inauguration, her eyes began to bother her.5 The new first lady described her symptoms in a March 20 diary entry: “They started acting up the week before the inauguration. I thought it was a makeup problem, allergy to makeup, etc. But it didn’t stop. They are red, sort of tearing all the time, itch, are puffy and I see double…. Frankly, it is a little scary.”6
The innately voluble Barbara Bush was the first to inform the public about her illness. She broke the news at an informal March 29 news conference in the White House: “I wouldn’t have told you this, but I’m so bored reading about my weight; people keep saying: ‘She’s dieting.’“ She revealed that Dr. Burton Lee III, the Bush family’s personal physician in the White House, insisted on diagnostic tests after he was informed of her symptoms. She added that her eyes looked like “horrible-big puffy, horrible eyes.” “Pop eyes,” she described their appearance.7
The tests were performed at Walter Reed Army Medical Center, where the diagnosis of Graves’ disease (hyperthyroidism) was established. Mrs. Bush colorfully described her problem as “an overactive thyroid—it just went wacko.” Her diary entry, dated March 20, 1989, reads colloquially: “they think I have a thyroid gone berserk.”8 The first lady determined that the public should be informed immediately since Graves’ disease was not a life-threatening condition if treated. Later in the day of her news conference, her press office belatedly caught up with the story. It formally announced that Barbara Bush had Graves’ disease. In addition, its official statement disclosed that treatment with methimazole had commenced and that marked improvement of her eye symptoms had occurred. Methimazole is a drug that inhibits the synthesis of the thyroid gland’s hormones.9 The following month Mrs. Bush was again an outpatient at Walter Reed. She sipped a solution of a radioactive form of iodine to further suppress the hyperactivity of her thyroid gland.10
Graves’ disease is the most common cause of hyperthyroidism, i.e., increased activity of the thyroid gland. For reasons still unknown, antibodies to the patient’s own thyroid are produced which lead to an uncontrolled production of thyroid hormone. The hormone controls the body’s metabolism and is critical for regulating mood, weight, and mental and physical energy levels. Surprisingly, thyroid hormone receptors are also present elsewhere in the body other than the thyroid. The adipose (fat) and muscle cells of the eye orbit contain such receptors. In Graves’ disease, these orbital constituents expand and crowd out the eyeball; protrusion of the eyes is a result. Eye protrusion, also known as exophthalmos, is a diagnostic sign of Graves’ disease and in Mrs. Bush’s case it produced weight loss and eye problems. At sixty-two years of age, she was older than the usual patient—a woman closer to the age of twenty.11
Graves’ disease was named for an astute nineteenth-century Irish physician, Robert Graves, who at age thirty-nine described four young women with the condition. Three presented symptoms of an enlarged thyroid gland and tachycardia (an abnormally increased heart rate). The fourth exhibited severe exophthalmos. Graves’ insight was to connect the symptoms of the four women into a single clinical entity. However, as frequently is the case with eponyms, the namesake was mistaken regarding its essential features. Graves erroneously concluded that the diseased organ was the heart, not the thyroid gland.12
Mrs. Bush’s ocular symptoms continued. Despite initial optimism, the double vision, tearing, and irritation did not improve. An August return visit to Walter Reed concluded that although her thyroid function was under control the uncomfortable eye complaints persisted. Consequently, another treatment was instituted: Oral steroids in the form of prednisone.13 Despite prednisone therapy, the symptoms still persisted three months later. Therefore, the first lady sought a second opinion apart from Doctor Lee and the specialists attached to the military hospitals in the Washington, D.C., area. She flew to the Mayo Clinic in Rochester, Minnesota, for a series of tests and recommendations for alternative treatment. Perhaps her choice of an external consultant was influenced by the Reagans’ past successful treatments by physicians from this esteemed institution. The Mayo Clinic reduced the daily prednisone dosage and recommended a course of radiation to her eye orbits.14 Prednisone is not without side effects, which Mrs. Bush acknowledged: “I was weaning myself off the prednisone … and it was very painful. I was taking therapy to strengthen my muscles…. [P]rednisone … killed something in my right hip and caused muscles to weaken, especially around my knee and hips. I confess that I was in a lot of pain that would last through the fall.”15
A ten-day course of low-level X-rays at Walter Reed Army Medical Center followed in January 1990. The objective of the irradiation was shrinkage of the muscles and fat of the eye orbits in order to reduce swelling and inflammation. The hope was to provide more room for the eye muscles to adjust, limit double vision, and reduce the exophthalmos.16
There is no indication that the first lady’s disease affected the functioning of the president. Mrs. Bush’s account of the first hundred days of the Bush administration showed no let-up in the 41st president’s hectic executive, travel, and social schedule.17
Two decades later, in March 2010, the eighty-four-year-old Mrs. Bush was briefly hospitalized in Houston with undisclosed, but baffling, symptoms. After several days of testing the diagnostic conclusion was a mild relapse of Graves’ disease. The Bush family spokesman “described her symptoms as not life-threatening but would not go into further detail at the time.” A slight adjustment was made to her medications that she had been taking for twenty years. Since 1990, there has been no reference to exophthalmos.18
Barbara Bush, the wife of George H. W. Bush. Both Bushes developed Graves’ disease (Library of Congress).
