sign in sign up
<<
Home , Adam Hamilton, Alois Mock, Benedetto Cairoli, Bruno Pittermann, Carl Vaugoin, Charles Jonnart

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: 2162864923; 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: 6174328322; 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: 6174328322 39 Fax: 6174320173 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 runnerup candidates who never served. 12 13 Design: Observational study. 14 15 Setting: Historical survival data on elected and runnerup candidates in parliamentary or 16 17 18 presidential elections in Australia, , , , Finland, France, Germany, 19 20 , Ireland, , New Zealand, , Poland, Spain, Sweden, , 21 22 and the United States. 23 24 25 Participants : Elected and runnerup political candidates. 26 27 Main outcome measures : We assembled data on elected and runnerup 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 runnersup), 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 runnersup. 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 postelection life years between elected candidates and runnersup, 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 runnersup. 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 0.724.99) 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 runnersup was 1.27 (95% CI 1.031.56). 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 runnerup 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 runnerup 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 1DP5OD01789701) 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. Given their higher socioeconomic status, one would have 28 29 expected presidents to live longer than the general population based on known inverse 30 31 4 32 associations between social class and mortality. The fact that they do not live longer 33 34 may suggest accelerated mortality compared to others of similar socioeconomic status. 35 36 37 In other words, when the correct comparisons are made, one may find that the stress of 38 39 politics does kill. 40 41 We explored whether the stress of politics leads to accelerated mortality by 42 43 44 analyzing historical data on survival of nationally elected leaders from 17 countries. 45 46 Rather than compare survival of these leaders to the overall population, who may not be 47 48 comparable, we compared their survival to runnerup candidates who never served in 49 50 51 office, assuming that both types of candidates would be of similar socioeconomic status 52 53 and have similar access to health care (and therefore have similar baseline mortality risk) 54 55 but not face the same stress of being elected to and serving as head of government. 56 57 58 59 60 6 https://mc.manuscriptcentral.com/bmj Page 7 of 46 BMJ

1 2 3 METHODS 4 5 6 Data sources and overview of approach 7 8 Confidential:We assembled data on elected Forand runnerup Review candidates for national Only elections 9 10 11 occurring in Australia (prime minister (PM) elections, 1901 to 2013), Austria (chancellor, 12 13 19452013), Canada (PM, 1867 to 2011), Denmark (PM, 1903 to 2015), Finland 14 15 (president, 1919 to 2012), France (president, 1873 to 2012), Germany (chancellor, 1949 16 17 18 to 2013), Greece (PM, 19562009), Ireland (Taoiseach, 19222011), Italy (PM, 1861 to 19 20 2013), New Zealand (PM, 1855 to 2014), Norway (PM, 1885 to 2013), Poland (PM, 21 22 19222011), Spain (PM, 1876 to 2015), Sweden (PM, 1911 to 2014), United Kingdom 23 24 25 (PM, 1722 to 2015), and the United States (president, 1789 to 2012), using online 26 27 sources. Because candidates frequently ran in multiple elections – e.g., some candidates 28 29 lost several elections before finally winning one, while others won multiple elections – 30 31 32 this produced a duplication problem. For duplicate candidates, we selected the last year 33 34 he or she ran for office. Our final dataset was therefore at the candidatelevel. 35 36 37 Our basic approach was to compare observed life years from the time of last 38 39 election between elected leaders and runnersup who never served in office under the 40 41 assumption that both groups were of similar socioeconomic status and had similar access 42 43 44 to health care, two factors that could potentially confound estimated differences in 45 46 mortality if one simply compared the average observed number of years alive after 47 48 election among elected leaders versus life expectancy in the general population. Similar 49 50 51 approaches to ours have been used in prior studies which compare mortality among 52 53 winners and losers of specific events to identify the effect of winning that event on 54 55 mortality (e.g., comparison of mortality among actors winning versus losing an Academy 56 57 58 59 60 7 https://mc.manuscriptcentral.com/bmj BMJ Page 8 of 46

1 2 3 Award, or “Oscar”, conditional on nomination; baseball players inducted into the Hall of 4 5 79 6 Fame; and Nobel Prize winners). 7 8 Confidential:Importantly, in earlier years in Formany countries Review with parliamentary Only systems, the 9 10 11 head of government was not necessarily the majority party leader, but was instead 12 13 selected after the elections took place (e.g., Manuel Azaña in Spain). In other instances, 14 15 the head of government was appointed without any electoral experience (e.g., Neville 16 17 18 Chamberlain, in the UK, who rose to the premiership after his predecessor retired). To 19 20 address these issues, we focused our analysis on candidates who ran in a national election 21 22 and either (a) won election and served or (b) never won election and never served. In 23 24 25 countries with nominating processes, typically in a presidential format such as the United 26 27 States, identifying the candidates who “ran” was a straightforward exercise. However, in 28 29 parliamentary systems, it was often less clear who the “candidates” were – for these 30 31 32 countries, we focused on individuals who served as party leaders at the time of election. 33 34 We specifically compared mortality between the above two groups for two 35 36 37 reasons. First, it is possible that candidates who served in office but lost or never ran in 38 39 election may systematically differ in mortality risk from candidates who won election and 40 41 served. Because our goal was to compare mortality among candidates who were as 42 43 44 similar as possible in terms of mortality risk, but differed only in whether they won 45 46 election and therefore served in office, we restricted our analysis only to candidates who 47 48 ran in election, won, and served versus those who ran, happened to lose, and did not 49 50 51 serve.. This approach is consistent with prior studies which compare mortality among 52 53 winners and losers of specific events to identify the effect of winning that event on 54 55 mortality.79 Second, in very few countries today is the head of government not originally 56 57 58 59 60 8 https://mc.manuscriptcentral.com/bmj Page 9 of 46 BMJ

1 2 3 a party leader in some form. Hence, excluding candidates who were not elected to office 4 5 6 in the now conventional form allowed us to more appropriately generalize our findings to 7 8 Confidential:today’s candidates. For Review Only 9 10 11 For both elected leaders and runnerup candidates, we identified age at time of 12 13 last election and age at death, the difference of which was the observed number of years a 14 15 candidate lived from the time the election was held. Observed years alive postelection 16 17 18 was censored for those candidates still alive by September 9, 2015. Because elected 19 20 leaders and runnerup candidates may differ in age at last election, observed remaining 21 22 life years may be impacted by agerelated mortality differences alone. We therefore 23 24 25 accounted for overall differences in life expectancy for someone of the same age and sex 26 27 as the candidate in the general population. Based on a prior study, 3 life expectancies for 28 29 European candidates were obtained from life tables of English civilian males and females 30 31 32 (conditional on age and sex) for elections occurring post1841 and from life tables of 33 34 French civilian males and females prior to 1841.5,6 The 17 countries that we analyzed 35 36 37 were chosen because of their similarity to France and the UK, for which reliable life 38 th 39 tables exist dating back to the 19 century. 40 41 Analysis 42 43 44 We performed two candidatelevel statistical analyses. First, we estimated a 45 46 multivariable linear regression of observed years alive after last election as a function of a 47 48 candidate’s life expectancy and whether he or she served as a head of government. Our 49 50 51 sample consisted of 382 unique candidates who were deceased as of September 9, 2015 52 53 and who either ran for office and lost, or ran for office and served. 54 55 56 57 58 59 60 9 https://mc.manuscriptcentral.com/bmj BMJ Page 10 of 46

1 2 3 Second, we plotted KaplanMeier survival curves for elected leaders and runner 4 5 6 up candidates from year of last election until death. We then estimated a Cox 7 8 Confidential:proportional hazards model which estimated For the mortReviewality hazard associated Only with being 9 10 11 elected leader. The model measured the time from last election until death (or end of the 12 13 study period, whichever came first) for all candidates, adjusting for life expectancy at 14 15 time of last election. Unlike the first multivariable analysis which included 382 deceased 16 17 18 candidates, the hazard model could include an additional 162 candidates who were still 19 20 alive as of September 9, 2015 (544 candidates in total; Table 1 shows distribution by 21 22 country). 23 24 25 All data were publicly available and the study was exempt from human subjects 26 27 review at Harvard Medical School. The 95% confidence interval around reported 28 29 estimates reflects 0.025 in each tail or P≤0.05. 30 31 32 RESULTS 33 34 The earliest candidates in our sample stretched back to the 1722 UK 35 36 37 parliamentary election (Table 2 contains 45 UK candidates; full set of candidates 38 39 available in online supplement eTable 1 ). In that election, the losing candidate, Sir 40 41 William Wyndham was 34 and lived an additional 18 years, which was less than the 42 43 44 expected 31 years of remaining life for an average 34yearold male in 1722 (i.e., the 45 46 candidate died prematurely). He did not run again, and so 1722 was the election we used 47 48 for him. The elected candidate, Robert Walpole, ran several more times, with his last 49 50 51 appearance in 1741 (and so that is the election selected for him). He lived only three 52 53 years longer, less than the expected 11 years for a 65yearold in 1741. 54 55 56 57 58 59 60 10 https://mc.manuscriptcentral.com/bmj Page 11 of 46 BMJ

1 2 3 Elected leaders lived approximately 4.42 years (95% CI 2.176.67) less than 4 5 6 runnersup without adjustment for life expectancy at time of last election. However, 7 8 Confidential:elected leaders were also on average 2.8For years olde Reviewr in the year of their lastOnly election 9 10 11 compared to runnersup (58.8 vs. 56.0). After adjustment for life expectancy, elected 12 13 leaders lived approximately 2.85 years (95% CI 0.72 to 4.98) less than runnersup. 14 15 KaplanMeier survival curves demonstrated statistically significantly higher 16 17 18 mortality among elected leaders compared to runnersup ( Figure 1 ). In the Cox 19 20 proportional hazards model, which adjusted for a candidate’s life expectancy at the time 21 22 of last election, we estimated a mortality hazard of 1.26 (95% CI 1.031.56) for elected 23 24 25 leaders versus runnersup, when restricting our analysis only to candidates deceased as of 26 27 September 9, 2015. In a model that included candidates currently alive as censored 28 29 observations, we estimated a similar hazard ratio of 1.23 (95% CI 1.01 to 1.53). 30 31 32 DISCUSSION 33 34 It has been suggested that the stress of political life may lead to accelerated aging 35 36 37 and premature mortality. We assembled historical election data from 17 countries and 38 39 compared rates of mortality between those elected to head of government and runnersup 40 41 who never served, under the assumption that baseline mortality risk of elected leaders and 42 43 44 runnerup candidates, adjusted for differences in life expectancy due to differing age, 45 46 would otherwise be similar except for differential exposure to serving as head of 47 48 government. Any observed differences in mortality between groups may therefore be 49 50 51 plausibly attributed to differences in mortality risk created by the political stress of 52 53 leading a nation. Analyzing data spanning more than two centuries, we found that being 54 55 56 57 58 59 60 11 https://mc.manuscriptcentral.com/bmj BMJ Page 12 of 46

