President Joe Biden speaks during a Medal of Honor Ceremony at the White House in Washington, Wednesday, July 3, 2024, posthumously honoring two U.S. Army privates who were part of a daring Union Army contingent that stole a Confederate train during the Civil War. U.S. Army Pvts. Philip G. Shadrach and George D. Wilson were captured by Confederates and executed by hanging. (AP Photo/Susan Walsh)

WASHINGTON (AP) — President Joe Biden's conduct behind closed doors, in the Oval Office, on Air Force One and in meetings around the world is described in the same dual way by those who regularly see him in action.

He is often sharp and focused. But he also has moments, particularly later in the evening, when his thoughts seem jumbled and he trails off mid-sentence or seems confused.

Biden’s occasional struggles with focus may not be unusual for someone his age. But at 81 years old and seeking another four years in the White House, the moments when he’s off his game have taken on a fresh resonance following his disastrous debate performance against Republican Donald Trump.

The June 27 faceoff alarmed Democrats and his financial backers in part because Biden seemed so much worse than during the almost routine moments when he’s less sharp. And that has raised questions about whether he’s up for a campaign that’s only going to get nastier and whether he can effectively govern for another four years if he wins.

“We understand the concerns. We get it,” White House press secretary Karine Jean-Pierre said this week. But she insisted Biden has no intention of stepping away from the campaign.

This story is based on interviews with two dozen people who have spent time with the president privately, some of whom were granted anonymity to discuss interactions that were not intended to be public.

How he is in private is how he often is in public — uneven

The way Biden acts in private, according to regular observers, often tracks how he comes off publicly. In both settings, he can be commanding one day and halting another.

A day after his debate blunder, Biden's voice at a North Carolina rally was forceful, his eyes alert, his delivery confident. As he spoke, cheers filled the room.

“I give you my word as a Biden. I would not be running again if I didn’t believe with all my heart and soul I can do this job,” he told supporters. “Because, quite frankly, the stakes are too high.”

Through it all, public concern about Biden's fitness for another four years has been persistent. In an August 2023 poll from The Associated Press-NORC Center for Public Affairs Research, fully 77% of U.S. adults said Biden was too old to be effective for four more years. Not only did 89% of Republicans say that, but so did 69% of Democrats.

A shift in strategy to get Biden out there more

Biden’s advisers have long been aggressively dismissive of questions about his age. But now they’re acknowledging that Biden’s slowdown is undeniable. The debate has forced the president to more frontally acknowledge the limitations of his age, when before he largely made light of it.

After internal discussion within the campaign, the White House on Tuesday announced a public blitz: Biden will sit for an interview Friday with ABC’s George Stephanopoulos. The president added a trip to Wisconsin on Friday, and will head to Philadelphia on Sunday. And he will hold a press conference during the NATO summit in Washington next week.

Biden's allies worry that the next inevitable misstep — even if it’s not of the magnitude of his debate disaster — will resurrect voter concerns about the president’s fitness for office.

Grueling foreign trips

Three French officials who helped organize Biden’s visit to France earlier this month said their U.S. counterparts’ reactions to options offered for a state visit in Paris and D-Day commemorations in Normandy made them think the president’s health must be fragile.

After the Group of Seven summit in Italy, where Biden appeared pale and his movements slow, he flew across nine time zones to Los Angeles for a glitzy Hollywood fundraiser. One person who spoke with Biden at the event was struck by how tired the president had seemed during backstage conversations.

How Biden is on the job

Many in the White House say the president is in command across both domestic issues and critical foreign policy problems.

“I have been with the president a number of times over the last 3 1/2 years on some of the most consequential kind of life, death or peace-type decisions,” said Brett McGurk, a senior National Security Council official who has worked for both Republican and Democratic administrations.

“And what I have seen time and again — repeatedly and consistently — from the first week of the administration until now — is a president who prepares for those engagements, who has very detailed and comprehensive briefs for those engagements, and then does the engagement, and then has very active follow up.”

Unsatisfied with the explanations

Democrats so far have been largely unsatisfied with the explanations for Biden’s debate performance from White House staff, his campaign and the president himself. And there is a deeper frustration among some who feel like the president should have handled this much sooner, and he has put them in a difficult position by staying in the race.

Another problem for Democrats: With the focus so squarely on Biden, there has been less attention paid to Trump, whose debate performance was riddled with falsehoods about the Jan. 6, 2021, Capitol riot, Democrats’ views on abortion rights and his own revisionist comments about his response on a 2017 neo-Nazi rally.

Only Biden's doctors can really answer

Really, only Biden’s personal physician can answer questions about the president’s cognitive fitness — and given the level of public concern, he should do so, said aging researcher S. Jay Olshansky of the University of Illinois at Chicago.

Biden’s physician, Dr. Kevin O’Connor, deemed the president fit for duty after a February checkup that included a neurologic assessment. White House officials at the time said Biden wasn’t given a specific cognitive test because O’Connor and the neurologist decided he didn’t need one.

One bad appearance on TV isn’t enough to assess anyone’s cognitive ability, Olshansky stressed, “even for those of us that study aging for a living.”

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Corbet reported from Paris. Associated Press Writers Seung Min Kim, Mary Clare Jalonick, Josh Boak, Matthew Lee and Lauran Neergaard in Washington contributed to this report.

News from © The Associated Press, 2024