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A Final Summation of the U.S. Presidents for the ISHLT

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Vincent Valentine, MD
University of Texas Medical Branch
Galveston, TX, USA

There have been 43 U.S. Presidents inaugurated as 44 times with a median and mean age 55 ± 6.3 years, range [42 (Teddy Roosevelt - youngest inaugurated and Kennedy age 43 - youngest elected) to nearly 70 (Reagan, 16 days shy of his 70th birthday)]. Grover Cleveland was notable for being the only one elected for two nonconsecutive terms, as the U.S.' 22nd and 24th President. Also, Cleveland was the only multimillionaire from the reconstruction era, see figure. There are many ways to organize and characterize the U.S. Presidents. In an effort to reflect on and summarize the journey to the 36th Annual Meeting in Washington, D.C with America's leaders through all issues of Volume 7 of the Links, let's examine some interesting and meaningful characterizations that might provide us some insight on leadership for the ISHLT. Obviously, as an International Society, we have had different presidents from different nations as well as female presidents and deservedly so in the ISHLT. If you include the number of U.S. vice presidents for 227 years in contrast, all 90 presidents and vice-presidents have been male and all but one (incumbent, Barack Obama) were white with a variety of backgrounds.

By all accounts, America's inimitable leader, Abraham Lincoln, who emerged from a single-room log cabin in the backwoods of extreme poverty with virtually no education and the first U.S President born west of the Appalachian Mountains, has been consistently ranked among the greatest of all U.S Presidents. He broke through a sea of less than mediocre and conflict-averse leaders, at a time of civil unrest, who led us in preserving the Union during the Civil War, proclaimed the emancipation to end slavery and delivered his famous remarks at Gettysburg. Lincoln stands out in this second era of Presidents (1850 - 1897), who collectively rank among the worse, the poorest and least likely to live past age 70 with rapid turnover in office. The first 12 presidents who make up the first era were integral in expanding the United States from the original English Colonies to the Pacific coast. This revolutionary group collectively rank among our best Presidents with George Washington and Thomas Jefferson towering above others. The first six were among the founding fathers and possessed an aristocratic heir in the new democracy. It was these genius and bold visionary founders who declared their independence in the quest for life, liberty and the pursuit of happiness and conceived of the U.S. Presidency and made it strong and independent. Andrew Jackson broke this Virginian and Bostonian rule who defined the first rags to riches story with minimal education and became the fifth wealthiest President. This revolutionary and expansionist group is also collectively ranked amongst richest and with a slow turnover serving as President over a 61-year time frame (1789 - 1850) vs the 47-year time frame of the second era. (see figure) Of note, in a society of the self-evident truth that all men are created equal, 12 of the first 18 presidents were slave owners and some tried to protect it. Although Van Buren, William Henry Harrison, Andrew Johnson and Grant at one time owned slaves, they didn't own any as President. John and John Quincy Adams, Fillmore, Pierce, Buchanan and Lincoln never owned slaves.

While more than half the Presidents were born or elected from a state from the original thirteen colonies and another 11 east of the Mississippi River, it wasn't until Herbert Hoover, the first President born and elected from a state west of the Mighty Mississippi, nearly 140 years after Washington was elected. Since Hoover in 1928, eight of the last 14 Presidents were from this region with three from Texas, two California, and Obama of Hawaii was elected from Illinois. Some of our Presidents came from very poor and middling conditions and some had very little to no formal education, most notably George Washington with no education consistently ranks amongst the greatest and the second wealthiest worth over half a billion dollars. Other Presidents of wealth and privilege lend to another categorization. From The American President by the Kunhardts, there is a group with family ties including: John Adams and John Quincy Adams, William Henry and Benjamin Harrison, Theodore and Franklin Roosevelt, George Bush and George W Bush. John F Kennedy is categorized here, his wealth, privilege and family influence positioned him as the wealthiest valued over a billion dollars, followed by the Roosevelts together nearly 200 million, the Adams and Bush families of near equal worth of around 40 million then the Harrison's. Half the Presidents are worth 10 million dollars of more while the poorest eleven are worth a million or less. Six of the poorest served between 1857 and 1881, a tough time to be Commander-in-Chief with Lincoln and Grant among the poorest. Perhaps after all it pays to be President of the U.S., most were multi-millionaires. The most recent Presidents from the New Frontier and Technology era are worth no less than 7 million dollars each.