1 2 3 elected to head of government was associated with a substantive increase in mortality 4 5 6 compared to runnersup. 7 8 Confidential: Our study contributes to prior analysesFor of mortaliReviewty among U.S. presidentsOnly and 9 10 3,8 11 vice presidents and may help explain why prior findings have been mixed. One study 12 13 of U.S. presidents found no difference in survival after election compared to males of the 14 15 same age in the general population. 3 One might expect, however, that presidents (or 16 17 18 those in the same socioeconomic strata) would have substantially lower mortality than the 19 20 general population; a failure to detect a difference in mortality could therefore be 21 22 evidence that presidency is associated with higherthanexpected mortality. It is also 23 24 25 likely that analysis of a single country’s elections may be underpowered. Another study 26 27 that compared mortality among U.S. presidents and vice presidents versus presidential 28 29 and vice presidential candidates found that election to office was associated with earlier 30 31 8 32 death among both presidents and vice presidents. This study did not account for 33 34 differences in age at election between elected and runnerup candidates, which may 35 36 37 confound analysis if elected candidates were on average older than runnerup candidates 38 39 and had lower remaining life expectancy, as we found to be true. Moreover, the study 40 41 was limited to an analysis of U.S. elections alone. 42 43 44 Our study had several limitations. First, although our study included data from 17 45 46 countries, our results may not generalize to other countries. The majority of the countries 47 48 that we analyzed were chosen on the basis of having similar historical population survival 49 50 51 as Britain and France, two countries for which reliable lifetables were available as far 52 53 back as the 18 th century (e.g., France). Second, we were unable to analyze whether 54 55 higher mortality among those elected to office was true in individual countries. In both 56 57 58 59 60 12 https://mc.manuscriptcentral.com/bmj Page 13 of 46 BMJ

1 2 3 politics and statistics, power is critical. In posthoc power calculations, the statistical 4 5 6 power to detect an absolute difference of 2.85 postelection life years (our estimated 7 8 Confidential:difference in between elected and runnerup For candida Reviewtes) in a singlecountry Only comparison 9 10 11 of 34 elected and 19 runnerup candidates (the sample for the United Kingdom) was only 12 13 14%. Third, we compared premature mortality among elected leaders and runnersup 14 15 under the assumption that both groups would differ only in whether a candidate served in 16 17 18 office, rather than differences in baseline mortality risk. However, it is possible that both 19 20 groups, who by definition are heavily involved in political life, may experience 21 22 accelerated mortality relative to individuals in similar socioeconomic strata who are not 23 24 25 involved in politics. Our approach may therefore bias our estimates towards the null. 26 27 Mortality among elected leaders may be more suitably compared to others of similar 28 29 socioeconomic status not involved in politics. Similarly, in some countries, candidates 30 31 32 from different parties may reflect different socioeconomic strata (for instance, the UK 33 34 historically featured leaders who began as farmers and miners, in stark 35 36 37 contrast to the classically aristocratic ) and therefore not have similar baseline 38 39 mortality risk. 40 41 In summary, we found that candidates elected to head of government had 42 43 44 substantially accelerated mortality compared to runnersup. Our findings suggest that the 45 46 stress of politics could lead to earlier mortality. 47 48 49 50 51 52 53 54 55 56 57 58 59 60 13 https://mc.manuscriptcentral.com/bmj BMJ Page 14 of 46

1 2 3 REFERENCES 4 5 6 1. Park M. Advice to Obama on battling presidential aging. CNN 2009; 7 http://www.cnn.com/2009/HEALTH/01/06/presidential.health.aging/index.html?_ 8 Confidential:s=PM:HEALTH . Accessed August For 4, 2015. Review Only 9 2. Hanna J. Do presidents age faster in office? CNN 2011; 10 11 http://www.cnn.com/2009/HEALTH/01/06/presidential.health.aging/index.html?_ 12 s=PM:HEALTH . Accessed August 4, 2015. 13 3. Olshansky SJ. Aging of US presidents. Jama. Dec 7 2011;306(21):23282329. 14 4. Marmot MG, Smith GD, Stansfeld S, et al. Health inequalities among British civil 15 servants: the Whitehall II study. Lancet. Jun 8 1991;337(8754):13871393. 16 5. The Human Mortality Database. U.K., England, and Wales Civilian Population. 17 18 2015; http://www.mortality.org/cgi 19 bin/hmd/country.php?cntr=GBRCENW&level=1 . Accessed June 6, 2015. 20 6. The Human Mortality Database. France, Civilian population. 2015; 21 http://www.mortality.org/cgibin/hmd/country.php?cntr=FRACNP&level=1 . 22 Accessed June 6, 2015. 23 24 7. Redelmeier DA, Singh SM. Survival in Academy Awardwinning actors and 25 actresses. Annals of internal medicine. May 15 2001;134(10):955962. 26 8. Link BG, Carpiano RM, Weden MM. Can Honorific Awards Give Us Clues 27 about the Connection between Socioeconomic Status and Mortality? American 28 Sociological Review. February 20, 2013 2013. 29 9. Rablen MD, Oswald AJ. Mortality and immortality: the Nobel Prize as an 30 31 experiment into the effect of status upon longevity. J Health Econ. Dec 32 2008;27(6):14621471. 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 14 https://mc.manuscriptcentral.com/bmj Page 15 of 46 BMJ

1 2 3 TABLE 1— Study population 4 5 6 Runners-up 7 Elected who did not Country leaders serve in office Total 8 Confidential: For Review Only 9 Australia 21 9 30 10 Austria 24 32 56 11 Canada 16 12 28 12 13 Denmark 15 9 24 14 Finland 6 8 14 15 France 22 17 39 16 17 Germany 7 10 17 18 Greece 8 3 11 19 Ireland 14 6 20 20 21 Italy 18 20 38 22 New Zealand 22 10 32 23 Norway 9 16 25 24 25 Poland 7 14 21 26 Spain 14 33 47 27 Sweden 8 9 17 28 29 UK 34 19 53 30 USA 38 34 72 31 Total 283 261 544 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 15 https://mc.manuscriptcentral.com/bmj BMJ Page 16 of 46 TABLE 2—Lifespans among elected leaders and runnerup candidates in UK prime minister elections, 17222015

1 2 Expected / 3 Observed Years 4 Age at Age at Served Alive after last Country Candidate Last Election Election Death in office election 5 6 Sir William Wyndham, 3rd 7 UK Baronet 1722 34 52 No 31 / 18 8 Confidential:Henry St John, 1st Viscount For Review Only 9 UK Bolingbroke 1734 56 73 No 16 / 17 10 11 UK William Pulteney 1741 57 80 No 16 / 23 12 13 UK Robert Walpole 1741 65 68 Yes 11 / 3 14 15 UK Henry Pelham 1747 53 59 Yes 18 / 6 16 Thomas Pelham-Holles, 1st Duke 17 of Newcastle upon Tyne and 1st 18 UK Duke of Newcastle-under-Lyne 1761 68 75 Yes 10 / 7 19 Augustus Henry FitzRoy, 3rd 20 UK Duke of Grafton 1768 33 75 Yes 32 / 42 21 22 23 UK Marquess of Rockingham 1780 50 52 No 20 / 2 24 25 UK Lord Frederick North 1780 48 60 Yes 21 / 12 26 27 UK William Pitt 'The Younger' 1796 37 46 Yes 29 / 9 28 29 UK Charles James Fox 1802 53 57 No 18 / 4 30 31 UK Henry Addington 1802 45 86 Yes 23 / 41 32 William Bentinck Duke of 33 UK Portland 1807 69 71 Yes 9 / 2 34 35 Robert Banks Jenkinson Earl of UK Liverpool 1826 56 58 Yes 16 / 2 36 37 38 UK Marquess of Lansdowne 1830 50 82 No 20 / 32 39 40 UK Charles Grey, 2nd Earl Grey 1832 68 81 Yes 9 / 13 41 42 UK Robert Peel 1841 46 62 Yes 23 / 16 43 44 UK John Russell 1847 55 85 Yes 16 / 30 45 Henry John Temple, 3rd Viscount 46 UK Palmerston 1865 80 80 Yes 5 / 0 47 Archibald Philip Primrose, 5th 48 Earl of Rosebery, 1st Earl of 49 UK Midlothian 1895 48 82 No 21 / 34 50 51 UK Robert Cecil 1900 70 73 Yes 8 / 3 52 53 54 UK Sir Henry Campbell-Bannerman 1906 70 71 Yes 9 / 1 55 Arthur James Balfour, 1st Earl of 56 UK Balfour 1910 62 81 No 13 / 19 57 58 UK Herbert Asquith 1910 58 75 Yes 16 / 17 59 60 16 https://mc.manuscriptcentral.com/bmj Page 17 of 46 BMJ UK John Robert Clynes 1922 53 80 No 19 / 27