Two years after her diagnosis of Graves’ disease, her husband, President George Bush, became symptomatic with the same condition in a dramatic fashion. Bush collapsed while jogging; the cause was atrial fibrillation, a significant abnormality of the heart rhythm (cardiac arrhythmia). Hospital tests disclosed Graves’ disease, for which he was then treated successfully. Fortunately for the president, his symptoms did not include eye problems, the symptoms that were most bothersome for his wife.19 Doctor Burton Lee III, the civilian who served as the first family’s personal physician in the White House and who astutely directed Mrs. Bush for medical testing when her symptoms appeared in 1989, failed to diagnose the President’s illness. Lee inserted his academic philosophy into his practice of medicine. In an interview for the Journal of the American Medical Association, the White House physician criticized physicians for ordering too many unnecessary blood tests, including screening tests for thyroid disease. Lee did not order these for President Bush’s annual physicals, and as a result, an early diagnosis of Graves’ disease was missed.20
Barbara Bush mused about the rarity of a husband and wife contracting an uncommon disease: “What a peculiar illness—it attacked my eyes and George’s heart. It is unusual for a husband and wife to both have this problem, but not unheard of. I received several letters telling me of other couples who sha
red our same disease.” The Bushes’ dog, Millie, contracted lupus, another autoimmune disease, which led to all sorts of crazy speculation, including an investigation of the water supply at the vice president’s house. The search for answers continued, and in response “in December 1993, George, Millie and I [Barbara] gave blood to Dr. Jonathan Jaspan at Tulane University to be tested for a common virus that might be responsible for our autoimmune diseases.”21
Barbara Bush’s public advocacy for thyroid disease awareness, detection, treatment, and research barely outlasted her years in the White House. In 1992 she gave an address in Boston for Dr. Lawrence C. Wood and the Thyroid Foundation of America, which he started and headed at the Massachusetts General Hospital.22 In addition, the Bushes made public service announcements for the Thyroid Foundation in Houston and were made honorary members of the Graves’ Disease Foundation, an organization founded in 1990, a year after the first lady’s diagnosis.23
However, publicity was fleeting regarding the extremely unusual occurrence of an uncommon malady in both a president and his first lady. Perhaps this resulted from the treatability of Graves’ disease and very good prognosis. Mrs. Bush’s name now has become unassociated with her malady, outside of biographies and history books. The Graves’ Foundation has received little feedback and minimal support from the White House connection. The Foundation’s director speculated that Mrs. Bush’s inattention and reluctance to speak out was due to a desire to keep her disease a private matter.24
At the time of this writing, it has been twenty years since George and Barbara Bush were tenants of the White House. For most of the time, the genial couple have enjoyed a peripatetic existence. Barbara Bush, like Betty Ford before her, chronicled her post–White House experiences in two autobiographies.25
The medical care of an ex-first lady is her responsibility; no longer would her health be under the close scrutiny of the physicians of the White House Medical Unit. Barbara Bush, pleased with her previous experience in Rochester, Minnesota, like her predecessor Nancy Reagan, selected the Mayo Clinic facilities in Minnesota and Scottsdale, Arizona, to monitor her care. The bond was fortified by the appointment of Mrs. Bush to the Mayo Clinic Foundation Board, an honor that “happened because I married well.”26
The Mayo Clinic was the site for most of the operations Mrs. Bush underwent during her first decade as a private citizen. Osteoarthritis necessitated nine surgeries: replacements of both hips, five foot operations, and two back surgeries.27 The Bushes selected a Houston physician, Dr. Ben Orman, to be their primary care doctor. The former first lady has since been hospitalized several times at Houston’s Methodist Hospital. The most recent admission was for pneumonia on December 30, 2013.28
Hillary Clinton (1993–2001)
“She did have pain in her calf, but her staff thought she had pulled a muscle exercising.”29
Hillary Clinton was America’s first lady during the two-term presidency of Bill Clinton (1993–2001). Hers was not the traditional narrative of a president’s wife. Her activities, both during and subsequent to her White House residency, were remarkably political in nature, even exceeding those of her cherished predecessor Eleanor Roosevelt.30
Early in 1993 President Clinton announced that his wife would chair the President’s Task Force on National Health Care Reform, which included seven cabinet secretaries and numerous White House staff members.31 A few months later a federal appeals court ruled that her open advocacy as chair of the task force made her a “de facto” fulltime government official.32
In her last year as first lady, Mrs. Clinton campaigned for and won a seat as United States senator from New York. She was reelected in 2006 and served as secretary of state between 2009 and 2013. She sought the 2008 Democratic nomination for president and is rumored to be very interested in its 2016 nomination.
