July 5, 2024
Dear Interested Readers
Let’s Think about Joe
There has been something weird going on in cyberspace. Three weeks ago the notification service that I use each week to send an email to you saying that there is a new letter for you to read did not send me the message. A brief look into what might be the problem came up without an explanation. Two weeks ago, I got the usual Friday email notification and assumed that all was well again. Still, there was no explanation for what had happened. Last Friday, neither my wife nor I got the email notification that the letter was out, but several other readers did get it because I got personal emails from them saying how concerned they were about Joe Biden’s debate performance.
I fear that there are other readers who, like me, didn’t get the notification. Proof of that concern came in the form of a personal email from a faithful reader and frequent commenter who lives in the Washington, D.C. area. She wrote to me over the weekend:
Hi Gene,
I didn’t see your Strategy Healthcare last Friday. I hope you’re okay. I don’t remember a Friday when I didn’t get one.
I felt paralyzed after watching 37 minutes of the debate last Thursday night. I had to turn it off after that. I just couldn’t take anymore. I was devastated by Biden’s performance, as so many of us were. Is that why you didn’t send out a letter on Friday? I wouldn’t be surprised if it left you speechless too.
What now? He simply is in no shape to be President again and Harris can’t beat Trump. I can’t even watch the news anymore because they keep replaying pieces of that debacle. It just makes me want to throw up. I hope Biden will step aside for someone who can get elected and save our democracy. I never thought I’d be so afraid of the outcome of an election.
Anyway, I just wanted to check on you. I hope you and your family are well. Or as well as any of us can be right now.
My best,
xxxx
President Biden’s poor debate performance has deeply concerned most dedicated Democrats whether or not they will admit it to the press. Journalists have felt less constrained and they have created a firestorm of opinion pieces in newspapers across the country. Most notable was the suggestion from the editorial board of The New York Times that the president announce that he was withdrawing his candidacy. The Chicago Tribune and The Washington Post have also made the same drastic suggestion. The journalists were quick to echo what was on the minds of many who did not have a ready megaphone to express their fears and concerns. In a podcast with Ross Douthat and Michelle Cottle an hour after the disastrous debate, Ezra Klein was very specific about how Democrats could transition to an open convention that could nominate a replacement candidate for President Biden. What follows is a rough reproduction of Klein’s suggestion.
First, Biden must resign without throwing his support to any potential candidate. The sooner the better. The Democratic Convention is scheduled for August 19 to 22, 2024, at the United Center in Chicago, Illinois. Between now and the convention, candidates can meet with delegates and the public Perhaps, one or two debates could be arranged so that the general electorate might have some feel for the candidates that could be communicated to their delegates. At the convention, the business of nominating a candidate for president could occur by the vote of delegates as was the practice before 1972. If the candidate was from a swing state like Gretchen Whitmer, the governor of Michigan, or Josh Shapiro, the governor of Pennsylvania, it might make winning in the Electoral College easier. Klein believes that the downside possibility of selecting a new, younger candidate is no greater than Biden’s continuing candidacy under the questions that have now been created by his poor performance at the debate.
As poor as Biden’s performance was in the CNN studios in Atlanta on June 27, he rebounded as a star at a previously scheduled campaign rally the next day in North Carolina. If you read the entirety of his speech, his performance was as good as his very positive performance at the State of the Union address last winter. You may have already heard his most energetic and defiant quote from near the end of the speech. In case you missed it:
Folks, I don’t walk as easy as I used to. I don’t speak as smoothly as I used to. I don’t deba- — debate as well as I used to. But I know what I do know: I know how to tell the truth. (Applause.)
I know — I know — I know right from wrong. (Applause.) And I know how to do this job. (Applause.) I know how to get things done. (Applause.) And I know like millions of Americans know: When you get knocked down, you get back up. (Applause.)
Since the debate, Biden’s family and inner circle of advisors have continued to defend his capability to serve another four years. The twenty-five Democratic governors have met with the president to hear his argument that he is still up to the job. Perhaps his most vigorous defender has been his wife, Jill. As of today, most Democratic politicians have been mute or supportive of Biden’s continued candidacy. The question is whether his disastrous performance was an explainable event from benign causes and the president is capable of serving another four years when he will be eighty-six or was the debate performance like his interview with special counsel Robert Hur, who decided not to prosecute the president? Mr. Hur explained his decision not to indict President Biden by writing:
The concerns about the president’s fitness for four more years in office have been the major focus of many concerned citizens who have have now witnessed several moments of apparent confusion as when he mixed up the leaders of Egypt and Mexico while answering a question about Gaza, People have also noted how he walks, sometimes falls, and frequently has a flat expressionless visage suggesting to them that he is not engaged in the events of the moment.