1 UK Andrew Bonar Law 1922 64 65 Yes 12 / 1 2 3 4 UK James Ramsay MacDonald 1929 63 71 Yes 12 / 8 5 6 UK Arthur Henderson 1931 68 72 No 10 / 4 7 8 UK Confidential: Stanley Baldwin For 1935 Review 68 80 Yes Only 10 / 12 9 Sir Winston Leonard Spencer- 10 UK Churchill 1951 77 90 Yes 6 / 13 11 12 UK Anthony Eden 1955 58 79 Yes 17 / 21 13 14 UK Hugh Todd Naylor Gaitskell 1959 53 56 No 21 / 3 15 16 17 UK Harold Macmillan 1959 65 92 Yes 13 / 27 18 Alexander Frederick Douglas- 19 UK Home, Baron Home of the Hirsel 1964 61 92 No 15 / 31 20 Sir Edward Richard George "Ted" 21 UK Heath 1970 54 89 Yes 20 / 35 22 23 UK Leonard 1979 67 92 No 12 / 25 24 25 UK Michael Mackintosh Foot 1983 70 96 No 11 / 26 26 27 UK 1987 62 87 Yes 16 / 25 28 29 30 UK Neil Gordon Kinnock 1992 50 - No 27 / 23 31 32 UK William Jefferson Hague 2001 40 - No 38 / 14 33 Michael Howard, Baron Howard 34 UK of Lympne 2005 64 - No 18 / 10 35 36 UK 2005 52 - Yes 28 / 10 37 38 UK James Gordon Brown 2010 59 - No 23 / 5 39 40 UK Edward Samuel "Ed" Miliband 2015 46 - No 35 / 0 41 42 43 UK David Cameron 2015 49 - Yes 33 / 0 44 45Notes : Expected years of life following national election were based on an average individual of the same age and sex as the candidate, taken 46from historical lifetables described in the Methods. Premature death was defined by whether a candidate lived strictly less than what would be 47expected for an average individual in the population of the same age and sex as the candidate (i.e., observed < expected life expectancy). Note 48that living candidates who exceeded their demographicallydetermined life expectancy were identified as nonpremature deaths. Periods reflect 49candidates who were elected after 2013, the last year in the life tables. Dashes indicate a stillliving candidate. 50 51 52 53 54 55 56 57 58 59 60 17 https://mc.manuscriptcentral.com/bmj BMJ Page 18 of 46 FIGURE 1—KaplanMeier survival curves for those elected to head of government and runnersup

1 2 3 4 5 6 7 8 Confidential: For Review Only 9 10 11 12 13 14 15 16 17 18 19 20 21 22 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 18 https://mc.manuscriptcentral.com/bmj Page 19eTABLE of 46 1— Lifespans among elected leaders and runnerupBMJ candidates, from national elections of 17 countries

Expected / 1 Age Served Observed Years 2 Last Age at at in Alive after last 3 Country Candidate Election Election Death office election 4 5 Australia Edmund Barton 1901 52 70 Yes 19 / 18 6 7 8 Confidential:Australia George Reid 1906 For 61 Review 73 Yes 13 / Only12 9 10 Australia Alfred Deakin 1910 54 63 Yes 18 / 9 11 12 Australia Andrew Fisher 1914 52 66 Yes 19 / 14 13 14 Australia Joseph Cook 1914 54 86 Yes 18 / 32 15 16 Australia Frank Tudor 1919 53 55 No 19 / 2 17 18 Australia Stanley Bruce 1929 46 84 Yes 24 / 38 19 20 21 Australia James Scullin 1934 58 76 Yes 17 / 18 22 23 Australia Joseph Lyons 1937 58 59 Yes 16 / 1 24 25 Australia John Curtin 1943 58 60 Yes 17 / 2 26 27 Australia Ben Chifley 1951 65 65 Yes 12 / 0 28 29 Australia H. V. Evatt 1958 64 71 No 13 / 7 30 31 Australia Robert Menzies 1963 69 83 Yes 10 / 14 32 33 34 Australia Arthur Calwell 1966 70 76 No 10 / 6 35 36 Australia Harold Holt 1966 58 59 Yes 17 / 1 37 38 Australia John Gorton 1969 58 90 Yes 17 / 32 39 40 Australia Billy Snedden 1974 48 60 No 26 / 12 41 42 Australia Gough Whitlam 1977 61 98 Yes 16 / 37 43 44 Australia Bill Hayden 1980 47 - No 27 / 35 45 46 47 Australia Malcolm Fraser 1983 53 84 Yes 22 / 31 48 49 Australia Andrew Peacock 1990 51 - No 26 / 25 50 51 Australia Bob Hawke 1990 61 - Yes 17 / 25 52 53 Australia John Hewson 1993 47 - No 29 / 22 54 55 Australia Paul Keating 1996 52 - Yes 26 / 19 56 57 Australia Kim Beazley 2001 53 - No 26 / 14 58 59 60 Australia Mark Latham 2004 43 - No 36 / 11 19 https://mc.manuscriptcentral.com/bmj BMJ Page 20 of 46 Australia John Howard 2007 68 - Yes 16 / 8

1 Australia Julia Gillard 2010 49 - Yes 32 / 5 2 3 4 Australia Kevin Rudd 2013 56 - Yes 26 / 2 5 6 Australia Tony Abbott 2013 56 - Yes 26 / 2 7 8 Confidential:Austria 1919 For 66 Review 76 No 11 / Only10 9 10 Austria 1920 54 57 No 19 / 3 11 12 Austria 1920 40 77 No 30 / 37 13 14 Austria 1920 56 58 Yes 18 / 2 15 16 17 Austria Johann Schober 1921 47 58 Yes 24 / 11 18 19 Austria 1922 46 81 No 25 / 35 20 21 Austria 1922 46 56 Yes 25 / 10 22 23 Austria 1922 51 73 Yes 21 / 22 24 25 Austria Leopold Waber 1924 49 70 No 23 / 21 26 27 Austria Rudolf Ramek 1924 43 60 Yes 27 / 17 28 29 30 Austria Franz Dinghofer 1926 53 83 No 20 / 30 31 32 Austria Karl Hartleb 1927 41 79 No 29 / 38 33 34 Austria Vinzenz Schumy 1929 51 84 No 20 / 33 35 36 Austria Ernst Streeruwitz 1929 55 78 Yes 18 / 23 37 38 Austria 1930 45 69 No 26 / 24 39 40 Austria 1930 57 76 Yes 17 / 19 41 42 43 Austria 1930 55 85 Yes 19 / 30 44 45 Austria 1931 53 58 Yes 20 / 5 46 47 Austria Franz Winkler 1932 42 55 No 29 / 13 48 49 Austria Engelbert Dollfuss 1932 40 42 Yes 30 / 2 50 51 Austria 1933 47 52 No 24 / 5 52 53 Austria Ernst Rüdiger Starhemberg 1934 35 57 No 35 / 22 54 55 56 Austria 1934 37 80 Yes 33 / 43 57 58 Austria Eduard Baar-Baarenfels 1936 51 82 No 21 / 31 59 60 20 https://mc.manuscriptcentral.com/bmj Page 21 of 46 BMJ Austria Ludwig Hülgerth 1936 61 64 No 14 / 3

1 Austria Edmund Glaise-Horstenau 1938 56 64 No 18 / 8 2 3 4 Austria Arthur Seyss-Inquart 1938 46 54 Yes 26 / 8 5 6 Austria Adolf Schärf 1945 55 75 No 19 / 20 7 8 Confidential:Austria 1945 For 75 Review 80 Yes 8 / 5Only 9 10 Austria 1945 43 63 Yes 29 / 20 11 12 Austria 1953 62 73 Yes 14 / 11 13 14 Austria 1957 52 78 No 21 / 26 15 16 17 Austria 1961 63 74 Yes 14 / 11 18 19 Austria 1964 54 91 Yes 20 / 37 20 21 Austria 1966 55 82 No 19 / 27 22 23 Austria Hermann Withalm 1968 56 91 No 19 / 35 24 25 Austria Rudolf Häuser 1970 61 91 No 15 / 30 26 27 Austria 1970 59 79 Yes 17 / 20 28 29 30 Austria 1976 38 - No 35 / 39 31 32 Austria 1983 39 - No 35 / 32 33 34 Austria 1983 54 79 Yes 22 / 25 35 36 Austria 1986 49 - Yes 26 / 29 37 38 Austria 1987 53 - No 23 / 28 39 40 Austria Josef Riegler 1989 51 - No 25 / 26 41 42 43 Austria 1991 50 - No 27 / 24 44 45 Austria 1997 50 - Yes 28 / 18 46 47 Austria -Passer 2000 39 - No 39 / 15 48 49 Austria Wolfgang Schüssel 2000 55 - Yes 24 / 15 50 51 Austria 2003 47 - No 32 / 12 52 53 Austria 2003 56 - No 24 / 12 54 55 56 Austria 2007 52 - No 29 / 8 57 58 Austria 2007 47 - Yes 33 / 8 59 60 21 https://mc.manuscriptcentral.com/bmj BMJ Page 22 of 46 Austria Josef Pröll 2008 40 - No 40 / 7

1 Austria 2008 48 - Yes 32 / 7 2 3 4 Austria 2011 52 - No 30 / 4 5 6 Austria 2014 59 - No 24 / 1 7 8 Confidential:Canada George Brown 1867 For 49 Review 61 No 20 / Only12 9 10 Canada Alexander Mackenzie 1878 56 70 Yes 16 / 14 11 12 Canada 1887 54 78 No 17 / 24 13 14 Canada John A. Macdonald 1891 76 76 Yes 6 / 0 15 16 17 Canada 1917 76 77 Yes 6 / 1 18 19 Canada 1917 63 82 Yes 12 / 19 20 21 Canada 1921 45 98 No 26 / 53 22 23 Canada 1926 52 86 Yes 21 / 34 24 25 Canada R.B. Bennett 1935 65 76 Yes 12 / 11 26 27 Canada 1940 59 61 No 15 / 2 28 29 30 Canada 1945 62 85 No 15 / 23 31 32 Canada W.L. Mackenzie King 1945 71 75 Yes 10 / 4 33 34 Canada George A. Drew 1953 59 78 No 16 / 19 35 36 Canada Louis St. Laurent 1957 75 91 Yes 8 / 16 37 38 Canada 1965 70 83 Yes 10 / 13 39 40 Canada Lester B. Pearson 1965 68 75 Yes 11 / 7 41 42 43 Canada Robert 1974 60 89 No 16 / 29 44 45 Canada 1980 39 - Yes 35 / 35 46 47 Canada 1980 61 80 Yes 16 / 19 48 49 Canada 1988 49 - Yes 27 / 27 50 51 Canada 1993 55 - No 22 / 22 52 53 Canada 1997 55 - No 23 / 18 54 55 56 Canada 2000 50 - No 29 / 15 57 58 Canada Jean Chretien 2000 66 - Yes 16 / 15 59 60 22 https://mc.manuscriptcentral.com/bmj Page 23 of 46 BMJ Canada 2006 68 - Yes 16 / 9

