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The scandal of big tobacco’s behaviour in the developing world | Letters

I welcome your editorial and related coverage (Stop the spread of the tobacco companies’ poison, 13 July). Tobacco smoking is still the largest single preventable cause of ill-health and death. In the UK the reduction in smoking is one of the great public health success stories. However, it is important that this achievement is not reversed. E-cigarettes should be monitored closely.

Tobacco companies have tremendous financial and political power and, despite the overwhelming medical evidence against cigarettes, they are still able to sell their products. Moreover, certain markets are expanding. Two of the world’s largest tobacco companies are based in the UK. Both continue to perform strongly and are confident about their future performances, especially as markets are growing in lower income countries where there is tremendous potential for profit.

Many of the current strategies used by tobacco companies are not new. More than 30 years ago, Peter Taylor published a seminal book which provided a comprehensive insight into the world of public health politics. The Smoke Ring discusses the ring of political and economic interests surrounding the tobacco industry.
Dr Michael Craig Watson
University of Nottingham

We are concerned, if not surprised, to read the Guardian’s exposé of big tobacco’s use of trade measures to threaten African countries into watering down their efforts to promote public health (Report, 12 July).

A major problem with trade and investment agreements is their chilling effect on public interest legislation: countries that lack the time or resources to defend themselves against a trade dispute hold back from introducing new measures that are good for the public but threaten corporate profits and could provoke a trade challenge. This is particularly problematic where corporations are able to use the investor-state dispute settlement mechanism to sue governments in private tribunals where corporate lawyers act as judges.

For example, after Philip Morris challenged Uruguay and Australia for introducing graphic warnings on cigarette packaging and plain packaging respectively, Costa Rica, Paraguay and New Zealand delayed introducing similar measures. Philip Morris lost that case, but big tobacco is still attempting to bully (particularly low and middle income) countries that attempt to put the health of their citizens before shareholder profit. This has to be stopped.

Countries must be free to pursue independent development and public health strategies. That means having the space to regulate and tax in the public interest without the threat of litigation. We would like to see trade agreements that encourage governments to promote public health objectives, rather than acting as a brake on progress. This requires a fundamental shift in the way that we approach trade deals in the future.
Matthew Bramall Health Poverty Action
Paul Keenlyside Trade Justice Movement
David McCoy Professor of Global Public Health, Queen Mary University London
Dr Penelope Milsom Medact
Deowan Mohee African Tobacco Control Alliance
Alvin Mosioma Tax Justice Network – Africa
Mary Assunta South East Asia Tobacco Control Alliance
Deborah Arnott ASH (UK)
Laurent Huber Action on Smoking and Health (US)
Chiara Bodini and David Sanders People’s Health Movement 
Andreas Wulf Medico International
Jean Blaylock Global Justice Now
Mark Dearn War on Want
Tabitha Ha STOPAIDS
Thanguy Nzue Obame People’s Health Movement Gabon

That big tobacco hinders the adoption of anti-smoking legislation is no surprise. Your leader correctly identifies the best route to behavioural change – shareholder pressure – but does not highlight the key channel to achieve this. Big tobacco needs to diversify. This is where shareholder pressure should be applied: to encourage manufacturers and associated leaf merchants to invest in non-harmful products and speed up the process of product diversification. In addition, governments in the south and their development partners should work with manufacturers and merchants to reduce big tobacco’s own addiction to the evil weed.
Dr Martin Prowse
Lund University, Sweden

It is a proud claim we make in this country that 0.7% of our GDP is committed to international development. But efforts to reduce poverty and ill health in developing countries are seriously undermined by the activities of companies such as British American Tobacco.

The tobacco industry has an unrivalled record for dishonesty in trying to prevent its customers becoming aware that there is a 50% chance that they will die from smoking-related causes. It has been a long battle in this country to establish strong measures of tobacco control which have significantly reduced the prevalence of smoking.

In response, the tobacco companies are seeking to get many more people in the developing world addicted to their products. They use the same bogus arguments that have been defeated in the UK to prevent attempts by governments in those countries to prevent this happening. They behave in this way because they make great profits.

