The cognitive health of a nation’s leader can have far-reaching consequences that extend beyond their term in office. A striking example of this is the case of President Woodrow Wilson, whose impairment during crucial post-World War I negotiations may have indirectly contributed to the conditions that led to World War II.

In 1918, Wilson contracted influenza during the global pandemic. This illness, coupled with a severe stroke in October 1919, left him significantly impaired during the final year of his presidency[1]. This period coincided with critical negotiations for the Treaty of Versailles, which would shape the post-war world order.

Wilson’s diminished capacity meant he was unable to effectively advocate for his “Fourteen Points” plan, which aimed for a more balanced peace[2]. Instead, harsher terms were imposed on Germany, creating economic hardship and national resentment that would later be exploited by extremist political movements[3].

The consequences of these decisions were catastrophic. World War II resulted in an estimated 70-85 million deaths worldwide[4], a scale of loss that might have been preventable had the post-WWI peace process been handled differently.

This historical example underscores the critical importance of a president’s cognitive function. Executive functions such as decision-making, problem-solving, and communication are essential for effective leadership, particularly in times of crisis or complex international negotiations[5].

One aspect of cognitive function that plays a crucial role in leadership is prosody – the rhythm, stress, and intonation of speech. Prosody is not merely about eloquence; it significantly impacts how messages are received and interpreted. Research has shown that prosodic features of speech can influence listeners’ comprehension, emotional response, and even decision-making[6].

In the context of presidential communication, prosody can affect a leader’s ability to motivate a nation, provide hope in times of crisis, and effectively convey complex policy decisions. Presidents who have been noted for their strong oratorical skills, such as Franklin D. Roosevelt and John F. Kennedy, used prosody effectively to rally public support and communicate their vision[7].

The implications of this are significant for the democratic process. When electing a president, voters are not just choosing a set of policies, but also a communicator-in-chief who must be able to lead effectively in times of national and global crisis. The cognitive health of candidates should be a key consideration in the electoral process.

It’s important to note that cognitive health is a complex issue influenced by many factors, and simplistic or discriminatory approaches should be avoided. However, given the potential long-term consequences of presidential decision-making, it is crucial that voters have accurate information about candidates’ cognitive capabilities and that robust systems are in place to ensure continuity of effective governance under all circumstances.

[1] Cooper, J. M. (2009). Woodrow Wilson: A Biography. Knopf.
[2] MacMillan, M. (2001). Paris 1919: Six Months That Changed the World. Random House.
[3] Keynes, J. M. (1920). The Economic Consequences of the Peace. Harcourt, Brace and Howe.
[4] Weinberg, G. L. (2005). A World at Arms: A Global History of World War II. Cambridge University Press.
[5] Goldstein, K. (2015). The Executive Brain: Frontal Lobes and the Civilized Mind. Oxford University Press.
[6] Scherer, K. R., & Bänziger, T. (2004). Emotional Expression in Prosody: A Review and an Agenda for Future Research. Speech Communication, 46(1-2), 180-203.
[7] Leanne, S. (2016). Say It Like Obama and Win!: The Power of Speaking with Purpose and Vision. McGraw Hill Professional.

It is troubling that his closest allies dismissed this as just a “bad night.” This situation is reminiscent of Monty Python’s Black Knight, who, after losing all his limbs after a duel with King Arthur, insists it is “only a flesh wound.” Such deflection ignores the serious implications of what we witnessed.

While I am not a neurologist, but just a humble retired GI doc, I have observed patients and family with neurologic symptoms and signs, taught mental status exams  for 5 years to  medical students and watched 10 seasons of ER. While watching the debate, terms like “abnormal prosody” and “paraphrasing errors” came to mind.. Coupled with a noticeably slowed, narrow gait, vascular Parkinson’s disease may be the disease process we are witnessing. This can mimic neurodegenerative disorders and  often follows a progressive course.

The stakes are too high to ignore these signs. Ensuring that the most powerful position in the world is held by someone who is neurologically and psychologically sound is not just a matter of political strategy—it is a matter of national and global security. If we are to avoid potential tragedy, we must confront these issues with the seriousness they deserve.

The recent debate should prompt a thorough and transparent evaluation of President Biden’s capacity to fulfill the demands of his office. Anything less risks dooming not just our nation, but the world, to the consequences of impaired leadership. The time for empathy and decisive action is now, for the sake of all our futures.

While learning about truth, honesty, civility and camaraderie in school, the real world of hidden agendas creeped in. New and improved Fruit Loops tasted  exactly the same as the old Fruit Loops. Two box tops and $2.00 did not get you “life sized action figures” but ant sized plastic toy soldiers. Reality only accelerated with age. “This VCR  is state of the art and will remain a standard for years,” the Circuit City salesman told me with a straight face in 1982 as I drained my bank account of $1,200.  Obviously, the advertising on cereal boxes and a stereo salesman suffered from hidden agendas or conflicts of interest.