1 Canada Stephane Dion 2008 53 - No 28 / 7 2 3 4 Canada 2011 61 61 No 22 / 0 5 6 Canada 2011 52 - Yes 30 / 4 7 8 Confidential:Denmark 1903 For 58 Review 73 Yes 15 / Only15 9 10 Denmark Jens Christian Christensen 1906 50 74 Yes 20 / 24 11 12 Denmark Peter Christian Knudsen 1909 61 62 No 13 / 1 13 14 Denmark Ludvig Holstein-Ledreborg 1909 70 73 Yes 9 / 3 15 16 17 Denmark 1918 74 83 Yes 7 / 9 18 19 Denmark 1924 70 82 Yes 9 / 12 20 21 Denmark 1939 66 69 Yes 11 / 3 22 23 Denmark John Christmas Møller 1943 49 54 No 24 / 5 24 25 Denmark 1953 50 52 Yes 23 / 2 26 27 Denmark H. C. Hansen 1957 51 54 Yes 22 / 3 28 29 30 Denmark 1960 50 66 Yes 23 / 16 31 32 Denmark Poul Sørensen 1968 64 65 No 13 / 1 33 34 Denmark Erik Ninn-Hansen 1971 49 92 No 25 / 43 35 36 Denmark 1971 57 64 Yes 18 / 7 37 38 Denmark Mogens Glistrup 1977 51 82 No 23 / 31 39 40 Denmark Henning Christophersen 1979 40 - No 33 / 36 41 42 43 Denmark Anker Jørgensen 1987 65 - Yes 14 / 28 44 45 Denmark Uffe Ellemann-Jensen 1998 57 - No 22 / 17 46 47 Denmark 2001 58 - Yes 22 / 14 48 49 Denmark 2005 59 - No 22 / 10 50 51 Denmark 2007 54 - Yes 27 / 8 52 53 Denmark Lars Løkke Rasmussen 2011 47 - Yes 34 / 4 54 55 56 Denmark Kristian Thulesen Dahl 2015 46 - No 35 / 0 57 58 Denmark Helle Thorning-Schmidt 2015 49 - Yes 33 / 0 59 60 23 https://mc.manuscriptcentral.com/bmj Carl Gustaf Emil BMJ Page 24 of 46 Finland Mannerheim 1919 52 84 No 20 / 32

1 Finland Kyösti Kallio 1937 64 67 Yes 12 / 3 2 3 4 Finland Pehr Evind Svinhufvud 1937 76 83 Yes 6 / 7 5 6 Finland Johan Helo 1940 51 77 No 20 / 26 7 8 Confidential:Finland Risto Ryti 1940 For 51 Review 67 Yes 20 / Only16 9 10 Finland Juho Kusti Paasikivi 1950 80 86 Yes 6 / 6 11 12 Finland Paavo Aitio 1962 44 71 No 28 / 27 13 14 Finland Matti Virkkunen 1968 60 72 No 16 / 12 15 16 17 Finland Raino Westerholm 1978 59 - No 17 / 37 18 19 Finland Urho Kekkonen 1978 78 86 Yes 7 / 8 20 21 Finland Paavo Väyrynen 1988 42 - No 33 / 27 22 23 Finland Mauno Koivisto 1988 65 - Yes 14 / 27 24 25 Finland Elisabeth Rehn 1994 59 - No 20 / 21 26 27 Finland Pekka Haavisto 2012 54 - No 28 / 3 28 29 30 France Patrice de Mac-Mahon 1873 64 85 Yes 11 / 21 31 32 France Antoine Chanzy 1879 56 59 No 15 / 3 33 34 France Jules Grevy 1879 71 84 Yes 8 / 13 35 36 France Felix-Gustave Saussier 1887 59 77 No 14 / 18 37 38 France Sadi Carnot 1887 50 56 Yes 19 / 6 39 40 France Jean Casimir-Perier 1894 46 59 Yes 23 / 13 41 42 43 France Henri Brisson 1895 60 76 No 13 / 16 44 45 France Felix Faure 1895 53 58 Yes 17 / 5 46 47 France Felix Jules Meline 1899 61 87 No 13 / 26 48 49 France Emile Loubet 1899 60 90 Yes 13 / 30 50 51 France Armand Fallieres 1906 64 89 Yes 12 / 25 52 53 France Jules Pams 1913 61 78 No 14 / 17 54 55 56 France Raymond Poincare 1913 52 74 Yes 19 / 22 57 58 France Gustave Delory 1920 63 68 No 13 / 5 59 60 24 https://mc.manuscriptcentral.com/bmj Page 25 of 46 BMJ France Charles Jonnart 1920 63 70 No 13 / 7

1 France 1920 65 67 Yes 12 / 2 2 3 4 France 1920 61 84 Yes 15 / 23 5 6 France Paul Painleve 1924 61 69 No 14 / 8 7 8 Confidential:France 1924 For 60 Review 73 Yes 15 / Only13 9 10 France Pierre Marraud 1931 70 97 No 9 / 27 11 12 France Paul Doumer 1931 74 75 Yes 7 / 1 13 14 France Paul Faure 1932 54 82 No 19 / 28 15 16 17 France 1932 60 78 Yes 15 / 18 18 Auguste Champetier de 19 France Ribes 1947 65 65 No 12 / 0 20 21 France Vincent Auriol 1947 62 81 Yes 14 / 19 22 23 France Marcel-Edmond Naegelen 1954 62 86 No 14 / 24 24 25 France Rene Coty 1954 71 80 Yes 9 / 9 26 27 France Georges Marrane 1959 71 88 No 9 / 17 28 29 30 France Charles de Gaulle 1959 68 79 Yes 11 / 11 31 32 France Alain Poher 1969 60 87 No 16 / 27 33 34 France Georges Pompidou 1969 57 62 Yes 18 / 5 35 36 France Valery Giscard d'Estaing 1981 55 - Yes 21 / 34 37 38 France Francois Mitterrand 1988 64 79 Yes 15 / 15 39 40 France Lionel Jospin 1995 58 - No 20 / 20 41 42 43 France Jean-Marie Le Pen 2002 74 - No 11 / 13 44 45 France 2002 70 - Yes 13 / 13 46 47 France Segolene Royal 2007 54 - No 27 / 8 48 49 France Francois Hollande 2012 57 - Yes 26 / 3 50 51 France 2012 57 - Yes 26 / 3 52 53 Germany Kurt Schumacher 1949 54 56 No 20 / 2 54 55 56 Germany Erich Ollenhauer 1957 56 62 No 18 / 6 57 58 Germany 1961 85 91 Yes 4 / 6 59 60 25 https://mc.manuscriptcentral.com/bmj BMJ Page 26 of 46 Germany Ludwig Erhard 1965 68 80 Yes 11 / 12

1 Germany Kurt Georg Kiesinger 1969 65 84 Yes 12 / 19 2 3 4 Germany Rainer Barzel 1972 48 82 No 25 / 34 5 6 Germany 1972 59 79 Yes 17 / 20 7 8 Confidential:Germany Hans-Jochen Vogel 1983 For 57 Review - No 19 / Only32 9 10 Germany Johannes Rau 1987 56 75 No 21 / 19 11 12 Germany Oskar Lafontaine 1990 47 - No 29 / 25 13 14 Germany Rudolf Scharping 1994 47 - No 30 / 21 15 16 17 Germany 1998 68 - Yes 14 / 17 18 19 Germany Edmund Stoiber 2002 61 - No 20 / 13 20 21 Germany Gerhard Schröder 2005 61 - Yes 21 / 10 22 23 Germany Frank-Walter Steinmeier 2009 53 - No 28 / 6 24 25 Germany Peer Steinbrück 2013 66 - No 18 / 2 26 27 Germany 2013 59 - Yes 24 / 2 28 29 30 Greece Ioannis Passalidis 1958 72 82 No 9 / 10 31 32 Greece 1964 76 80 Yes 8 / 4 33 34 Greece Georgios Mavros 1974 65 86 No 13 / 21 35 36 Greece 1977 70 91 Yes 10 / 21 37 38 Greece 1981 63 88 Yes 15 / 25 39 40 Greece 1993 74 77 Yes 10 / 3 41 42 43 Greece Constantine Mitsotakis 1993 75 - Yes 9 / 22 44 45 Greece Miltiadis Evert 1996 57 72 No 22 / 15 46 47 Greece 2000 64 - Yes 17 / 15 48 49 Greece 2009 57 - Yes 25 / 6 50 51 Greece 2009 53 - Yes 28 / 6 52 53 Ireland Thomas Johnson 1922 50 91 Yes 21 / 41 54 55 56 Ireland W. T. Cosgrave 1932 52 85 Yes 21 / 33 57 58 Ireland Thomas F. O'Higgins 1944 54 63 No 20 / 9 59 60 26 https://mc.manuscriptcentral.com/bmj Page 27 of 46 BMJ Ireland Richard Mulcahy 1944 58 85 No 17 / 27

1 Ireland John A. Costello 1957 66 85 Yes 12 / 19 2 3 4 Ireland Éamon de Valera 1957 75 93 Yes 8 / 18 5 6 Ireland James Dillon 1959 57 84 No 18 / 27 7 8 Confidential:Ireland Seán Lemass 1959 For 60 Review 72 Yes 16 / Only12 9 10 Ireland 1973 53 - Yes 21 / 42 11 12 Ireland 1977 60 82 Yes 16 / 22 13 14 Ireland Garret FitzGerald 1982 56 85 Yes 20 / 29 15 16 17 Ireland Alan Dukes 1987 42 - No 33 / 28 18 19 Ireland 1987 62 81 Yes 16 / 19 20 21 Ireland Albert Reynolds 1992 60 82 Yes 19 / 22 22 23 Ireland 1997 50 - Yes 28 / 18 24 25 Ireland 1997 46 - Yes 32 / 18 26 27 Ireland Michael Noonan 2001 58 - No 22 / 14 28 29 30 Ireland Brian Cowen 2008 48 - Yes 32 / 7 31 32 Ireland Micheál Martin 2011 51 - No 31 / 4 33 34 Ireland Enda Kenny 2011 60 - Yes 23 / 4 35 Camillo Benso, Count of 36 Italy Cavour 1861 50 50 Yes 20 / 0 37 Alfonso Ferrero La 38 Italy Marmora 1865 61 73 Yes 13 / 12 39 40 Italy 1870 62 64 Yes 13 / 2 41 42 43 Italy 1870 60 72 Yes 14 / 12 44 45 Italy 1880 55 64 Yes 17 / 9 46 47 Italy Agostino Bertani 1882 70 74 No 9 / 4 48 49 Italy 1882 64 68 Yes 12 / 4 50 51 Italy 1886 73 74 Yes 7 / 1 52 53 Italy Andrea Costa 1892 41 59 No 25 / 18 54 55 56 Italy 1895 77 82 Yes 6 / 5 57 58 Italy Felice Cavallotti 1897 55 56 No 17 / 1 59 60 27 https://mc.manuscriptcentral.com/bmj BMJ Page 28 of 46 Italy Ettore Sacchi 1913 62 73 No 13 / 11