The world would be a much better place if such dangerous products were banned. But if this cannot be done by international agreement, then we must at least ensure that we tax them in such a way as to deter such behaviour. The funds raised could also help poorer countries in their fight to establish similar measures of tobacco control to those that are working in the UK.
Chris Rennard
Liberal Democrat, House of Lords

It is deeply unethical that BAT has taken African countries to court to dilute their efforts to protect their populations’ health from tobacco. These countries are still fighting infectious diseases and face a double burden of poor health as a result of non-communicable diseases, with very limited budgets to deal with these.

According to the international covenant on economic, social and cultural rights in the context of business activities (June 2017), these countries are obliged to protect their public’s health, and this includes regulating to restrict marketing and advertising of harmful products such as tobacco.

BAT is headquartered in the UK, so the UK is required to take the necessary steps to prevent human rights violations abroad and it is “contradictory to remain passive where the conduct of an entity may lead to foreseeable harm”.

Moreover, “extraterritorial obligation to protect requires the UK to take steps to prevent and redress infringements of rights that occur outside their territories due to the activities of business entities over which they can exercise control.”

If the UK does not fulfil its extraterritorial responsibility to protect future smokers in Africa, it is possible that it could be liable for damages when many develop cancer, heart disease and strokes. It is incoherent to give British aid for healthcare to these countries while at the same time a UK company is promoting harmful products that diminish people’s right to health.

On a related subject, British MP pension fund, the Parliamentary Contributory Pension Fund (PCPF), invests in BAT and some UK local authority pensions invest large sums in the tobacco industry which many already consider unethical even before the article in the Guardian.
Dr Bernadette O’Hare
University of Malawi and University of St Andrews

Smoking remains a major public health concern, a major contributor to overall mortality and morbidity, to air and water pollution and to physical, economic, social and psychological trauma. However, I must take issue with your allusion to the size of the distance from the developed to the developing world.

The Grenfell tragedy has shone a light on the ills of western societies where people are denied their fundamental rights to safe, clean and adequate housing; where hundreds of thousands are languishing in cramped and dangerous buildings; where homelessness, labour exploitation, knife crimes, racial and religious intolerance and joblessness are increasingly becoming hallmarks of society – and where cover up and deceit are becoming the norm rather than the exception.

To be fair, many developing countries have already recovered from the ills that still plague the developed world. Take a look in the mirror.
Dr Munjed Farid Al Qutob
London

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Art can be a powerful medicine against dementia | Nicci Gerrard

A few weeks ago, turning on the radio, I hear a voice saying that creative writing can help wounds heal faster. Startled, I turn the volume up. Volunteers were given small wounds; half were then asked to write about something distressing in their life, the other half about something mundane. The wounds of the confessional writers healed substantially more quickly. A thought or a feeling is felt on the skin. Our minds, which have power over our bodies, are in our bodies and are our bodies: we cannot separate the two. Words, self-expression, can tangibly help pain and suffering. Art can be medicine, for body and soul.

Over and over again, I am reminded of the transformative power of art. Answering the phone, I hear a deep and husky voice: “Doe, a deer, a female deer.” My mother, 85, frail, registered blind, bashed about by cancer and several strokes, is having singing lessons. At school, she was made to mouth the words of songs and she never sang again until now. Eighty years after being told she was tone deaf, her voice is being released. “Me, a name I call myself…”

Or recently I found myself in a hall in London, holding hands with a tiny woman from Jamaica and a large man from Birmingham, we dance. Bit by bit, our self-consciousness falls away and we grin at each other, laugh. Dementia has robbed them of their verbal ability – but there are many different languages, many different forms of embodied knowledge and ways that we can connect with each other.


Dementia can look like solitary confinement – and solitary confinement is a torture that drives most people mad

Or sitting in a church in Essex on a Sunday in June, I look across at my friend’s mother. She is in her 90s and has dementia. There are days when she is wretched, chaotic and scared, but each Sunday she is soothed and even enraptured by singing the hymns that she sang when she was a girl. The music has worn grooves in her memory and while she may not be able to speak in full sentences any more, she can sing Abide With Me in a true voice and her face, lifted up, looks young, eager, washed clean of anxiety. My friend thinks that at these moments her mother’s brain comes together, “like a flower reviving when it’s being soaked in water”. People with dementia, she says, need to be drenched in art.

