BMJ Confidential: For Review Only Does the stress of politics kill? An observational study comparing premature mortality of elected leaders to runner-ups in national elections of 8 countries Journal: BMJ Manuscript ID BMJ.2015.029691 Article Type: Christmas BMJ Journal: BMJ Date Submitted by the Author: 02-Oct-2015 Complete List of Authors: Abola, Matthew; Case Western Reserve University School of Medicine, Olenski, Andrew; Harvard Medical School, Health Care Policy Jena, Anupam; Harvard Medical School, Health Care Policy Keywords: premature mortality, politics https://mc.manuscriptcentral.com/bmj Page 1 of 46 BMJ 1 2 3 Does the stress of politics kill? An observational study comparing accelerated 4 5 6 mortality of elected leaders to runners-up in national elections of 17 countries 7 8 Confidential: For Review Only 9 10 1 2 3 11 Andrew R. Olenski, B.A., Matthew V. Abola, B.A., , Anupam B. Jena, M.D, Ph.D. 12 13 14 15 1 Research assistant, Department of Health Care Policy, Harvard Medical School, 180 16 Longwood Avenue, Boston, MA 02115. Email: [email protected] . 17 18 2 19 Medical student, Case Western Reserve University School of Medicine, 2109 Adelbert 20 Rd., Cleveland, OH 44106. Phone: 216-286-4923; Email: [email protected]. 21 22 3 Associate Professor, Department of Health Care Policy, Harvard Medical School, 180 23 24 Longwood Avenue, Boston, MA 02115; Tel: 617-432-8322; Department of Medicine, 25 Massachusetts General Hospital, Boston, MA; and National Bureau of Economic 26 Research, Cambridge, MA. Email: [email protected]. 27 28 29 30 31 Corresponding author from which reprints should be requested: 32 33 Anupam Jena, M.D., Ph.D. 34 Department of Health Care Policy 35 Harvard Medical School 36 37 180 Longwood Avenue, Boston, MA 02115 38 Tel: 617-432-8322 39 Fax: 617-432-0173 40 Email: [email protected] . 41 42 Word count: 2,393 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 46 1 2 3 ABSTRACT 4 5 6 Objectives: To determine whether the stress of being elected to head of government is 7 8 Confidential:associated with accelerated mortality byFor studying Reviewsurvival differences among Only those 9 10 11 elected to office versus unelected runner-up candidates who never served. 12 13 Design: Observational study. 14 15 Setting: Historical survival data on elected and runner-up candidates in parliamentary or 16 17 18 presidential elections in Australia, Austria, Canada, Denmark, Finland, France, Germany, 19 20 Greece, Ireland, Italy, New Zealand, Norway, Poland, Spain, Sweden, United Kingdom, 21 22 and the United States. 23 24 25 Participants : Elected and runner-up political candidates. 26 27 Main outcome measures : We assembled data on elected and runner-up candidates for 28 29 parliamentary or presidential elections using online sources. To account for the fact that 30 31 32 many candidates ran in multiple elections (as both winners and runners-up), we 33 34 considered only one election per candidate. Since the treatment of interest was whether a 35 36 37 candidate was elected to and served as a head of government, we classified our treatment 38 39 group as candidates who won an election and served, while candidates who ran but were 40 41 never elected were defined as runners-up. We measured the observed number of years 42 43 44 alive after each candidate’s last election, relative to what would be expected for an 45 46 average individual of the same age and sex in that region as the candidate during the year 47 48 of the election, based on historical French and British life tables. We compared observed 49 50 51 post-election life years between elected candidates and runners-up, adjusting for life 52 53 expectancy at the time of election. We also estimated a Cox proportional hazards model 54 55 which considered years until death (or years until end of the study period for those not yet 56 57 58 59 60 2 https://mc.manuscriptcentral.com/bmj Page 3 of 46 BMJ 1 2 3 deceased by September 9, 2015) for elected candidates versus runners-up. The model 4 5 6 adjusted for candidate’s life expectancy at the time of election. 7 8 Confidential:Results: In a sample of 382 candidates For who were Reviewdeceased by September Only 9, 2015, 9 10 11 candidates who served as a head of government lived 2.85 (95% CI 0.72-4.99) fewer 12 13 years after last election, relative to the candidates who never served. In the Cox 14 15 proportional hazards model, the mortality hazard for elected candidates relative to 16 17 18 runners-up was 1.27 (95% CI 1.03-1.56). 