At a Senate debate Tuesday, the Pennsylvania Democrat John Fetterman, who is recovering from a stroke, at times stumbled over his words, jumbled his answers, and noticeably paused. In the political press, Fetterman’s performance was met with headlines about his “painful debate” and “struggles.”
The debate stirred up questions that have flared since Fetterman’s stroke five months ago, including how Republicans have been using it to stoke doubts about Fetterman, how transparent political campaigns should be about candidates’ health, and whether the media has been ableist and stigmatizing in its scrutiny of Fetterman.
“It knocked me down and I’m going to keep coming back up,” Fetterman said about his stroke during the debate with his Republican opponent, Mehmet Oz.
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Experts in stroke and speech, though, stressed that issues with language skills following a stroke are often separate from any potential impact on someone’s cognitive abilities. Moreover, they said they hope the attention on Fetterman will raise awareness about and acceptance of the types of accommodations that are commonly used by people with disabilities, including some of the 800,000 people who have strokes a year in the United States. Fetterman, for example, has used closed-captioning systems during interviews and at the debate.
Troubles with language “may affect how people perceive a person’s intelligence, but in many instances, the way a person sounds is not indicative of what their cognitive capability is,” said Adena Dacy, a speech language pathologist and the associate director of health care services at the American Speech-Language-Hearing Association. “Even if someone is having trouble retrieving words or names, a person’s intelligence can still be intact.”
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It’s fair for people to ask whether someone can work in a role as demanding as a U.S. senator after he has a stroke, said Borna Bonakdarpour, an associate professor of neurology at Northwestern University’s Feinberg School of Medicine. But Bonakdarpour said he didn’t think language issues should be the barrier that precludes that, noting that a third to half of people who have strokes have language problems.
“I don’t think intellectually he has any issues,” Bonakdarpour said. “That’s a very important distinction.”
“Fetterman may not be good at delivering a speech” for now and might need to find alternate ways to communicate more effectively, Bonakdarpour said. “The question is, how will the public accept that?”
The experts STAT spoke with noted they were not Fetterman’s clinicians and were either talking generally or relying on what has been reported publicly about his condition. Some have pointed to the fact that Fetterman is back to campaigning — with rallies and fundraisers — and that he can read, understand, and respond to debate and interview questions that way as indications of his apparent cognitive function.
In a letter earlier this month, Fetterman’s doctor wrote that Fetterman spoke “without cognitive deficits.”
The main lingering effect of the stroke that Fetterman and his campaign have pointed to is his auditory processing disorder. As his doctor’s note said, this can make it seem like he’s not hearing certain words or phrases, but really, it’s the result of his brain having trouble decoding the meaning of those words as quickly or efficiently as he did before his stroke. The injury to the brain can also make it harder for him to come up with what he wants to say clearly and expeditiously, experts said.
The experts also framed the captioning system Fetterman has been relying on not as a sign of weakness but rather as a compensatory tool that many people with auditory processing or hearing issues use. Having such an accommodation is a way for Fetterman to use the pathways in his brain that weren’t injured — in this case, his visual processing system.
Fetterman’s campaign had also said before the debate that there could be “awkward pauses, missing some words, and mushing other words together,” and noted that the captioning process could lead to pauses and miscommunications.
Alexandre Carter, a neurorehabilitation expert at Washington University in St. Louis, said that 50 years ago, the thinking was that someone couldn’t really recover after a stroke. But both because of better acute care and rehabilitation improvements, significant advances have been made. Other parts of the brain can compensate for the area that’s damaged during a stroke by making new connections or taking on new roles, and it’s possible that the brain can generate new neurons to restore some functions after an injury (though experts debate whether that is occurring or contributing to recovery).
Still, Carter said that people generally recover most of whatever function they’re going to regain within a matter of months after a stroke. The exception, Carter said, was language skills, which can continue to improve well over a year after a stroke.
Carter said he had seen how the public assumes that someone who has ongoing physical weakness or trouble speaking after a stroke is cognitively impaired as well. Sometimes there’s overlap, he said, but not always.
“People can have all different kinds of neurologic impairments, and it doesn’t mean necessarily that they have a problem with thinking,” Carter said. “Cognition — thinking and memory and problem solving — that’s a whole other set of functions in the brain.”
Fetterman suffered his stroke back in May. He has said the underlying cause was atrial fibrillation, an irregular heart rhythm that Fetterman had known about for years but for which he has not consistently kept up with treatment. Fetterman has also had a pacemaker and defibrillator implanted after his stroke.
Other politicians have had strokes or heart-related health issues while in office. Dick Cheney had a defibrillator implanted in 2001, during his first term as vice president. A decade ago, Republican Sen. Mark Kirk was away from the Senate for months after having a stroke. This year, two sitting Democratic senators, Chris Van Hollen and Ben Ray Luján, have had strokes and missed several weeks of work.
It seems that Fetterman’s case has received so much attention not only because of the continuing and clear impact on his speech and auditory processing, but also because of the closeness of his race, which could decide which party controls the Senate next term.
In the most recent update — a letter dated Oct. 15 — Fetterman’s physician, Clifford Chen (who has also donated to Fetterman’s campaign), wrote that Fetterman’s “communication is significantly improved compared to his first visit” and that he was continuing to go to speech therapy. It also said Fetterman “has no work restrictions and can work full duty in public office.”
Still, Fetterman’s campaign has been dogged by questions about how upfront it’s being with voters. The campaign hasn’t released Fetterman’s full medical records about his stroke, according to Politico, or allowed reporters to talk with Fetterman’s medical team. That has limited how much outside experts have been able to say about Fetterman’s condition.
The campaign has also said, according to the Washington Post, that Fetterman “does not have aphasia,” a disorder that limits language processing and speech that can occur after a stroke, but rather “auditory processing issues.” Some doctors have said they would describe Fetterman’s communication issues as aphasia, which can be resolved with therapy.
Some experts and advocates have argued the country should use the attention on Fetterman as a teaching moment about strokes and what the recovery process can look like.
As neuroscientist Jill Bolte Taylor, who herself had a severe stroke, wrote this week in the New York Times ahead of the Fetterman-Oz debate, “It would behoove our society to better understand strokes, including how someone can be slow to recover certain abilities and yet remain cognitively intact. We also do a poor job of understanding how the brain can heal itself and why stroke survivors may recover more completely when those around them are supportive and compassionate.”
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