And this is precisely what the report of an all-party parliamentary group inquiry into arts, health and wellbeing, to be launched on Wednesday 19 July, will say. After two years of evidence gathering, roundtables and discussions with service users, health and social care professionals, artists and arts organisations, academics, policy-makers and parliamentarians, its unambiguous findings are that the arts can help keep us well, aid our recovery and support longer lives better lived; they can help meet major challenges facing health and social care – ageing, long-term conditions, loneliness and mental health; and they can help save money in the health service and in social care.

Dementia is an area where the arts can radically enhance quality of life by finding a common language and by focusing on everyday, in-the-moment creativity. As Lord Howarth of Newport, co-chair of the all-party parliamentary group, said: “The arts have a vital role to play for people with dementia. Research demonstrates that visual arts, music, dance, digital creativity and other cultural activities can help to delay the onset of dementia and diminish its severity. This not only makes a huge difference to many individuals but also leads to cost savings. If the onset of Alzheimer’s disease (which accounts for 62% of dementias) could be delayed by five years, savings between 2020 and 2035 are estimated at £100bn. Those are powerful statistics, but this isn’t just about money; the arts can play a powerful role in improving the quality of life for people with dementia and for their carers.”

It’s what Seb Crutch and his team are exploring in their inspiring project at the Wellcome Foundation. It’s what is happening with Manchester Camerata’s Music in Mind or with Music for a While, a project led by Arts and Health South West with the Bournemouth Symphony Orchestra, with Wigmore Hall’s participatory Music for Life, with the project A Choir in Every Home and Singing for the Brain; with dance classes in hospitals and residential homes; with art galleries and museums that encourage those with dementia to come and talk about art.

One of a number of drawings by the artist David Shrigley, reflecting on individuals’ stories, that will be published with the report on arts, health and wellbeing on Wednesday.


One of a number of drawings by the artist David Shrigley, reflecting on individuals’ stories, that will be published with the report on arts, health and wellbeing on Wednesday. Photograph: David Shrigley

There are optimistic, imaginative endeavours going on all over the country, in theatres, galleries, cinemas, community centres, pubs, bookshops, peoples’ houses. It’s happening at a macro- and a micro-level. At a conference run by the Creative Dementia Arts Network, where arts organisations and practitioners gathered to share experience, I met two young students from an Oxford school who with fellow students go into local old people’s homes to make art: not the young and healthy doing something for the old and the frail, but doing it with them, each helping the other: this is the kind of project that is springing up all over the country.

I attended one of the monthly sessions at the Royal Academy in London where people with dementia who have been art-lovers through their life – and are art-lovers still – come to talk about a particular work, led by two practising artists. We sat in front of an enigmatic painting by John Singer Sargent, and there was an air of calmness, patience and above all, time, and there were no wrong opinions. There are many ways of seeing. People with dementia are continually contradicted and corrected, their versions of reality denied: it’s Sunday not Friday; you’ve already eaten your breakfast; I’m your wife not your mother; anyway, you are old and she is dead …. In this humanising democratic space, people were encouraged to see, think, feel, remember and express themselves. Slowly at first, they began to talk. There was a sense of language returning and of thoughts feeding off each other. They were listened to with respect and were validated.

Validation is crucial. We are social beings and exist in dialogue; we need to be recognised. In health, we live in a world rich with meanings that we can call upon as a conductor calls upon the orchestra, and are linked to each other by a delicate web of communications. To be human is to have a voice that is heard (by voice I mean that which connects the inner self with the outer world). Sometimes, advanced dementia can look like a form of solitary confinement – and solitary confinement is a torture that drives most people mad. To be trapped inside a brain that is failing, inside a body that is disintegrating, and to have no way of escaping. If evidence is needed, this report robustly demonstrates that the arts can come to our rescue when traditional language has failed: to sing, to dance, to put paint on paper, making a mark that says I am still here, to be touched again (rather than simply handled), to hear music or poems that you used to hear when you were a child, to be part of the great flow of life.

