As he exited the stairs of his "Straight Talk Express" campaign bus on a chilly March day in Iowa, Sen. John McCain carefully took one step at a time, his left hand gripping a rail and his right knee looking stiff.
A bum knee isn't surprising in a 70-year-old man -- particularly one whose right leg was shattered about four decades ago when his jet fighter was shot down over North Vietnam.
But his wooden movements, along with his age and appearance, are creating an impression about McCain's health that could be a liability for the Arizona Republican as he tries to persuade Americans to elect him president.
McCain brings to the campaign a body and mind with some heavy wear and tear, including a couple of bouts of cancer and the effects of years of torture. If elected, he would be the oldest person in history to enter the White House, and if he served two terms he would leave office an octogenarian.
Other presidential contenders have health issues, including Sen. Joseph R. Biden Jr.'s two brain aneurysms in 1988, Rudolph W. Giuliani's prostate cancer in 2000 and former Sen. Fred Thompson's lymphoma. But they are all younger and haven't experienced McCain's physical and mental agonies.
Voters should not worry, the senator's staff says. He passed a recent health exam with flying colors, they say, the results of which will be publicly released in coming weeks.
"We all have trouble keeping up with him," said Eileen McMenamin, communications director in McCain's Senate office.
Indeed, when life spans are lengthening and people in their 80s are running companies and marathons, McCain's age in itself shouldn't be an issue, some experts say.
"Don't give me that age business," said Dr. James E. Birren, a prolific medical author known as the father of gerontology, who still lectures at USC at age 89. "If the task requires speed, then you want the younger person. But if it requires wisdom, you want somebody old."
But McCain's health, much like his politics, is a complex matter.
McCain has twice developed melanoma, a potentially deadly form of skin cancer. He had four surgeries between 1993 and 2002: two to remove melanomas, one to remove skin lesions and one to treat an enlarged prostate.
When doctors removed a melanoma from his left temple in 2000, they did exploratory surgery to look for cancer in his lymph nodes, leaving a buildup of scar tissue -- a big lump -- on his left jaw. So far, McCain has rejected his staff's suggestions to have it removed by cosmetic surgery. To prevent a recurrence of the melanoma, McCain slathers himself with sunscreen whenever he ventures out.
"John looks pale, but he has to stay out of the sun," said James McGovern, a longtime friend and a campaign fundraiser, who asserts McCain has more than enough stamina to be president.
McCain, whose staff did not make him available to be interviewed for this article, described his health as excellent Sunday on NBC's "Meet the Press."
Critics have a tougher assessment of how the public perceives him.
"What does in McCain is the fact that he looks old," said Loren Thompson, an expert on military affairs at the Lexington Institute, a public policy think tank in Arlington, Va. "Looks count, and McCain looks terrible."
A recent Roper poll found that 30% of registered voters had "some reservations" or were "very uncomfortable" about the fact that McCain would be the oldest president elected to a first term.
McCain does not regularly run, lift weights or go to a gym, and he smoked cigarettes until age 45, his staff said. But he is not a couch potato. McCain, who regularly hikes near his home in northern Arizona, marched across the Grand Canyon last year from rim to rim, a task equal to climbing and descending the Empire State Building more than three times in just a few days.
"He jokes that it almost killed him," spokesman Tucker Bounds said.
McCain can also point to good genes, at least on his mother's side. Roberta McCain is 95. With her twin sister, she traveled around Europe last year about the time McCain was slogging across the Grand Canyon. On the other hand, McCain's father, a Navy admiral, died of a heart attack at 70, and his grandfather, another Navy admiral, died at 61.
The melanoma that McCain suffered was probably related to a genetic predisposition and sunburns he may have sustained as a young man, medical experts say.
The cancer has no implications for his general health, and the fact that it did not spread into his lymph nodes is a good sign, said Dr. Jeffrey Weber, associate director at USC's Norris Comprehensive Cancer Center.
A person who has one melanoma is at greater risk to have another, adds Dr. Antoni Ribas, a melanoma expert and associate professor at UCLA, but that is considered a manageable risk. Like others with his condition, McCain is checked every three months for new signs of problems.