1 Italy Luigi Sturzo 1921 50 87 No 22 / 37 2 3 4 Italy 1921 79 86 Yes 6 / 7 5 6 Italy 1924 41 61 Yes 29 / 20 7 8 Confidential:Italy Ivan Matteo Lombardo 1948 For 46 Review 78 No 27 / Only32 9 10 Italy 1953 72 73 Yes 9 / 1 11 12 Italy 1958 50 91 Yes 23 / 41 13 14 Italy 1963 72 89 No 9 / 17 15 16 17 Italy Palmiro Togliatti 1963 70 71 No 10 / 1 18 19 Italy 1963 47 61 Yes 26 / 14 20 21 Italy Luigi Longo 1968 68 80 No 11 / 12 22 23 Italy 1968 53 74 Yes 21 / 21 24 25 Italy Francesco De Martino 1976 69 95 No 11 / 26 26 27 Italy Enrico Berlinguer 1983 61 62 No 16 / 1 28 29 30 Italy Alessandro Natta 1987 69 83 No 12 / 14 31 32 Italy 1987 59 - Yes 18 / 28 33 34 Italy 1992 67 - Yes 14 / 23 35 36 Italy Achille Occhetto 1994 58 - No 20 / 21 37 38 Italy Mario Segni 1994 55 - No 23 / 21 39 40 Italy Umberto Bossi 1996 55 - No 23 / 19 41 42 43 Italy Francesco Rutelli 2001 47 - No 32 / 14 44 45 Italy 2001 61 - No 20 / 14 46 47 Italy 2006 67 - Yes 16 / 9 48 49 Italy 2008 53 - No 28 / 7 50 51 Italy Walter Veltroni 2008 53 - No 28 / 7 52 53 Italy Beppe Grillo 2013 65 - No 19 / 2 54 55 56 Italy 2013 77 - Yes 11 / 2 57 58 New Zealand 1855 48 72 Yes 21 / 24 59 60 28 https://mc.manuscriptcentral.com/bmj Page 29 of 46 BMJ New Zealand Edward Stafford 1866 47 82 Yes 21 / 35

1 New Zealand 1871 59 81 Yes 14 / 22 2 3 4 New Zealand Sir 1875 40 64 Yes 25 / 24 5 6 New Zealand John Hall 1881 57 83 Yes 15 / 26 7 8 Confidential:New Zealand John Balance 1890 For 51 Review 54 Yes 18 / Only3 9 10 New Zealand Sir Harry Albert Atkinson 1890 59 61 Yes 14 / 2 11 12 New Zealand William Rolleston 1893 62 72 No 12 / 10 13 14 New Zealand William Russell 1899 61 75 No 13 / 14 15 16 17 New Zealand 1905 60 61 Yes 14 / 1 18 19 New Zealand 1922 52 69 No 20 / 17 20 21 New Zealand 1922 66 69 Yes 11 / 3 22 23 New Zealand 1928 72 74 Yes 8 / 2 24 25 New Zealand 1931 63 65 No 13 / 2 26 27 New Zealand 1931 53 65 Yes 20 / 12 28 29 30 New Zealand 1938 58 72 No 17 / 14 31 32 New Zealand 1938 66 68 Yes 12 / 2 33 34 New Zealand 1949 65 66 Yes 12 / 1 35 36 New Zealand 1954 61 68 Yes 15 / 7 37 38 New Zealand 1960 78 86 Yes 7 / 8 39 40 New Zealand Arnold Nordmeyer 1963 62 88 No 14 / 26 41 42 43 New Zealand 1969 65 79 Yes 12 / 14 44 45 New Zealand 1972 49 51 Yes 24 / 2 46 47 New Zealand 1984 63 71 Yes 15 / 8 48 49 New Zealand 1987 45 63 Yes 30 / 18 50 51 New Zealand 1996 61 - Yes 18 / 19 52 53 New Zealand 2002 41 - No 37 / 13 54 55 56 New Zealand 2005 65 - No 17 / 10 57 58 New Zealand 2008 58 - Yes 24 / 7 59 60 29 https://mc.manuscriptcentral.com/bmj BMJ Page 30 of 46 New Zealand Phil Goff 2011 58 - No 25 / 4

1 New Zealand David Cunliffe 2014 51 - No 31 / 1 2 3 4 New Zealand 2014 53 - Yes 29 / 1 5 6 Norway 1900 47 68 No 21 / 21 7 8 Confidential:Norway Ole Larsen Skattebøl 1903 For 59 Review 85 No 15 / Only26 9 10 Norway Edmund Harbitz 1906 45 55 No 24 / 10 11 12 Norway 1909 42 74 No 26 / 32 13 Christian Holtermann 14 Norway Knudsen 1912 67 84 No 10 / 17 15 16 17 Norway Otto Bahr Halvorsen 1921 49 51 Yes 23 / 2 18 19 Norway 1924 52 77 Yes 20 / 25 20 21 Norway 1924 76 80 Yes 7 / 4 22 23 Norway Johan H. Andresen 1936 48 65 No 24 / 17 24 25 Norway 1936 43 65 Yes 28 / 22 26 27 Norway Arthur Nordlie 1949 66 82 No 12 / 16 28 29 30 Norway C. J. Hambro 1953 68 79 No 11 / 11 31 32 Norway Alv Kjøs 1961 67 96 No 11 / 29 33 34 Norway 1965 68 90 Yes 11 / 22 35 36 Norway Sjur Lindebrække 1969 60 89 No 16 / 29 37 38 Norway 1973 63 74 Yes 14 / 11 39 40 Norway 1981 57 89 No 19 / 32 41 42 43 Norway 1985 57 70 No 19 / 13 44 45 Norway 1993 44 - No 32 / 22 46 47 Norway 1993 54 - Yes 23 / 22 48 49 Norway 2001 55 - No 25 / 14 50 51 Norway Thorbjørn Jagland 2001 51 - Yes 28 / 14 52 53 Norway Carl I. Hagen 2005 61 - No 21 / 10 54 55 56 Norway Siv Jensen 2009 40 - No 40 / 6 57 58 Norway 2013 54 - Yes 28 / 2 59 60 30 https://mc.manuscriptcentral.com/bmj Page 31 of 46 BMJ Poland Zygmunt Marek 1928 56 59 No 18 / 3

1 Poland Yitzhak Gruenbaum 1928 49 91 No 23 / 42 2 3 4 Poland Mieczysław Niedziałkowski 1930 37 47 No 33 / 10 5 6 Poland Joachim Bartoszewicz 1930 63 71 No 13 / 8 7 8 Confidential:Poland Walery Sławek 1935 For 56 Review 60 Yes 18 / Only4 9 10 Poland Tadeusz Michejda 1947 68 77 No 11 / 9 11 12 Poland Stanisław Mikołajczyk 1947 46 65 No 26 / 19 13 14 Poland Bolesław Bierut 1952 60 64 Yes 16 / 4 15 16 17 Poland Czesław Wycech 1969 70 78 No 10 / 8 18 19 Poland Stanisław Gucwa 1980 61 75 No 16 / 14 20 21 Poland Lech Wałęsa 1989 46 - No 30 / 26 22 23 Poland Roman Malinowski 1989 54 - No 23 / 26 24 25 Poland Wojciech Jaruzelski 1989 66 91 Yes 14 / 25 26 27 Poland Wiesław Chrzanowski 1991 68 89 No 13 / 21 28 29 30 Poland Tadeusz Mazowiecki 1993 66 86 Yes 14 / 20 31 32 Poland Leszek Balcerowicz 1997 50 - No 28 / 18 33 34 Poland Maciej Płażyński 2001 43 52 No 35 / 9 35 36 Poland Leszek Miller 2001 55 - Yes 25 / 14 37 38 Poland Andrzej Lepper 2005 51 57 No 29 / 6 39 40 Poland 2011 54 - Yes 28 / 4 41 42 43 Poland Jarosław Kaczyński 2011 62 - Yes 21 / 4 44 Antonio Canovas del 45 Spain Castillo 1896 68 69 Yes 10 / 1 46 47 Spain Praxedes Mateo Sagasta 1901 76 78 Yes 7 / 2 48 49 Spain Francisco Silvela 1903 60 62 Yes 14 / 2 50 51 Spain Eugenio Montero Rios 1905 73 82 Yes 8 / 9 52 53 Spain Nicolás Salmerón y Alonso 1907 69 70 No 9 / 1 54 55 56 Spain Jose Canalejas 1910 56 58 Yes 17 / 2 57 58 Spain Alvaro Figueroa 1916 53 87 Yes 18 / 34 59 60 31 https://mc.manuscriptcentral.com/bmj BMJ Page 32 of 46 Spain Antonio Maura 1919 66 72 Yes 11 / 6

1 Spain Melquíades Álvarez 1920 56 72 No 18 / 16 2 3 4 Spain Pablo Iglesias Posse 1920 70 75 No 10 / 5 5 6 Spain Eduardo Dato e Iradier 1920 64 64 Yes 13 / 0 7 8 Confidential:Spain Francesc Cambó 1923 For 47 Review 71 No 25 / Only24 9 Juan de la Cierva and 10 Spain Peñafiel 1923 59 74 No 16 / 15 11 Manuel Garcia-Prieto, 1st 12 Spain Marquis of Alhucemas 1923 64 79 Yes 13 / 15 13 14 Spain Francesc Macià i Llussà 1931 72 74 No 8 / 2 15 16 17 Spain Blas Piñar 1979 61 96 No 16 / 35 18 19 Spain Enrique Tierno Galván 1979 61 68 No 16 / 7 20 21 Spain Jordi Pujol i Soley 1979 49 - No 25 / 36 22 23 Spain Adolfo Suarez 1979 47 81 Yes 27 / 34 24 25 Spain Landelino Lavilla Alsina 1982 48 - No 27 / 33 26 27 Spain Santiago Carrillo 1982 67 97 No 12 / 30 28 29 30 Spain Gerardo Iglesias 1986 41 - No 34 / 29 31 32 Spain Adolfo Suárez 1989 57 82 No 20 / 25 33 34 Spain Manuel Fraga Iribarne 1989 67 89 No 13 / 22 35 36 Spain Rafael Calvo Ortega 1993 60 - No 18 / 22 37 38 Spain Miquel Roca 1993 53 - No 24 / 22 39 40 Spain José Carlos Mauricio 1996 55 - No 23 / 19 41 42 43 Spain Joaquim Molins 1996 51 - No 27 / 19 44 45 Spain Julio Anguita 1996 55 - No 23 / 19 46 47 Spain Felipe Gonzalez 1996 54 - Yes 24 / 19 48 49 Spain Xavier Trias 2000 54 - No 25 / 15 50 51 Spain Francisco Frutos 2000 61 - No 19 / 15 52 Francisco Rodriguez 53 Spain Sanchez 2000 55 - No 24 / 15 54 55 56 Spain Iñaki Anasagasti 2000 53 - No 26 / 15 57 58 Spain Joaquin Almunia 2000 52 - No 27 / 15 59 60 32 https://mc.manuscriptcentral.com/bmj Page 33 of 46 BMJ Spain Jose Maria Aznar 2000 47 - Yes 31 / 15