I think of the wonderful film Alive Inside, made about a project in a huge care home in America: an old man with advanced dementia sits slumped in a wheelchair. He drools; his eyes are half closed and it’s impossible to know if he is asleep or awake. A few times a day, soft food is pushed into his mouth. Then someone puts earphones on his head and suddenly the music that he loved when he was a strong young man is pouring into him. Appreciation of music is one of the last things to go. His head lifts. His eyes open and knowledge comes into them. His toothless mouth splits into a beatific grin. And now he is dancing in his chair, swaying. And then this man – who doesn’t speak any longer – is actually singing. The music has reached him, found him, gladdened him and brought him back into life.

It’s like a miracle – but one that happens every day, in care homes, in community halls, in hospitals, wherever kind and imaginative people are realising that the everyday creativity is not an add-on to the basic essentials of life, but woven into its fabric. Oliver Sacks wrote “the function of scientific medicine… is to rectify the ‘It’.” Medical intervention is costly, often short-term and in some cases can be like a wrecking ball swinging through the fragile structures of a life. But art calls upon the “I”. It is an existential medicine that allows us to be subjects once more.

Nicci Gerrard is a novelist and author and co-founder of John’s Campaign johnscampaign.org.uk

The man who may have secretly fathered 200 children

Twenty five years ago, when she was 35, Esther-Louise Heij made two decisions that would shape the rest of her life. The first decision went entirely to plan: it gave her the children she longed for. But the second decision would play out in a bizarre twist she could never have imagined, and would plunge her family into a sea of heartache that continues to this day.

Both decisions were brave to make a quarter of a century ago, and are testament to Heij’s judgment as well as her tenacity. First, she decided that although she was single, and had recently ended a 12-year relationship, she would forge ahead with her plans to become a mother by opting for IVF with donor sperm.

Second, and no less unusual at the time, she would make sure that her children would be able to trace their genetic father.

“Back then, the accepted wisdom was that donor children didn’t need to know,” she says. “But I felt it was their right to know. Where we come from, who our parents are – these things are important in anyone’s life, and I wanted them for my children.”

She heard about a clinic near Rotterdam whose director sounded forward-thinking, went along for a consultation, and was impressed.

“The doctor seemed very good at what he did,” she says. “He was a pioneer in his attitudes. He talked me through what it would be like to raise children on my own; he seemed very serious and professional.”

And he was supportive, too, of her hope that any children she had would be able to know their father. “He assured me that would be possible. He was an important doctor in a white coat. I trusted him; it never crossed my mind that I couldn’t.”

The doctor, Jan Karbaat, told Heij that he would find a donor whose physical attributes fitted into her family. “He asked me for pictures of my relatives, so he could find a good match. And he said he would make sure the donor was a man who would be open to being traced later.”

The Heij family.


The Heij family. Photograph: Joanna Moorhead

Heij and her children live in the southernmost tip of the Netherlands: their village, she tells me proudly, is on the only mountain in the country. “You won’t see scenery anywhere else in Holland like this,” she says, as we drive up the hill towards their house. Its hilltop position is fitting, because there have been many peaks and troughs to navigate for the Heij family.

During a long relationship with a partner, the one that lasted 12 years, she was pregnant twice; both times it ended in a stillbirth. Once she got the go-ahead for IVF from Karbaat, there would be nine unsuccessful attempts before she got a positive result. A daughter, Lotte, now 23, was born in 1994. Almost two years later, in 1995, Heij gave birth to a second child, Yonathan; Karbaat assured her the sperm was from the same donor.

Being a single mother of two was tough; but it was also the life she had wanted, and Heij has no complaints. The family moved around, supported by her work as a physiotherapist: living first in a village on an island in the north of Holland, then on an island in Norway.

She tried to be as open as possible with the children about their roots. “I told them: ‘A man gave his seed and that’s how you were born: if you want to know who he is you will get the chance to do that one day.’”

There were many children in the neighbourhood who didn’t live with both parents; but people asked questions that weren’t always easy to deal with, particularly for Yonathan. “They would say, ‘Where is your father?’ I made up a story about him being a man called Peter from Rotterdam, who was the captain of a ship, which explained why he was never around.”

One of the things that brought them back to Holland was Yonathan’s academic prowess: he was bright, and teachers at the small school in Norway felt they couldn’t challenge him sufficiently. Back in Holland, though, he flourished; Lotte, too.