"The majority of people are cured with surgery, if [it is] detected early," Ribas said.
Scarred by war
McCain's war experience sets him apart. No president has endured the tribulations McCain faced in 5 1/2 years as a prisoner of war, said Georgetown University historian Michael Kazin. Judging from interviews with medical experts and with fellow prisoners in North Vietnam, and from McCain's own writings, those dark days left many scars.
George "Bud" Day, a Medal of Honor recipient, vividly remembers the day McCain's broken body was brought by guards through the door of Hoa Lo prison, the infamous Hanoi Hilton.
"He had been starved," Day said. "He was emaciated and weighed around 100 pounds. He had lost a third of his body weight. He had a fracture of his right knee that had been unskillfully repaired, as well as multiple fractures of his right arm. His left shoulder was dislocated and he had been bayoneted in the left leg. And he was filthy. You could smell him a quarter-block away.
"I expected he would die before morning," Day continued. "I thought the Vietnamese had dropped him off with us so he would die with us and they would be able to blame his death on us. About 40% of the prisoners had some kind of a broken limb or combination of broken limbs or skull fractures. I would say John was in the top 2% of the worst-injured in the system."
To this day, McCain can barely lift his arms above his head. At the 2000 Republican convention, President Bush tried to hoist joined hands with McCain over their heads, leaving the senator grimacing, recalls Mark Salter, a senior advisor to his campaign: "He is stiff."
Of his leg injury, McCain acknowledged years later in his acclaimed autobiography, "When I am tired or when the weather is inclement, my knee stiffens in pain and I pick up a trace of my old limp."
Questions about McCain's temperament also have dogged him for years. His personal style is often combative, and some who have run afoul of him in government say he is vindictive; Newsweek magazine once dubbed him "Senator Hothead." By most accounts, it's a personality that predates his wartime experience.
The incarceration, the broken bones, the beatings and years of starvation have left little lasting damage, McCain's staff says.
McCain released extensive medical records when he sought the presidency in 2000, including reports of his periodic examinations at the Robert E. Mitchell Center for Prisoner of War Studies at the Naval Operational Medicine Institute in Pensacola, Fla. Those reports indicated that McCain was in generally good health and did not suffer any psychological illness.
Dr. Bob Hain, director of the study program, said McCain was examined almost every year until 1994, when he stopped returning to the voluntary program.
"The people who were captured in the mid-'60s underwent very serious torture," Hain said. "The people who underwent that certainly have significant orthopedic problems as a result."
But Hain added that the men generally remained in good physical and emotional health.
"These people are very unusual, very gregarious, very outgoing as a majority," Hain said. "There are some people who have some problems. As far as I know, John McCain is not one of them."
Change in outlook
McCain spent extended periods in solitary confinement, a punishment that many considered worse than the physical beatings and limb-stretching tortures the men endured, said Mary Schantag, who with her husband runs www.pownetwork.org, a history of the 660 Vietnam War POWs who came home and others who did not.
"It seems impossible to have no scarring, given the isolation, the torment," Schantag said. "To be totally alone for months and months, whether it touches you or not, it is going to shape how you see the rest of your life."
During the experience, McCain's outlook darkened considerably. After a particularly brutal period of beatings, McCain attempted to take his life several times. And when his communist captors finally beat a political confession out of him, McCain was left an emotional wreck.
"I was ashamed," McCain wrote in his book "Faith of My Fathers."
"I felt faithless and couldn't control my despair. I shook, as if my disgrace were a fever. I kept imagining that they would release my confession to embarrass my father. All my pride was lost and I doubted I would ever stand up to any man again. Nothing could save me. No one would ever look upon me again with anything but pity or contempt."
Some of the men had a difficult time recovering from such despair. Fellow prisoner Day, for example, contrasts himself with McCain, who he says benefited from an "outgoing, gregarious, sunny personality."
"I have trouble laughing at a lot of things that I used to think were pretty funny," Day said. "It was because so many bad things happened with such regularity that I got thinking that horror and underlying bad motives were the theme and not the exception. But John did extremely well."