1 Spain Josep-Lluís Carod-Rovira 2004 52 - No 28 / 11 2 3 4 Spain Gaspar Llamazares 2008 51 - No 30 / 7 5 6 Spain Josu Erkoreka 2008 48 - No 32 / 7 7 Jose Luis Rodriguez 8 Confidential:Spain Zapatero 2008 For 48 Review - Yes 32 / Only7 9 10 Spain Iñaki Antigüedad 2011 56 - No 26 / 4 11 12 Spain Alfredo Perez Rubalcaba 2011 60 - No 23 / 4 13 14 Spain Cayo Lara 2011 59 - No 24 / 4 15 16 17 Spain Rosa Díez 2011 59 - No 24 / 4 18 19 Spain Josep Antoni Duran i Lleida 2011 59 - No 24 / 4 20 21 Spain Pedro Sanchez 2015 43 - No 38 / 0 22 23 Spain Mariano Rajoy 2015 60 - Yes 23 / 0 24 25 Sweden Gustaf Fredrik Östberg 1911 64 77 No 12 / 13 26 27 Sweden Daniel Persson 1917 67 68 No 10 / 1 28 29 30 Sweden Hjalmar Branting 1924 64 65 Yes 12 / 1 31 32 Sweden Arvid Lindman 1932 70 74 Yes 9 / 4 33 34 Sweden Gösta Bagge 1944 62 69 No 15 / 7 35 36 Sweden Per Albin Hansson 1944 59 61 Yes 16 / 2 37 38 Sweden Jarl Hjalmarson 1958 57 92 No 18 / 35 39 40 Sweden 1964 65 80 No 13 / 15 41 42 43 Sweden Tage Erlander 1968 67 84 Yes 11 / 17 44 45 Sweden Gunnar Hedlund 1970 70 89 No 10 / 19 46 47 Sweden Gösta Bohman 1979 68 86 No 11 / 18 48 49 Sweden Ulf Adelsohn 1985 44 - No 31 / 30 50 51 Sweden 1985 58 59 Yes 19 / 1 52 53 Sweden Ingvar Carlsson 1994 60 - Yes 19 / 21 54 55 56 Sweden Bo Lundgrem 2002 55 - No 25 / 13 57 58 Sweden Göran Persson 2006 57 - Yes 24 / 9 59 60 33 https://mc.manuscriptcentral.com/bmj BMJ Page 34 of 46 Sweden Stefan Löfven 2014 57 - Yes 26 / 1

1 Sir William Wyndham, 3rd UK Baronet 1722 34 52 No 31 / 18 2 3 Henry St John, 1st Viscount 4 UK Bolingbroke 1734 56 73 No 16 / 17 5 6 UK William Pulteney 1741 57 80 No 16 / 23 7 8 Confidential:UK Robert Walpole 1741 For 65 Review 68 Yes 11 / Only3 9 10 UK Henry Pelham 1747 53 59 Yes 18 / 6 11 Thomas Pelham-Holles, 1st 12 Duke of Newcastle upon 13 Tyne and 1st Duke of 14 UK Newcastle-under-Lyne 1761 68 75 Yes 10 / 7 15 Augustus Henry FitzRoy, 16 UK 3rd Duke of Grafton 1768 33 75 Yes 32 / 42 17 18 UK Marquess of Rockingham 1780 50 52 No 20 / 2 19 20 UK Lord Frederick North 1780 48 60 Yes 21 / 12 21 22 23 UK William Pitt 'The Younger' 1796 37 46 Yes 29 / 9 24 25 UK Charles James Fox 1802 53 57 No 18 / 4 26 27 UK Henry Addington 1802 45 86 Yes 23 / 41 28 William Bentinck Duke of 29 UK Portland 1807 69 71 Yes 9 / 2 30 William Wyndham 31 Grenville, 1st Baron 32 UK Grenville 1812 53 74 Yes 18 / 21 33 Robert Banks Jenkinson 34 UK Earl of Liverpool 1826 56 58 Yes 16 / 2 35 36 UK Marquess of Lansdowne 1830 50 82 No 20 / 32 37 Arthur Wellesley, 1st Duke 38 UK of 1832 63 83 Yes 11 / 20 39 40 41 UK Charles Grey, 2nd Earl Grey 1832 68 81 Yes 9 / 13 42 43 UK Robert Peel 1841 46 62 Yes 23 / 16 44 William Lamb, 2nd 45 UK Viscount Melbourne 1841 62 69 Yes 13 / 7 46 47 UK John Russell 1847 55 85 Yes 16 / 30 48 Henry John Temple, 3rd 49 UK Viscount Palmerston 1865 80 80 Yes 5 / 0 50 51 UK Benjamin Disraeli 1880 76 76 Yes 6 / 0 52 53 54 UK William Ewart Gladstone 1892 83 88 Yes 4 / 5 55 Archibald Philip Primrose, 56 5th Earl of Rosebery, 1st UK Earl of Midlothian 1895 48 82 No 21 / 34 57 58 59 UK Robert Cecil 1900 70 73 Yes 8 / 3 60 34 https://mc.manuscriptcentral.com/bmj Page 35 of 46 Sir Henry Campbell- BMJ UK Bannerman 1906 70 71 Yes 9 / 1

1 Arthur James Balfour, 1st UK Earl of Balfour 1910 62 81 No 13 / 19 2 3 4 UK Herbert Asquith 1910 58 75 Yes 16 / 17 5 6 UK John Robert Clynes 1922 53 80 No 19 / 27 7 8 Confidential:UK Andrew Bonar Law 1922 For 64 Review 65 Yes 12 / Only1 9 10 UK James Ramsay MacDonald 1929 63 71 Yes 12 / 8 11 12 UK Arthur Henderson 1931 68 72 No 10 / 4 13 14 UK Stanley Baldwin 1935 68 80 Yes 10 / 12 15 16 Sir Winston Leonard 17 UK Spencer-Churchill 1951 77 90 Yes 6 / 13 18 19 UK Anthony Eden 1955 58 79 Yes 17 / 21 20 Clement Richard Attlee, 1st 21 UK Earl Attlee 1955 62 84 Yes 14 / 22 22 23 UK Hugh Todd Naylor Gaitskell 1959 53 56 No 21 / 3 24 25 UK Harold Macmillan 1959 65 92 Yes 13 / 27 26 Alexander Frederick 27 Douglas-Home, Baron 28 UK Home of the Hirsel 1964 61 92 No 15 / 31 29 Sir Edward Richard George 30 UK "Ted" Heath 1970 54 89 Yes 20 / 35 31 32 UK Harold Wilson 1970 54 79 Yes 20 / 25 33 34 35 UK Leonard James Callaghan 1979 67 92 No 12 / 25 36 37 UK Michael Mackintosh Foot 1983 70 96 No 11 / 26 38 39 UK Margaret Thatcher 1987 62 87 Yes 16 / 25 40 41 UK Neil Gordon Kinnock 1992 50 - No 27 / 23 42 43 UK 1997 54 - Yes 24 / 18 44 45 UK William Jefferson Hague 2001 40 - No 38 / 14 46 47 Michael Howard, Baron 48 UK Howard of Lympne 2005 64 - No 18 / 10 49 50 UK Tony Blair 2005 52 - Yes 28 / 10 51 52 UK James Gordon Brown 2010 59 - No 23 / 5 53 Edward Samuel "Ed" 54 UK Miliband 2015 46 - No 35 / 0 55 56 UK David Cameron 2015 49 - Yes 33 / 0 57 58 USA George Washington 1792 60 67 Yes 14 / 7 59 60 35 https://mc.manuscriptcentral.com/bmj BMJ Page 36 of 46 USA John Adams 1800 65 90 Yes 11 / 25

1 USA Thomas Jefferson 1804 61 83 Yes 13 / 22 2 3 Charles Cotesworth 4 USA Pinckney 1808 62 79 No 13 / 17 5 6 USA DeWitt Clinton 1812 43 58 No 25 / 15 7 8 Confidential:USA James Madison 1812 For 62 Review 85 Yes 13 / Only23 9 10 USA Rufus King 1816 61 72 No 13 / 11 11 12 USA James Monroe 1820 62 73 Yes 13 / 11 13 14 USA John Quincy Adams 1828 61 80 Yes 13 / 19 15 16 17 USA Andrew Jackson 1832 65 80 Yes 10 / 15 18 19 USA William Henry Harrison 1840 68 68 Yes 10 / 0 20 21 USA Martin Van Buren 1840 58 79 Yes 15 / 21 22 23 USA Henry Clay 1844 67 75 No 10 / 8 24 25 USA James K. Polk 1844 49 53 Yes 21 / 4 26 27 USA Lewis Cass 1848 66 83 No 11 / 17 28 29 30 USA Zachary Taylor 1848 64 65 Yes 12 / 1 31 32 USA Winfield Scott 1852 66 79 No 11 / 13 33 34 USA Franklin Pierce 1852 48 64 Yes 22 / 16 35 36 USA John C. Fremont 1856 43 77 No 26 / 34 37 38 USA James Buchanan 1856 65 77 Yes 12 / 12 39 40 USA John C. Breckinridge 1860 39 54 No 27 / 15 41 42 43 USA George B. McClellan 1864 38 58 No 27 / 20 44 45 USA Abraham Lincoln 1864 56 56 Yes 16 / 0 46 47 USA Horatio Seymour 1868 58 75 No 15 / 17 48 49 USA Horace Greeley 1872 61 61 No 14 / 0 50 51 USA Ulysses S. Grant 1872 50 63 Yes 20 / 13 52 53 USA Samuel J. Tilden 1876 62 72 No 13 / 10 54 55 56 USA Rutherford B. Hayes 1876 54 70 Yes 17 / 16 57 58 USA Winfield Scott Hancock 1880 56 61 No 16 / 5 59 60 36 https://mc.manuscriptcentral.com/bmj Page 37 of 46 BMJ USA James A. Garfield 1880 49 49 Yes 20 / 0