When Lotte reached 16, she turned out not to have a burning desire to contact their father. Two years later, Yonathan took a different view. “For a boy to grow up without a father figure is a big thing; a father is important, especially for a boy. I wanted to know who he was: there were things I wanted to ask him. And I wanted to find out whether certain ways I behaved were connected with him – things that made me seem different from my mother and my sister, like that I’m much more laid back than they are.”

In 2011, Yonathan and his mother approached the organisations that should have been able to get the information she needed from Karbaat’s clinic. The news that came back was worrying: the files were in disarray, records had not been properly kept, and it was going to be difficult to find out who their donor was. What had originally seemed like an easy quest was going to be a much tougher haul; but they pressed on, making phone calls and filling in forms and requesting information.

Yonathan and Lotte speak to journalists prior to a court decision last month.


Yonathan and Lotte speak to journalists prior to a court decision last month. Photograph: Remko de Waal/EPA

At the same time, though, they became aware of growing suspicions about Karbaat’s clinic. “Rumours were rife,” says Yonathan. There were stories starting to circulate that the sperm donors had been fellow doctors, medical students; but the biggest upset of all were rumours that Jan Karbaat himself had provided much of the sperm that had impregnated his patients.

“We were in shock – it was a feeling of total disbelief. Karbaat was a doctor, and to use his own sperm to get women pregnant would have been totally prohibited. It was difficult to process the enormity of what this meant. But right away I thought: ‘This man could be my father.’ I was scouring pictures of him, looking for physical similarities.”

Yonathan was thrown into emotional turmoil. He had previously written to Karbaat asking for information about his father, and the letters had been returned unopened. “I thought, is that how little he cares? He seemed so cold, so arrogant. And this man could be my father – it was all very hard to come to terms with.”

Then a documentary about the clinic, shown on Dutch TV, raised the disturbing possibility that as many as 200 children could have been fathered by the same sperm donor.

“Yonathan was watching the television, saying: ‘These could be our brothers and sisters,’” says Heij. “A lot of them were very intelligent, just like him; and we were looking at them thinking: ‘Do they look like Yonathan and Lotte?’”

The family was thrown into a quandary, and found themselves at the centre of a very public controversy: eventually, both children gave DNA samples to find out whether they were related to any of the others conceived at the clinic who were now seeking answers.

Groups of individuals were found who were related to each other, but there seemed to be no sibling match for Yonathan and Lotte. “It was disappointing,” says Yonathan. “I hoped I would find at least some siblings. But I still wanted to know who my father was. Some people were saying: ‘If your father was Karbaat, maybe it would be better not to know.’ After all, he’s turned out to be an unscrupulous man. But I said no, I still want to know – however bad he was, he must have had some good qualities. It was like part of my identity was missing. I knew I needed to find out the truth.”

Over the past 18 months, a group of families whose children were born via IVF at Karbaat’s clinic have started legal proceedings to allow them to do DNA tests using cells from Karbaat.

Karbaat opposed the move, but he died, aged 89, in April this year. Police seized personal objects from his home, including his toothbrush, and a ruling on whether the DNA taken can be released to the families is expected shortly. In the meantime, though, the Heij family’s own DNA tests have proved Yonathan and Lotte are definitely full siblings, and that their father is most likely to come from central Europe.

The Heij family.


The Heij family. Photograph: Courtesy Esther-Louise Heij

The situation is changing all the time, says Yonathan: one of Karbaat’s acknowledged children has now been DNA-tested, and the results of that test suggest it’s less likely the Heij children are Karbaat’s, though by no means certain.

“Everything is up in the air now. I’m conscious that I may get a phone call tomorrow telling me who my father was, or I might have to wait 20 years,” he says. “It feels like waiting to find out whether you’ve won the lottery, but knowing you probably will.”

Indeed, according to Laura Bosch, of Defence for Children in Leiden – the legal organisation representing the Heijes and other families – that is precisely the point: technological advances, she says, have made ethical issues concerning paternity identification redundant.

“The existence of large DNA databases mean it’s getting easier and easier to trace a donor parent – it’s no longer feasible for anyone to say donors have the right to anonymity. I would argue that in any case the child’s right to information should prevail, and takes precedence over the donor’s right to anonymity, but the landscape is shifting.”