Little is known about Hillary Clinton’s past or present medical history. She is the mother of one child. “Chelsea Victoria Clinton arrived three weeks early on February 27, 1980.”33 Hillary was healthy as first lady, as noted by the Clintons’ personal physician in the White House: “Hillary rarely had a sick day nor did she complain of feeling ill unless her illness risked compromising her scheduled activities.”34
Hillary Clinton, the wife of Bill Clinton. She concealed a dangerous deep vein thrombosis while first lady (Library of Congress).
Transparency regarding her health was absent from this first lady’s credo, in contrast to Barbara Bush, who, although she had some misgivings about the release of intimate medical information, was forthcoming with information about her non–life threatening Graves’ disease. Hillary Clinton, however, was silent about a more threatening condition, a deep vein thrombosis within the major vein of her right leg. This event became public knowledge only after a brief mention in her biography, Living History, five years after the fact.35 Her physician, navy captain Connie Mariano, was prohibited by professional ethics from releasing the information. It was only in Mariano’s 2010 memoir, The White House Doctor, that a comprehensive report of the incident became available.36
The first lady was a very active campaigner during the 1998 mid-term elections. While in New York City to attend a fund-raiser for her future New York State senatorial colleague, Charles Schumer, she realized her “right foot was so swollen that I could barely put my shoe on.” White House physicians are always at the beck and call of a first lady. Dr. Mariano was summoned to the White House upon Hillary Clinton’s return. An initial cursory examination diagnosed a deep vein thrombosis (DVT) behind the right knee. This was confirmed at Bethesda Naval Hospital by an ultrasound and consultation with Captain Frank Maguire of the hospital’s pulmonary medicine and critical care service.37
Navy physician Connie Mariano was the personal physician to Bill and Hillary Clinton during their two terms in the White House (courtesy Bureau of Medicine and Surgery Archives).
A DVT is a blood clot that forms in one or more deep veins of the body, usually in the legs. A deep vein thrombosis is a serious condition because a blood clot may break loose, travel through the bloodstream and lodge in the lungs. The result, a pulmonary embolism, may be fatal. In the United States, 600,000 cases of DVT occur each year. One of every 100 patients dies.38 Mrs. Clinton accurately identified the cause of the clot, her nonstop flying around the country. Sitting for long periods of time in a car or on an airplane is its most common risk factor. Other risk factors include prolonged bed rest, leg injury, pregnancy, and anovulants.39
Drs. Mariano and Maguire recommended hospitalization and anticoagulation. However, the first lady balked and forced the physicians to compromise. She was treated as an outpatient with a newly released blood thinner (anticoagulant). The first lady returned shortly to the campaign trail, repeating the long episodes of sitting that placed her at risk in the first place. Mariano assigned a White House nurse in civilian attire to accompany Mrs. Clinton on the campaign trail. As an added precaution the doctor informed the Secret Service that the first lady was on anticoagulant medication, to warn them: “In the event she was injured, excessive bleeding would be a dangerous complication.”40
The reasons for this first lady’s clandestine handling of a serious disease are best known only to her. Was it bravado, the belief that as a private citizen it was no one’s business, or a strictly political motive? “Very few people knew of Hillary’s blood clot at the time…. [S]he did have pain in her calf, but her staff thought that she had pulled a muscle exercising.”41 One result of this incident was medical coverage of a first lady on a domestic air flight. In the future, first ladies would be accompanied by a nurse from the WHMU. A physician and a nurse or physician assistant continues to escort a president’s wife on all international trips. At least one member of the WHMU contingent is a woman.42
During the Clinton presidency, the White House Medical Unit consisted of six military physicians, five physician assistants, five nurses, three hospital corpsmen, and three administrative personnel. All are military except for a few a
dministrative members.43 During the Bush presidency, his personal physician and chief of the WHMU, Colonel Richard Tubb, tasked a physician to accompany Mrs. Bush on all her trips, both domestic and international. The responsibilities of the WHMU increased and its corresponding personnel expanded to more than thirty. Its members now include eight or nine physicians, six nurses, and six physician assistants.44
Recent first ladies have undergone annual physicals during their tenure. Moreover, personalized physician examinations are available at their convenience. For gynecologic examinations, the president’s wife would visit a private gynecologist’s office, or the gynecologist would visit the White House. The annual physicals and other medical examinations are conducted without publicity or public comment.45
Mrs. Clinton’s past silence about her health, as well as her political and personal behavior during two decades on the national stage, produced significant cynicism over the initial silence and the subsequent explanation of a subdural hematoma suffered at the conclusion of her tenure as secretary of state in December 2012. The secretary of state contracted a viral infection which enervated her; the consequence was a fall and a head injury. Hemorrhage between the coverings of the brain resulted (subdural hematoma). The condition was diagnosed; it was treated appropriately; and the patient recovered completely.46
This chapter on Mrs. Hillary Clinton’s eventful career remains unfinished. An addendum may be required in the future.
Laura Bush
“She’s got the same right to medical privacy that you do.”47