1 USA James G. Blaine 1884 54 62 No 17 / 8 2 3 4 USA Grover Cleveland 1892 55 71 Yes 16 / 16 5 6 USA Benjamin Harrison 1892 59 67 Yes 13 / 8 7 8 Confidential:USA William McKinley 1900 For 58 Review 58 Yes 14 / Only0 9 10 USA Alton Brooks Parker 1904 52 73 No 19 / 21 11 12 USA William Jennings Bryan 1908 48 65 No 22 / 17 13 14 USA William H. Taft 1908 51 72 Yes 20 / 21 15 16 17 USA Theodore Roosevelt 1912 54 60 Yes 18 / 6 18 19 USA Charles Evans Hughes 1916 54 86 No 18 / 32 20 21 USA Woodrow Wilson 1916 60 67 Yes 14 / 7 22 23 USA James M. Cox 1920 50 87 No 22 / 37 24 25 USA Warren G. Harding 1920 55 57 Yes 18 / 2 26 27 USA John W. Davis 1924 51 81 No 21 / 30 28 29 30 USA Calvin Coolidge 1924 51 60 Yes 21 / 9 31 32 USA Al Smith 1928 55 70 No 19 / 15 33 34 USA Herbert Hoover 1932 58 90 Yes 16 / 32 35 36 USA Alf Landon 1936 49 100 No 23 / 51 37 38 USA Wendell Willkie 1940 48 52 No 23 / 4 39 40 USA Franklin D. Roosevelt 1944 63 63 Yes 14 / 0 41 42 43 USA Thomas E. Dewey 1948 46 68 No 27 / 22 44 45 USA Harry S. Truman 1948 64 88 Yes 14 / 24 46 47 USA Adlai Stevenson 1956 56 65 No 18 / 9 48 49 USA Dwight D. Eisenhower 1956 66 78 Yes 12 / 12 50 51 USA John F. Kennedy 1960 43 46 Yes 30 / 3 52 53 USA Barry Goldwater 1964 55 89 No 20 / 34 54 55 56 USA Lyndon B. Johnson 1964 55 64 Yes 20 / 9 57 58 USA Hubert Humphrey 1968 57 66 No 18 / 9 59 60 37 https://mc.manuscriptcentral.com/bmj BMJ Page 38 of 46 USA George McGovern 1972 50 90 No 24 / 40

1 USA Richard Nixon 1972 60 81 Yes 16 / 21 2 3 4 USA 1980 56 - Yes 20 / 35 5 6 USA Walter Mondale 1984 56 - No 20 / 31 7 8 Confidential:USA Ronald Reagan 1984 For 73 Review 93 Yes 9 / 20Only 9 10 USA Michael Dukakis 1988 55 - No 22 / 27 11 12 USA George H.W. Bush 1992 68 - Yes 13 / 23 13 14 USA Bob Dole 1996 73 - No 10 / 19 15 16 17 USA 1996 50 - Yes 28 / 19 18 19 USA Al Gore 2000 52 - No 27 / 15 20 21 USA John Kerry 2004 61 - No 20 / 11 22 23 USA George W. Bush 2004 58 - Yes 23 / 11 24 25 USA John McCain 2008 72 - No 13 / 7 26 27 USA Mitt Romney 2012 65 - No 19 / 3 28 29 30 USA Barack Obama 2012 51 - Yes 31 / 3 31 32 33Notes : Expected years of life following national election were based on an average individual of the same age and sex as the candidate, taken 34from historical lifetables described in the Methods. . Periods reflect candidates who were elected after 2013, the last year in the life tables. 35Dashes indicate a stillliving candidate. 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 38 https://mc.manuscriptcentral.com/bmj Page 39 of 46 BMJ

1 2 3 HAR VARD MEDICAL SCHOOL 4 5 DEPARTMENT OF HEALTH CARE POLICY 6 7 8 Confidential: For Review Only 9 HARVARD MEDICAL SCHOOL Anupam B. Jena, MD, PhD 10 Department of Health Care Policy Associate Professor of Health Care Policy and Medicine 11 180 Longwood Avenue, A Boston, MA 02115 P: (617) 432-8322 12 [email protected] 13

14 15 16 17 18 October 1, 2015 19 20 21 Dear Dr. Tonks, 22

23 24 Thank you again for the thoughtful review of our manuscript. The reviewers raised a number of 25 excellent suggestions which we deemed would be necessary before submitting the manuscript for 26 publication elsewhere. Because we feel that these changes have made the manuscript substantially 27 stronger, we are submitting for consideration a revised manuscript that addresses all of the 28 comments/suggestions of the referees and now expands our analysis to 17 countries rather 8 countries. 29 For your ease, we have detailed how our new manuscript responds to the comments of the reviewers. 30 31 Our basic findings are unchanged, namely that those elected to head of government have higher 32 mortality than those who ran for office but never served. As before, we interpret this to suggest that the 33 stress of politics could kill. 34 35 Many thanks, 36 37 38 39 40 41 Anupam B. Jena, MD, PhD 42 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 40 of 46

1 2 3 Response to Reviewer 1’s comments 4

5 6 Thank you for your thoughtful comments. 7 8 ThisConfidential: paper submitted for the Christmas edition For takes an interestingReview question and putsOnly together a largish 9 database to address it. I was enthusiastic to start with, but as I looked at the data in more detail I am 10 afraid that I was less and less convinced, and so, much as I hate to do it, I am going to have to play 11 Scrooge on this occasion. It may be that a proper re-analysis using more sophisticated statistics will find 12 13 an effect in here, although I would need convincing. 14 15 The paper looks at the age at death of the winners and losers in elections in eight different countries 16 over a number of centuries. The authors are to congratulated on tabulating their raw data fully, 17 although sadly it is that which allowed me to re-analyse the data and to have many concerns about the 18 data. 19

20 21 1. The datasets. I didn’t fully understand what had been included and excluded from the various 22 tables. Not to see Signor Berlusconi in the Italian lists seemed strange, and it presumably is not due to 23 him still being alive, as plenty of others are still alive. Similarly there seem to have been a number of 24 Italian prime ministers who are not included, but that may reflect the forging and reforging of coalitions 25 to which Italy has been prone. More clarification would be helpful. 26 27 28 In the earlier version of the paper, elections that did not feature at least one now-deceased candidate 29 were excluded from the analysis. Signor Berlusconi was a member of one such election. However, in our 30 new analysis, the dataset has been reformed into a candidate-level dataset, rather than an election-level 31 dataset, and so all such candidates are now included. Moreover, as you suggest below, we implement a 32 hazard analysis which uses data from all candidates, deceased or alive. Those candidates that are alive 33 today are treated as censored observations in terms of years alive since last election. 34 35 36 2. The German data are not very helpful. The President of Germany in post-war years is primarily 37 honorific and appointed by a special commission, and is not an election in any real sense (and not to see 38 Frau Merkel was surprising). The Chancellor is the equivalent of an American President. The details are 39 also unclear. Admiral Karl Doenitz (some attention to umlauts or their replacement is needed), said to 40 have beaten Hitler in 1932, was actually captaining a torpedo boat at the time (and was aged 41). He 41 was appointed Chancellor in the aftermath of Hitler’s death, but died aged 89 in 1980. Hitler’s 1932 42 opponent (and the victor) was actually Paul von Hindenburg, aged 84 and in poor health (although he 43 44 had already outlived the 5 years predicted from the life table for when he was victor in the 1925 45 election). The loser, Hitler, did die prematurely and from politics, but was by his own hand eventually. 46 47 The old German presidency data have been replaced entirely by new data on the German 48 chancellorship, beginning in 1949. Additionally, we now include data from 9 additional countries. 49 50 51 3. The Canadian data show other problems. The elections of 1957, 1958, 1962 and 1963 were 52 between Diefenbaker and Pearson, each winning two. These data seem to be in the database four 53 times, but presumably cannot be considered to be independent in any sense. The same applies to the 54 Laurier/Borden elections of 1904 to 1917. The latter are problematic in that Laurier seems to have had a 55 premature death after the 1911 and 1917 elections when he lost, but not for the 1904 and 1908 56 elections when he won. Something is not right here and it must surely affect the statistics. 57 58 59 60 2

https://mc.manuscriptcentral.com/bmj Page 41 of 46 BMJ

1 2 3 This was a serious shortcoming of the earlier paper. We now perform all analyses at the candidate-level, 4 not the election-level. To handle candidates with multiple runs, we now select each candidate’s last 5 6 election. For instance, in the case of these Canadian elections, Pearson and Diefenbaker both last ran in 7 the 1965 election. Both are treated as “winners,” and we measure their expected / observed life years 8 fromConfidential: that election. For Review Only 9 10 4. On a European pedantic point, many of the names are wrong. “C Gaulle” should be “C de 11 Gaulle”, “V d’Estaing” is “VMRCG d’Estaing” but he was known as Giscard. Hindenburg was “von 12 13 Hindenburg”. Andrew Bonar Law was always known as Bonar Law and not “A Law”. “S Spencer- 14 Churchill” was either “WL Spencer-Churchill” or more typically “W Churchill”. “L Callaghan”, may have 15 been LJ but was always known as Jim. As for “S Heath”, there was “Edward R G Heath”, whom I 16 presume is the one meant, even if he was known as Ted. The “one initial” policy is not working here 17 (and would work less well if the US Presidents had got into the era of the Bushes…). 18 19 We apologize for this inappropriate shorthand. We have the tables with each candidate’s full names. 20 21 22 5. The data. The abstract refers to 322 elections. Although the eTable has 329 rows, I think, the UK 23 data are repeated within that table. Removing the duplicates leaves 270 rows, which I presume is the 24 correct N. That would seem to invalidate most of the statistics in the present version of the paper. 25 26 The data have been expanded to include 9 more countries and duplicated candidates are now handled 27 28 differently (see above). 29 30 6. The key statistical analysis (reported in the abstract) compares premature death in winners 31 (132/322=41%) and losers (107/322=33%), with p=.04. That is a standard independent groups chi- 32 square. When I did it with the data after removing the duplicate UK elections I found the rate in winners 33 (48.4% of 258) was lower than that in losers (56.1% of 272), with p=.082. Those values are clearly very 34 different from those reported. Including the duplicates didn’t help, and so I hand-counted the number 35 36 of PremDeath=Yes in the etable, where there were 151 in total (clearly not the same as 132 above), and 37 removing the 28 UK duplicates reduced the value to 123, also not the same. I have no idea where the 38 calculation in the abstract came from. It should also be said that neither total should surely be 322 since 39 there are “n/a” in the data. 40 41 Unfortunately, the Table that we included in the manuscript submission mislabeled premature mortality 42 (e.g., those living longer than expected were incorrectly listed as dying prematurely), whereas it was 43 44 correct in the actual data that we analyzed. This is why your calculations did not match ours. We 45 apologize for this issue. 46 47 With that said, we now analyze a candidate-level analysis in which candidates are not duplicated. Based 48 on your suggestion, we instead employ better techniques to analyze the data, e.g., Kaplan-Meier 49 survival analysis and Cox proportional hazards. 50 51 52 7. The data are clearly paired, and using the data without duplications, I found that there were 70 53 pairs in which the winner died prematurely, and 53 in which the loser died prematurely, which is not 54 significant with a McNemar test (p=.149). 55 56 The data are now at the candidate-level rather than election-level and are therefore now no longer 57 ‘paired.’ 58 59 60 3