The world of medicine brought its own litany of hidden agendas. Pharmaceutical representatives extolling the virtue of their brand name products when a generic and a lower cost substitute achieved the same goals. I entered the profession during the era of drug sponsored free Caribbean vacations, five star restaurant outings,  and “free” basketball playoff tickets. Was there a potential for bias in prescribing habits when you’re cutting into a filet mignon paid for by an acid reducer you haven’t used before? One would have to think so.

Transparency in medicine became clearer when government edicts regulated Pharma’s gifts to the medical profession. The trips, five star restaurants, and  sporting event tickets disappeared.  Finally, even complementary pens and trackpads were forbidden. Quite rightly, transparency in prescribing was demanded by consumers. Today, the consumer can check on their provider’s lunch reimbursements, Medicare payments, and Big Pharma consultant fees. A simple internet search will quickly reveal the truth regarding your doctors financial ties—if any— to pharmaceutical companies and the like.

Regretfully, most of the world operates with hidden agendas and conflicts of interest unbeknownst to the consumer or general public. However, to the world of medicine’s credit, regulatory agents have collectively required physicians to publicly reveal conflicts of interest.  For example, if you are a physician presenting a paper at a meeting regarding your research on a drug, you must disclose any conflict you have with the company making or marketing said drug.  Furthermore, your research paper must cite any conflict you have as well.

Certain areas of the field of medicine have escaped transparency and issues of reporting conflicts of interest.  Lobbying has produced the DSHEA Act of 1994 which stripped regulation and FDA oversight from over-the-counter pharmaceuticals. Many over-the-counter medicines have not been subjected to vigorous oversight or proof of efficacy.  Billions of dollars of products are bought that may have little or no assurance that they help or improve what it professes to do on the package information. Fortunes have been made from this lack of transparency to the patient slash consumer.  It would seem, in the public’s interest, that a warning indicating that a product that has not been rigorously tested and proven in its stated efficacy, should be placed on the product packaging.

It seems that physicians and some areas of medicine are leaders in self-reporting conflicts of interest and public available transparency of these conflicts should be the standard applied to all businesses that interface with the public at large.  For example, politics operates in the world of dark money facilitated by Citizen’s United and the death of campaign reform.  So when a politician publicly espouses a certain political opinion, why do they not have to disclose any influence or conflicts of interest they might have that would benefit from their political stance on an issue?  Doesn’t the American citizen need this transparency to be an educated voter?

Furthering this argument, Journalists in a variety of communication forums report information in the public’s best interest.  Under their by-line in a newspaper or in a chyron on the bottom your television screen there should be a clear statement of any conflict of interest the journalist might have.  If you own stock in a company that spilled oil into the ocean, I’d like to know that when you present information on the oil-spill.  

A rational world should apply the rules that govern conflicts of interest or hidden agendas in a schoolyard playground the same as they should in the world of medicine, politics and journalism to name a few.  Self-reporting, fairness, and truthfulness should be a minimal requirement for all who interface with the public who are purportedly looking out for your best interest.  

Let’s level the playing field. 

Fast forward to New Years Eve, 2000 as I anxiously turned on the TV to watch the Times Square Ball drop to usher in the new millennium. Car commercials came on, all terrestrial vehicles, United Airlines ads promising low fares to Europe at subsonic speed and no robots in sight in my Southern California home. How could Joel, my upstairs neighbor, be so wrong?  A case of media distortion syndrome, baby boomer edition, no doubt. 

Social media is replete with opinions and conspiracies that pass as truth and shape our world today.  My generation, spared from the early influence of the internet, was a product of broadcast television. The three networks (CBS, ABC and NBC) and local New York City stations, WNEW channel 5 and WPIX, channel 11, raised us through the ‘50s and 60’s and shaped our proclivities, biases and sense of reality. Through the writer’s scripts, we were raised on the magical, the ingenuity of the white male, the geological time slips, bigotry-lite, and anthropomorphisms. Here is a sampling of television education gone wrong:

1. The Magical
   1. Bewitched: A corporate advertising executive who marries a witch that can twitch her nose and change reality.
   2. I Dream of Jeannie: An astronaut finds a magic lamp and releases an attractive genie who alters reality and discombobulates authority.
   3. The Flying Nun: Self explanatory.
2. Ingenuity and Family Glue: The White Male
   1. Family Affair: A wealthy, N.Y.  bachelor engineer becomes surrogate father to two prepubescent 6 year olds and a female teenager, assisted by his English valet. No problem!
   2. Bachelor Father: Bachelor attorney adopts his adolescent niece and live happily ever after. 
   3. Sky King: Rancher and aviator raises his niece and extricates her from all sorts of perils.
   4. My Three Sons: Widowed engineer raises three sons with the help of his father-in-law and later invites his daughter-in-law to live with the extended family. No problem!