The health minister of the Netherlands, Edith Schippers, has asked men who donated sperm pre-2005, when the right to anonymity was lifted, to do “a second good deed” and come forward to make it easier for their children to trace them.

The emotional turmoil has taken its toll on 58-year-old Heij, who seems tired, and is tearful discussing all she’s been up against. But when it comes to Karbaat, she finds it impossible to condemn him out of hand. “He made me a mother,” she says simply. “He gave me these wonderful children. But he was also arrogant and narcissistic. He seems to have thought he was better than other donors, that he was doing women a favour to get them pregnant using his sperm.”

For Yonathan, meanwhile, the saga has led to what might seem a surprising decision. “I’ve decided to become a sperm donor myself,” he says.

As he explains it, it makes perfect sense. “I know that any children born as a result will be able to find me in the future. And I feel I will be able to help them, I will understand their situation in a way some donors can’t, because I’ve been through everything they’re going through. I will be able to relate.”

On Karbaat, his feelings are mixed. “He was a clever man but it’s dangerous to allow someone to work with no brakes; he had a lot of power, and a big ego. He wasn’t honest with my mother or with other patients – he didn’t tell the whole truth. I feel he had good intentions but his methods were wrong – he didn’t do things the way they should have been done, and some of the things he should never have done at all.”

Republican health bill: latest draft would scrap contraception mandate

The latest version of the US Senate’s bill to repeal major portions of the Affordable Care Act would eliminate the so-called birth control mandate, handing a long-sought victory to conservative activists who have spent years assailing the regulation.

The mandate is one of the most controversial benefits of the Obama administration’s enforcement of the ACA.

As Senate Republican leaders insisted they would forge ahead with a vote by the end of next week on their latest version of legislation to replace the ACA, reproductive health provider Planned Parenthood warned about the threatened change.

Dawn Laguens, the executive-vice president of Planned Parenthood Federation of America, said: “This latest version of Trumpcare is even scarier for women. It would undermine access to basic preventive care, including women’s preventive care with no co-pays.

“Insurance companies would once again be allowed to refuse to cover basic preventive health care, as well as charge women co-pays for birth control, immunizations, and cancer screenings.”

Conservative religious employers in particular have objected loudly to offering insurance plans which covered devices or pills whose use they saw as immoral. The mandate was twice challenged before the supreme court, with one challenge ending in a broad exemption for any closely held corporations that raised religious objections.

Still, the mandate currently requires nearly all health insurance plans to cover contraception without a co-pay. The mandate was not part of the text of the ACA but part of its enforcement: under the law, insurance plans were required to cover all preventive services, which the Obama administration determined to include a range of contraception drugs and devices.

But a change in the Senate bill released on Thursday, adopted at the suggestion of Texas senator Ted Cruz, would give many insurers the ability to scrap preventive benefits. The change, first reported on by Vox, would affect all forms of preventive care for men and women, such as cancer screenings and STI testing.

Cruz’s amendment, dubbed the Consumer Freedom Option, allows insurers to offer plans that do not meet the regulatory requirements of the ACA.

The contraception mandate took effect in August 2012. Although it is not clear how many women gained contraception coverage as a result, estimates suggest the mandate saved millions of women with insurance more than $ 1.4bn in out-of-pocket spending on contraception. Early research has also associated the contraception mandate with a historic drop in the US abortion rate that occurred in 2014.

A recent nonpartisan poll found that a majority of women would struggle to afford birth control if they had a co-pay.

Laguens said: “Thanks to the birth control benefit in the ACA, more than 55 million women currently have access to birth control without co-payments. Without insurance coverage, birth control pills can cost up to $ 600 a year. Trumpcare will put contraception, which has been instrumental in furthering women’s educations, careers, and economic standing, out of reach for many women.”

President Trump has already moved to weaken the mandate with an executive order he signed earlier this year directing the health department to exempt employers with a religious mission. The agency has drafted, but not finalized, a rule that would establish an exemption.

Cruz’s proposal is just one way the bill moving through the Senate would place women’s health coverage in a precarious position. The bill would also grant individual states the right to allow insurance plans to be sold without maternity coverage. That could force large numbers of women to pay thousands of dollars extra for essential coverage during their pregnancies.