As far as college education and careers, eleven Presidents held no undergraduate college degree. However, the college degree does set the Presidents apart from the general population especially today, 24 have a degree from a private undergraduate college while nine possess one from a public college. Fifteen attended Ivy League schools, Harvard, Yale, Princeton, Columbia and Penn. Nixon attended Duke for Law, Hoover attended Stanford for Engineering and Kennedy attended Stanford for Business. Grant and Eisenhower graduated from West Point Academy and Carter graduated from the Naval Academy at Annapolis. Most Presidents studied law but few practiced law. Lincoln was an exception, he combined the practice of law as a small time politician. Many were Generals, mostly prior to the 20th Century, the only General afterwards was Eisenhower. Although, well over a third of the U.S. Presidents were military leaders which included a dozen generals and a half dozen others of a lesser rank, the American Presidency was the first leadership office created based on the consent of the governed and independent of the preferences of blood lines and conquests. Of the Generals elected President, only Jackson and Eisenhower were revered generals that came close to standing in the heroic image as the first U.S President, General George Washington. However, Jackson's unbridled ferociousness reduced his stature leaving only President Ike more like Washington than any other President. All in all, such military leaders were above politics and represented honor and duty rather than barter and compromise. With their first-hand experience in war, they were likely less willing than civilians to commit to any battle, they acted with military restraint. Among the other generals, General Grant was one of the greatest military leaders who proved to be a failure as a President. He was too inexperienced and unfocused to stand up in the tradition of George Washington. On the other hand, it was Lincoln and FDR with essentially no military experience who were the greatest war time leaders and have been included with Washington as the top three U.S. Presidents.

Other careers held by the Presidents included: a Political Theorist (Madison), a College Chancellor (Fillmore), a Tailor (Andrew Johnson), a Classics Professor and University President (Garfield), Teachers (Arthur, McKinley and Harding), an Author/Historian (Teddy Roosevelt), a Professor, PhD graduate and University President (Wilson), a Newspaper publisher and Insurance Salesman (Harding), a Geological Engineer (Hoover), a Farmer, Bank Clerk and Haberdasher (Truman), a Store Clerk and Peanut Farmer (Carter), and a Famous Actor (Reagan). Career politicians included Van Buren, Buchanan and Lincoln. Polk, Kennedy and Lyndon Johnson were politicians for all their adult lives. The American Presidency further subdivides the Presidents into the Compromise Choices: Pierce, Garfield, Harding and Ford; those with An Independent Cast of Mind: John Adams, Taylor, Hayes and Carter; Happenstance: Tyler, Fillmore, Andrew Johnson, Arthur, and Truman; Executive Vision - The American Way: Jefferson, Coolidge, Hoover and Reagan; Executive Vision - The World Stage: Monroe, McKinley, Wilson and George Bush; Expanding Power: Jackson, Cleveland, Teddy Roosevelt, and Nixon and The Balance of Power: Madison, Polk, Taft and Clinton. Regarding their personal styles, Lincoln, Teddy Roosevelt, Wilson, FDR and Reagan were great communicators. Polk, Truman and LBJ lacked great oratorical skills. While Polk may have been the most organized, FDR thrived under chaos. Reagan was disconnected from the day to day operations of his administration, however he possessed dynamic magnetism with the people.

Among the most positive qualities, the best American Presidents had a strong vision for the country and humanity. The Presidents were pragmatic and realistic politicians who could lead public opinion to get things done. There were flexible for the changing needs of the common good and national interests to improve life for all Americans. They had enough foresight to see the great challenges and responded to these challenges. If they lost their creative flexibility or tried to manipulate rather than lead, they would get into trouble. Their great courage and skill as leaders give them the ability to be responsive to the challenges faced during their times. Some of the negative qualities included that some were slaveholders but most importantly the Presidents have been slow to respond to the great diversity of America. It wasn't until World War I when there was presidential support of woman's suffragette. It wasn't until Harry Truman, 80 years after Lincoln that a civil rights agenda was developed. Perhaps being a great public leader doesn't equate with being a role model in the private life of a President. FDR, JFK, LBJ and Bill Clinton come to mind.

Finally, an analysis of their causes of death sheds some light of the effect of health care in America for the last two centuries. All Presidents uniformly were among the survival of the fittest to get to their position in life and elected to public office. The Table shows a reduction of infection as a cause of death probably related to improvements in sewage and sanitation as the United States shifted from an agrarian society to an advanced industrialized society. Increasing attention to personal hygiene, vaccines and antibiotics may have also contributed.

Cause of Death 1789 - 1850 1850 - 1897 1897 - 1960 1960 - 2016
Infection 6 2 1
Cardiac 4 2 4
CNS 1 3 3 4
Cerebral hemorrhage 1 1 1
CVA 2 2 3
Alzheimer's Disease 1
Gunshot Wound 2 1 1
Renal Failure 1
Liver Failure 1
Oral Cancer 1
Upper GI bleed 1

Although westernization and more of a sedentary lifestyle may have contributed to more strokes over time, the reduction of cardiac and infectious causes of death with increased longevity and more time in the post Presidential years may be the result of advanced modern medicine in the face of rapid pace technological advances and a fast paced lifestyle. The life span of our revolutionary Presidents may be the result of a selection process aided by ambition and wealth in a genteel and rustic society. Guiding values and principles coupled with an undying ambition are the marks of great leaders. Not only can they lead, they are insightful enough to be led. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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