1. Geological Mayhem
   1. The Flintstones: Stone age family lives in Bedrock with their pet sauropod dinosaur. Humans: Pleistocene epoch, Dinosaurs: died in Late Cretaceous: 65 million year gap; a rounding error to the networks.
   2. The Jetsons: Flying cars, humanized robots and push button jobs but no physicists consulting on the show..
2. Anthropomorphisms
   1. Mister Ed: A debonair horse who only talks to his owner and has an egotistical streak.
   2. The People’s Choice: Politician’s basset hound makes wise cracks about the hi jinx experienced by his owner.
   3. My Mother the Car: Self Explanatory.
3. Bigotry-Lite
   1. The Real McCoys: An Appalachian grandfather moves with his grandson, and his family to cast aspersions on California natives. Starring  Walter Brennan, a John Birch Society member and avowed racist. 
   2. All in the Family: A Queens cabdriver, Archie
      Bunker, spins prejudice at home but his persona softened by his work ethic and his financial and housing support of his liberal son-in-law.
   3. The Beverly Hillbillies: Appalachian family moves to California where rich, wealthy Californians belittle the rural immigrants. A mirror image of The Real McCoys.

What we digested from those 3 networks and local feeds was entertainment to some and truth and dogma to others. Twitch your nose, rub a lamp, consult your single male engineer/attorney about child rearing or converse with your horse or your loquacious canine and prepare for a blissful life.  As to our current world, with each more outrageous conspiracy theory espoused on cable and social media, the Senate ready to discuss disenfranchisement of  millions of voters I can only shake my head and utter the insightful and comforting words of an equine star of yesteryear, “Oh Wilbur.”

This moment in my medical training recurs in my mind as I watched for the past 3 ½ years at the news correspondents’ quizzical looks as they tried to respond to Donald Trump’s ever increasing disjointed communication.  While my patient in the county psych ward communicated with violent behavior, he nonetheless was unable to express a coherent on-topic conversation that mirrors reality like Donald Trump.  As the evidence mounts of Trump’s psychopathology,  supported by Ivy League and family embedded mental health specialists, the parallel becomes more realistic.

How can you account for the election and sustained authority of a man that has no appreciation for reality, no empathy and no problem solving ability? Three concepts are critical, in my opinion: 1) The firewall of falsehoods that support politics and insulate the economic, profit motive for governance; 2) the pseudo-reality of 7 decades of television watching; 3) the inability of rational people to respond to a psychotic dialogue.

The political firewall of falsehood is particularly thick in our early education. We learn that Thomas Jefferson, the author of the Declaration of Independence and the third president of the United States is a great American, however educators skim over his ownership of slaves.  Andrew Jackson, our “people’s president” and victor over the British in New Orleans during the War of 1812, was also the architect of the forced removal and slaughter of the Cherokee from Georgia despite two Supreme Court rulings against its legality.  Various wars fought in the name of preserving the American way of life were often a subterfuge for economic gain. The latter was particularly relevant for me during the Vietnam War, as my generation was drafted and conducted the war at the bequest of past presidents, including the corrupt Richard Nixon. The firewall called the war effort to “prevent the spread of communism” and contain China and Russia from world domination.  These pseudo-facts were debunked by Southeast Asian historical scholars and disseminated in political science courses during my college years and validated by the subsequent arc of history.  Profits and employment opportunities in the U.S. were the nested reasons for this conflict. Lobbyists dominate political decision making and mask the true reason for congressional and presidential decision making. When one does break the firewall of mendacity and falls on the other side, the lure of profiteering can steer you back to the wrong side. No wonder, during my one Vietnam era protest in Washington, I was warned by relatives that this could harm my future employment in Wall Street financial firms. It was hard to contest the Trump supporter’s claim that “all politicians lie.”

Television was the final coup de grace that catapulted Trump into the White House. The lack of critical thinking is pervasive in our society and television has obliterated the lines of news and entertainment. Early television could still cling to morality and group cooperation (think Father Knows Best and Gilligan’s Island). “Reality” shows that masquerade as truth created a fictional narrative that viewers accepted without reservation. Without The Apprentice, Donald wouldn’t have had the political on-ramp he enjoyed.  While all who worked with Trump in the real world of construction and media declared him a fraud, he was on television and they must be mistaken.

In summary, rational people brought up on falsehoods, ensconced in Reality TV  for a number of years combined with protective self-talk when confronted with uncomfortable behavior from elected leaders, begin to accept and adapt to irrational discourse and actions. Consequently, they excuse or ignore it.

So the narrative goes as follows: Yes, he tells lies, but don’t all politicians do the same (the firewall of falsehood) and he’s a competent businessman, it says so on television. The psychosis element is dismissed by either: 1) not dealing with it (think of how many people avoid the homeless);  2) he couldn’t be in his position with a diagnosis of mental illness.

Mental illness that erupts into violent and dangerous behavior is easy to discern and react to swiftly with isolating the perpetrator from society.  That was easy to understand in my early days of training. Like the frog slowly boiled in hot water,  we have as a society built a firewall from truth, televised abnormal behavior into entertainment and have been trained to look away and excuse or normalize statements of question or actions by leaders when confronted with uncomfortable behaviors.  My Uncle Jack use to respond to all inexplicable government driven situations with, “It’s Fixed.”  I think he is correct, but it is up to us to fix the fix.