As a former physician who cared for many elderly patients, I have wondered about what these physical features and events might mean. Since it has been over a decade since I retired, I decided to ask Chat GPT a simple, straightforward question about the origin of gait disorders in the elderly. My request to the free version of Chat GPT was:
Please discuss the causes of gait disorders in the elderly.
The response from Chat GPT magically appeared in less than two seconds:
Gait disorders in the elderly can arise from a variety of causes, including musculoskeletal, neurological, cardiovascular, and sensory impairments. Here are some key factors:
- Musculoskeletal Issues:
- Osteoarthritis: Degeneration of joint cartilage can lead to pain and stiffness, affecting mobility.
- Osteoporosis: Decreased bone density increases the risk of fractures, which can impair gait.
- Muscle Weakness: Age-related loss of muscle mass (sarcopenia) can lead to decreased strength and endurance.
- Neurological Disorders:
- Parkinson’s Disease: Characterized by tremors, rigidity, and bradykinesia, this disease can lead to a shuffling gait and instability.
- Stroke: Can result in hemiparesis or hemiplegia, leading to asymmetric gait patterns.
- Peripheral Neuropathy: Damage to peripheral nerves can cause numbness and weakness, affecting balance and coordination.
- Dementia: Cognitive impairments can affect motor planning and coordination.
- Cardiovascular Problems:
- Peripheral Artery Disease (PAD): Reduced blood flow to the legs can cause pain and cramps, impacting gait.
- Heart Failure: Can lead to fatigue and weakness, limiting mobility and endurance.
- Sensory Impairments:
- Vision Impairment: Poor vision can affect balance and the ability to navigate surroundings safely.
- Hearing Loss: Affects balance and spatial orientation, increasing the risk of falls.
- Other Factors:
- Medications: Certain medications can cause dizziness, hypotension, or muscle weakness, impacting gait.
- Psychological Factors: Fear of falling can lead to cautious or altered gait patterns.
Understanding the underlying cause of a gait disorder is crucial for appropriate management and treatment, which may include physical therapy, medication, assistive devices, or surgical interventions.
Gait disorders are common in older people and difficulty walking is not evidence of intellectual decline even though the two may coexist. It is important to know that the “mental test” that Trump frequently claims to have aced is essentially a simple screening test of thirty questions. The Montreal Cognitive Assessment (MoCA) is just a snapshot in time. All medical tests are fraught with false positive and false negative results. It is also true that Trump took the test several years ago. Perhaps, Congress should adopt Nikki Haley’s suggestion that all officeholders over 75 should take cognitive tests to uncover developing deficiencies that could impact their critical performance.
Like President Biden, I now have a gait disorder. I don’t think it impacts my cognitive function, but it does have an emotional impact. Despite my difficulty walking, I exercise a lot. I am not overweight. I average more than eight hours of sleep each night. I can remember working long hours and know that despite my fitness for a man in his very late 70s, I will be 79 next week, I don’t think that I could handle the sort of schedule that is demanded of an engaged president. Toward the end of my career, I was increasingly dependent upon “the kindness of others.” I am sure that some decline in stamina will be true for either President Biden or Donald Trump as the next four years roll by. I am sure that the president is now very dependent upon an exceptionally talented staff that is organized around his political positions. That reality is reassuring but doesn’t preclude a critical error that could impact us all. This danger of decline during office might be even more of a threat in a second Trump presidency. If reelected, by the end of his term, Trump will hold the distinction of being our oldest president.
The problem with intellectual function at any moment is that other factors are involved in producing what you see as a surprising error. The Biden campaign has focused on his apparent URI as an explanation for his performance. Anxiety can also be a factor. Logic might argue that the older you are the more you may be vulnerable to the immediate impact of a self-limited illnesses, fatigue, or moments of increased emotional stress or anxiety.