19 20 Conclusions: Election to head of government is associated with a substantial increase in 21 22 mortality risk compared to those candidates in national elections who never served. 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 46 1 2 3 What this paper adds? 4 5 6 What is already known on this subject? It has been suggested that the stress of political 7 8 Confidential:life may lead to accelerated aging and Forpremature moReviewrtality. However, existing Only studies on 9 10 11 the issue have focused on U.S. presidents alone and findings have been mixed. A 12 13 historical analysis of mortality among world leaders has not been conducted. 14 15 What this study adds . We assembled historical election data from 17 countries and 16 17 18 compared rates of premature mortality and observed life years between national leaders 19 20 and runner-up candidates under the assumption that the baseline risk of mortality between 21 22 elected and unelected candidates would be similar, because both groups would 23 24 25 presumably be of similar socioeconomic status and have similar access to health care. 26 27 Any observed differences in mortality between groups may therefore be plausibly 28 29 attributed to differences in mortality risk created by the political stress of leading a 30 31 32 nation. We found that being elected to and serving in public office was associated with a 33 34 substantive increase in mortality risk compared to runner-up candidates in these elections. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4 https://mc.manuscriptcentral.com/bmj Page 5 of 46 BMJ 1 2 3 The Corresponding Author has the right to grant on behalf of all authors and does grant 4 5 6 on behalf of all authors, an exclusive licence (or non exclusive for government 7 8 Confidential:employees) on a worldwide basis to theFor BMJ Publishi Reviewng Group Ltd to permit Only this article 9 10 11 (if accepted) to be published in BMJ editions and any other BMJPGL products and 12 13 sublicences such use and exploit all subsidiary rights, as set out in our licence. 14 15 All authors have completed the ICMJE uniform disclosure form at 16 17 18 www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) 19 20 and declare: ABJ had support from the Office of the Director, National Institutes of 21 22 Health (NIH Early Independence Award, Grant 1DP5OD017897-01) for the submitted 23 24 25 work; no financial relationships with any organisations that might have an interest in the 26 27 submitted work in the previous 3 years; no other relationships or activities that could 28 29 appear to have influenced the submitted work. 30 31 32 The research conducted was independent of any involvement from the sponsors of the 33 34 study. Study sponsors were not involved in study design, data interpretation, writing, or 35 36 37 the decision to submit the article for publication. 38 39 Transparency statement: Dr. Jena affirms that the manuscript is an honest, accurate, and 40 41 transparent account of the study being reported; that no important aspects of the study 42 43 44 have been omitted; and that any discrepancies are disclosed. 45 46 Authors contributions: All authors contributed to the design and conduct of the study, 47 48 data collection and management, analysis interpretation of the data; and preparation, 49 50 51 review, or approval of the manuscript. 52 53 Data sharing: no additional data available. 54 55 56 57 58 59 60 5 https://mc.manuscriptcentral.com/bmj BMJ Page 6 of 46 1 2 3 INTRODUCTION 4 5 6 Election to public office has been suggested to lead to premature aging due to 7 8 Confidential:stress of leadership and political life. InFor an examination Review of medical records Only of U.S. 9 10 11 presidents dating back to President Theodore Roosevelt – including information on 12 13 physical activity, diet, blood pressure, and lifestyle habits such as smoking – one analysis 14 15 suggested that U.S. presidents may age at twice the rate of the overall U.S. population. 1,2 16 17 18 A subsequent study which compared actual survival of U.S. presidents to average life 19 20 expectancy in the overall population at the time of each president’s election found no 21 22 difference in mortality between presidents and others. 3 However, although this finding 23 24 25 could support the view that nationally elected leaders do not die prematurely, it may just 26 27 as well suggest the opposite.