A couple of weeks ago, Donald Trump turned in one of his strangest performances in a campaign with no shortage of them—part of a series of oddities that may or may not constitute an October surprise but has certainly made for a surprising October. “Who the hell wants to hear questions?” he hollered at a town hall in Pennsylvania, after two attendees had suffered medical emergencies. Then he wandered the stage for nearly forty minutes, swaying to music from his playlist—“Ave Maria,” “Y.M.C.A.,” “Hallelujah.”
Trump has always given off Twenty-fifth Amendment vibes. But, even by that standard, his behavior has grown unnervingly bizarre, prompting new questions about his mental fitness and his emotional stability. In recent weeks, he has said that Haitian migrants should be deported “back to Venezuela,” rebranded the January 6th insurrection a “day of love,” mused about the size of Arnold Palmer’s genitals, and criticized Abraham Lincoln for not having “settled” the Civil War (though he did allow that Lincoln was “probably” a great President). Trump has also increasingly cancelled interviews, reportedly owing to exhaustion; he has held less than a quarter as many rallies in 2024 as he did in 2016.
Over time, Trump’s language has become angrier, simpler, less focussed, more violent, and more profane. According to the Times, his rally speeches are, on average, about twice as long as they were in 2016, and he swears nearly seventy per cent more often, a trait that can be associated with age-related disinhibition. The health-news site STAT has reported that since Trump left office his use of extreme and binary linguistic constructions such as “always” and “never”—which can also be a sign of cognitive decline or depression—has increased some sixty per cent, and that his speech now contains much more negative and backward-looking language. Trump himself has felt obliged to address his digressive rambling. “I do the weave,” he said recently. “I’ll talk about, like, nine different things, and they all come back brilliantly together.” He added, “English professors, they say, ‘It’s the most brilliant thing I’ve ever seen.’ ”
Joe Biden’s deficiencies became apparent in part because he has always behaved like a normal politician. But Trump’s conduct has been so aberrant for so long that separating genuine deterioration from routine volatility is no easy task—on what basis does one judge oscillations in something without precedent in public life? In the first half of this year, major U.S. newspapers ran dozens more articles about Biden’s mental acuity than they have about Trump’s in the past nine months, and, in the end, the Democratic leadership prevailed upon Biden to step aside for coalition and country. Republican leaders, confronted with the unravelling of their own nominee, have only reaffirmed their fealty.
Yet growing numbers of Americans seem to harbor misgivings about Trump’s age and cognitive abilities. In Wisconsin, according to polling from Marquette Law School, more than six in ten voters say that Trump is too old to be President; a recent Reuters/Ipsos poll found that, nationally, around half of Independents say that he doesn’t have the mental acuity for the job. The question is whether, after all that Trump has said and done—maligning the military, fawning over dictators, bragging about sexual assault, refusing to accept election results—the spectre of a man now even less in control of his faculties could be what moves voters.
The 2024 campaign has been unusual both in its intense focus on the health of the candidates and in its relative inattention to the health of the people. Whether owing to pandemic fatigue or to overworn slogans about Obamacare repeal and Medicare for All, health care has been less central to this election than to any in a generation. Bill Clinton fought for universal health care, and George W. Bush secured prescription-drug coverage for seniors. Barack Obama oversaw the passage of the Affordable Care Act, and Trump nearly orchestrated its demise. This year, a health-care transformation doesn’t seem to be in the offing—Trump’s “concepts of a plan” notwithstanding—but something more fundamental is on the ballot: a system of government that makes good health possible.
Not long after the American Revolution, Benjamin Rush, a physician and a signatory to the Declaration of Independence, proposed a link between healthy politics and healthy people. Rush argued that there is an “indissoluble union between moral, political, and physical happiness,” and that “elective and representative governments are most favourable” to both individual and societal well-being. His contention seems to have been borne out: research increasingly supports a salubrious effect of democratic governance.
A recent study in The Lancet, led by Thomas Bollyky, the chair of global health at the Council on Foreign Relations, suggests that, for many health outcomes, the strength of a country’s democracy may matter more than the size of its economy. On average, nations that transitioned from autocracy to democracy saw near-immediate improvements—within a decade, life expectancy increased by more than two years—and those which slid from democracy to autocracy experienced the opposite. Bollyky estimates that, in the decades between the fall of the Soviet Union and Trump’s glide down the golden escalator, democracy helped prevent some sixteen million deaths from cardiovascular disease alone.
Democratic governments are accountable to people, and people like to be healthy. Health care is what economists call a superior good, meaning that as societies get richer they want more of it. Democracies, accordingly, spend more on health than autocracies do, and are likely to preserve access to care even when the economy tanks. Meanwhile, a free press keeps people informed; the rule of law fuels innovation, by curbing corruption and protecting intellectual property; and independent agencies check power and implement regulations to promote clean water, breathable air, and safe food.
The real danger of a second Trump term is not that Trump is a man in decline. It is that, this time around, he would be surrounded by a cast of characters who aim to reify, not restrain, his worst impulses. John Kelly, Trump’s longest-serving chief of staff, has argued that Trump is “certainly an authoritarian”; Mark Milley, the former chairman of the Joint Chiefs of Staff, has warned that Trump is “fascist to the core.” Healthy democracy, like good health, requires adherence to a particular set of norms and behaviors, and the price of neglect is not just sick polities but sick people. With both, it’s better to push for prevention than to hope for a resuscitation. ♦