In late 2012, when I was sixty-seven, Marci Sindell, who at the time was one of my most trusted advisors and the Chief of Public Relations and Governmental Affairs at Atrius Health, arranged for me to have the honor of delivering The Annual Oration for the Massachusetts Medical Society. The Annual Oration has been delivered every year since 1804. In 1823 a distant relative, Dr. Heny Halsey Childs gave the Oration. My mother’s maiden name was Childs. I think that Dr. Henry Halsey Childs was a cousin of my Great Great Great Grandfather, Dr. Ebenezer Childs who was a physician in Shelbourne Falls, Massachusetts. In 1859, Dr. Henry Halsy Childs’ son, Dr. Timothy Childs, gave the oration. The discovery that these distant relatives had also given the Oration gave me a great sense of connection to the Oration which I shared with my mother who was a very active genealogist. She died less than two months later on January 5, 2013, just two months shy of her 94th birthday
What I never shared with Mom was that my Oration was a disaster that was a close equivalent to the egg that Biden laid at the debate. At the time I was essentially an extemporaneous speaker who would riff on my slide deck and feed on the expressions on the faces of those in my audience. You can read my speech in the reference section of this website. My problem on that late fall day was that I could not read my speech. I wear trifocals. I had early cataracts. The lighting on the podium in the fading late afternoon light was inadequate on a very dark late fall day. I could not see my words which were typed in an eleven-point font. I was also over-practiced but hadn’t memorized my speech. I lost it. What followed was forty-five minutes of agony for me and my audience which was similar to President Biden’s performance last week but was performed on a much less important stage. Anyone can have a bad day. My experience has been that as I got older and accumulated more physical liabilities and years of age, avoiding disappointing presentations became more difficult. My critical thinking improved with experience, but my ability to lead and pick up on developing problems seemed to decline.
While focusing on President Biden’s age-related frailties we must not forget that most of the concerns that apply to him also apply to former President Trump. Trump was born on June 1, 1946. So he is about a year younger than me. He has also demonstrated the momentary lapses that President Biden has demonstrated, but he lies so much that lies and nonsense are part of his presentation, and some of his slips go unnoticed or are explained by his faithful followers as part of his “schtick.”
If you click on the link above and read The Atlantic article by McKay Coppins you can get a good review of the chronicity of Trump’s pathology. You will be reminded in Coppins’ article, as I mentioned above, that during Nikki Haley’s ill-fated campaign against Trump in the primaries last winter she called for both Trump and Biden to take mental acuity tests. In an incident that most people have forgotten, Trump had confused Nikki Haley with Nancy Pelosi. You could see how that might happen, both of these people who annoy him are women with a first name that begins with “N.”
What will happen over the next few weeks is unclear. What faces President Biden is a mega problem fraught with uncertainty. The outcome of whatever President Biden decides to do will reverberate over the next several decades at a minimum. If he continues and loses, we can expect that many of the gains in access to healthcare will be threatened. If Biden withdraws, and if in the aftermath of Biden’s exit, the candidate who is rushed in to replace him fails to defeat Trump, we face the same losses and setbacks in our struggles to improve the social determinants of health. If Biden wins, there could also be problems with his performance if his health and cognitive function decline as some fear. I don’t know what the odds are for another successful four years from President Biden, nor is it possible to have any certain confidence that a replacement candidate could win. We face great uncertainties from the Democratic side of the ticket. There is no uncertainty on the Republican side of the vote. Trump will certainly be a threat to democracy in an unfettered second term.
Whatever is going to happen needs to happen very soon. I favor President Biden’s withdrawal with a focus of thankful gratitude for his many accomplishments. If he continues and loses, he faces the same criticism that has sullied the legacy of Justice Ruth Bader Ginsberg. If she had accepted her age and increased medical problems and resigned early in President Obama’s second term, we would have a more balanced Supreme Court. She didn’t, and we don’t.
There is no question that the events of the last week advantage a Trump victory. What will happen over the near future remains uncertain although I expect that President Biden will trudge on trying to climb what is now a steeper hill. Whatever happens, to protect healthcare and to hope for any progress in improving the social determinants of health, we must work hard for a Democratic victory. The down-ballot consequences of what happens will determine the composition of the House and Senate. The election will reverberate through several decades because the next president may have as many as three appointments to make for the Supreme Court.
Even if a Democratic candidate is elected, dark times could be on the horizon. If Trump loses and again fails to accept the results, we could see a reaction from the far right that will make the events of January 6, 2021, look like a garden party. I suggest that you read David Brooks’ interview with Steve Bannon as motivation for efforts to support whomever the Democratic candidate will be.
Rolling Into Summer
I spend a lot of time in the water. My view through my swim goggles is very similar to what you see in today’s header. Once again, I have lifted the picture from the underwater photography of my neighbor, Peter Bloch. Click here to enjoy the video from which the picture was lifted.
I hope that you had a terrific Fourth and that the fun and relaxation for you and your friends and family will continue through the weekend. The weather has been perfect here.
Be well,
Gene