https://mc.manuscriptcentral.com/bmj BMJ Page 42 of 46

1 2 3 4 8. I was less than happy with a simple binary “Prem/non-Prem” which throws away lots of data. 5 6 “Years before or after average date of death” would have been better. I calculated that, but still in a 7 paired-t-test it is not at all significant (and in fact in the opposite direction). 8 Confidential: For Review Only 9 We have conducted a new analysis that considers a continuous, rather than binary, dependent variable 10 of years alive since last election. We also plot Kaplan-Meier survival curves and estimate a Cox 11 proportional hazard model of years to death (or years to end of study period, whichever is earliest). 12 13 14 9. I also wasn’t happy with ignoring those still alive. In clinical trials it is conventional to take into 15 account that data are censored, so that a patient whois known to have survived “at least 12 years” 16 conveys more information about survival than one with “at least 1 year”. Those still alive have survived 17 for different amounts of time and some form of Cox regression would seem to be the proper solution 18 here. 19

20 21 We now incorporate those candidates who are not yet deceased in the relevant models as part of a 22 sensitivity analysis; our basic findings do not change. 23 24 Minor points 25 26 10. Abstract: “both groups would presumably be of similar socioeconomic status”. A rash 27 28 assumption, certainly in a time when in the UK the leaders of the Labour Party had often started down 29 the pit as miners, and worked their way to the top of their Party to compete with aristocracy (a 30 stereotype, but you get the idea). 31 32 We now highlight this as a specific limitation in the paper. 33 34 11. p.6. “may age at twice the rate”. Does this have any serious medical meaning or is it just popular 35 36 journalism? Better removed. 37 38 We have edited this to simply state that one analysis of presidential health records suggested that 39 presidents may age at an accelerated rate compared to the overall U.S. population. 40 41 12. p.10. “a substantive increase in premature mortality”. That is what effect sizes were invented 42 for… 43 44 45 We have modified the results to be more precise. 46 47 13. p.11. “If winning candidates were on average older than runner-up candidates”. Fair point, but I 48 cannot find any such effect in these data using a paired t-test. 49 50 51 We now report this information in the text. 52 53 Overall, as I said to start with, I like the idea of this study, but there are clearly many details which need 54 clarifying and checking, the duplicates need removing, both for the UK data, and for individual pairs of 55 candidates which also duplicate. Statistical analysis is far from straightforward of data such as this, and 56 while the authors make a reasonable attempt to model the data, not taking into account the censored 57 nature of many of the values is a problem. That the effect is not present in the simple analyses (and 58 59 60 4

https://mc.manuscriptcentral.com/bmj Page 43 of 46 BMJ

1 2 3 indeed some of the simple analyses cannot be replicated) obviously throws doubt on the entire exercise. 4 It may be that I have misinterpreted what the authors have done, in which case a re-review would be 5 6 indicated. 7 8 Again,Confidential: thank you for this thoughtful feedback. For We believe Reviewour revised manuscript addressesOnly a number of 9 your comments/suggestions, if not at all. 10 11 12 13 14 15 16 17 18 19

20 21 22 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 5

https://mc.manuscriptcentral.com/bmj BMJ Page 44 of 46

1 2 3 Response to Reviewer 2’s comments 4

5 6 Thank you for your thoughtful comments. 7 8 ThisConfidential: paper uses a generally sound methodology For to compare Review the subsequent mortality Only of elected 9 presidents/prime ministers to those of their opponents.. there are however two sets of questions/issues 10 to be resolved 11 12 13 1) clarification of some ambiguity in the methodology 14 15 2) discrepancies in the data for the UK 16 17 We have revamped the methodology, clarified it the manuscript, and have addressed potential 18 discrepancies in the data (as well as fixed the annoying way in which names were reported in the 19 tables). 20 21 22 Methodology 23 24 It appears that a leader/loser is "at risk" in whatever category they fall into for the rest of their lives i.e. 25 the outcome following election is binary (early death or not). However losers at one election may go on 26 to be winners at a later one. More clarity on how this is handled in the analysis would be useful and on 27 28 the interpretation of stress and risk that is implied by these crossover results. Is it the sort-term risk of 29 stress from being in office (a period covering somewhere between months to five years) or is it lifetime 30 risk or is it the lifelong stress of having once won an election? 31 32 We have changed how we handle these issues; they are now more clearly laid out both above and in the 33 paper. Candidates are considered as “treated” if they have been exposed to the lifetime risk of having 34 won at least one election and served. Candidates are considered as “untreated” if they ran for at least 35 36 one election but were never elected and never served. 37 38 In many situations, the politician in question does not win an outright majority but goes on to lead a 39 coalition which collapses after a time. The person who came second may then take over leadership of a 40 new coalition. How is this handled in terms of labelling people as winners and losers for life? 41 42 This is an excellent point. We now independently consider lists of heads of government, which 43 44 are matched to the election data. Our research design revolves around comparing the most similar 45 candidates, and so we only consider candidates who (a) won the plurality of votes and then served in 46 office, or (b) did not win a plurality, and never went on to serve. Thus, the candidate who comes into 47 office not directly following an electoral victory (e.g., through a coalition collapse, as you suggest, or a 48 predecessor’s retirement) is now excluded from our analysis, because we are not confident that these 49 candidates do not systematically differ in their mortality from our control group. This approach is 50 51 consistent with prior studies which compare mortality among winners and losers of specific events to 52 identify the effect of winning that event on mortality (references 7-9 in the manuscript). Second, in very 53 few countries today is the head of government not originally a party leader in some form. Hence, 54 excluding candidates who were not elected to office in the now conventional form allowed us to more 55 appropriately generalize our findings to today’s candidates. 56 57 58 59 60 6

https://mc.manuscriptcentral.com/bmj Page 45 of 46 BMJ

1 2 3 Data quality 4

5 6 I have examined the data presented for the UK. It does not have face validity in a number of respects. 7 this would undermine the credibility of the article if not fixed. The authors should cross check their data 8 withConfidential: the UK Government's list of Prime Ministers For Review Only 9 10 https://www.gov.uk/government/history/past-prime-ministers 11 12 13 The discrepancies are of two types (a) inconsistencies/errors in names (b) inconsistencies/errors in dates 14 of elections. 15 16 Under (a) there are errors some that are simply annoying . In particular, using a title as a first initial e.g. 17 D Wellington is actually the Duke of Wellington, S Spencer Churchill is . There is also 18 inconsistency in the use of double barrelled names e. A Law is actually Bonar Law, D George is actually 19 Lloyd George. Then there is flipping between given names and titles. So T Melbourne is shown as 20 21 winning two elections, after which W Lamb loses an election. But in cat both are William Lamb, the 22 second Viscount Melbourne. So it is unclear where this figured in the methodology - excluded as a 23 winner and loser or included under both headings. 24 In other cases the flip flopping between titles and given names is simply confusing historically (e.g. H 25 Temple for Lord Palmerston). 26 27 28 The candidates’ names are now listed in full. We apologize for the inappropriate shorthand that we took 29 in the earlier table. 30 31 Under (b), the dates given for winning elections are actually those when the ministry ended (e.g. 32 Wellington's first ministry was from 1828 to 1830, but the date of his only election victory is shown as 33 1830). It is not clear where the information on election outcomes was obtained. A second issue is that 34 until very recently, most prime ministers were appointed after factional disputes within their parties 35 36 rather than by popular ballot. So, for example the Earl of Shelburne, who had the most stressful 37 premiership of all - negotiating away the USA - is not shown has ever winning or losing. Similarly Neville 38 Chamberlain is not shown, despite the stress of negotiating The Munich treaty, and Winston Churchill is 39 only shown as winning the 1951 election - quite correct, but had this not happened he would have been 40 shown as a loser (thus excluding the stress of leadership throughout World War II). This is the case for 41 Lloyd George who is shown only as losing the 1918 election, never winning. In fact of course he was in 42 coalition with Bonar Law in the 1918 election and went on to be prime minister through the stress of the 43 44 Versailles Treaty and Irish Independence - as well as having led the pre-1918 cabinet. 45 46 As I indicated, these anomalies do undermine the credibility of the method and do need to be resolved 47 with the UK Government list. Results for other countries should be similarly cross-checked. 48 49 We now select the last election in which each candidate participated. In the case of the Duke of 50 51 Wellington, he was last the leader of the Tories during the 1832 election, and so that is the election used 52 for his analysis. 53 54 The second issue you raise is critical, and one that we have spent a great deal of time addressing. As 55 noted above, we now independently consider separate data on the heads of government in each 56 country, which allows us to identify (a) which of our winning candidates actually served as a head of 57 government and (b) which of our losing candidates did serve, if not through direct election. The former 58 59 60 7

https://mc.manuscriptcentral.com/bmj BMJ Page 46 of 46

1 2 3 group is now our treatment group, while the latter individuals are not considered in the analysis, for 4 reasons discussed above. 5 6 7 8 Confidential: For Review Only 9 10 11 12 13 14 15 16 17 18 19 20 21 22 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 8

https://mc.manuscriptcentral.com/bmj