Senate leaders revised their proposal to repeal the ACA after it was clear their original legislation would not garner enough votes. Conservative senators criticized the bill for preserving too many aspects of the ACA, while moderate senators representing poorer states were turned off by deep cuts to Medicaid, the government insurance plan for low-income Americans.

Slim majority

Republicans hold 52 seats in the Senate, meaning they can afford to lose only two votes in order to advance their healthcare bill, a scenario in which Mike Pence, as vice-president, would cast the tie-breaking vote.

At least two Republican senators, Susan Collins of Maine and Rand Paul of Kentucky, swiftly announced their opposition to the revised plan as it was unveiled on Thursday. Collins said that little, if anything, had been done to address her concerns over gutting Medicaid coverage, while Paul argued the legislation maintained much of the regulatory structure of the Affordable Care Act and was thus far from a repeal.

But several key Republican holdouts were reserving judgment until a score from the nonpartisan Congressional Budget Office, which is expected on Monday. The CBO projected that the previous bill would leave 22 million more Americans without insurance over a decade. Barring a significant change in forecast, the obstacles facing Republican leaders as they scramble to corral votes will only intensify.

Trump sought to amplify the pressure in a series of tweets late Thursday, urging Republicans to act on their seven-year vow to dismantle Obama’s healthcare law. “Republicans Senators are working hard to get their failed Obamacare replacement approved. I will be at my desk, pen in hand!” Trump wrote.

“So important Rep Senators, under leadership of McConnell, get healthcare plan approved. After seven years of O’Care disaster, must happen!”

Trump commended Pence for working with Republicans on Capitol Hill to reach a deal. But lawmakers in Washington have been struck by the lack of engagement from the White House.

Senator Bill Cassidy, a senator from Louisiana, said Pence’s message to Republicans in the Senate this week effectively boiled down to the need to simply pass a bill. Trump sent a similar signal on Twitter, stating that the onus was on Republicans to get the job done.

“After all of these years of suffering thru Obamacare, Republican Senators must come through as they have promised!” he wrote.

4 Unexpected Ways Summer Heat Is Throwing Your Body Out of Whack  

Summer is finally in full swing—which means cute sandals and sunglasses, beach vacations, and ridiculously scorching weather. If you’re feeling the heat, literally (does it really need to be 85 degrees before nine in the morning, seriously?) you’re not alone.

Hot temperatures can mess with your body in all sorts of sneaky ways, and we don’t just mean the threat of a sunburn or sweating through your outfit on the way to work. Here are four common ways hot, humid weather takes a toll on your health, plus how you can beat heat’s effect on your system.

RELATED: 20 Ways to Stop Allergies

You’re sniffling and sneezing

Flowers bloom in the summer—and so do plants and grasses that produce pollen, says Kim Knowlton, MD, an assistant clinical professor at Columbia University’s Mailman School of Public Health. In response to the warm weather, pollen production goes up, and the presence of pollen in the air can leave even people with mild allergies sneezing, sniffling, and rubbing their itchy eyes through Labor Day.

To reduce these allergy symptoms, pay attention to the daily pollen count and try to stay indoors as much as possible on high-count days. If you can’t give up your outdoor run or yoga class, try to time it (as well as other outside activities) toward the end of the day, when pollen counts go down. And keep windows shut in your house to keep allergens from turning you into a sneezy mess in your own home.

You toss and turn all night

Too hot to sleep—but the air conditioning in your room is making you shiver? Summer makes it tough to find that happy medium. Most people sleep best when the temperature is at 65 to 66 degrees; as the temperature goes up, sleep quality tends to go down, says Chris Winter, MD, neurologist and sleep medicine specialist at Charlottesville Neurology and Sleep Medicine in Virginia. 

The right temperature could also help you stay asleep through the night and score better sleep quality. So if you find yourself waking up fatigued and fuzzy-brained, try adjusting the thermostat. Dr. Winter says many of his patients have reported resting much better when they lower their bedroom temperature, even if they hadn’t noticed sleep problems. Don’t feel guilty for using so much electricity—cranking up the AC to a healthy level is good for you.

Your heart pounds way more than normal 

You do a hard-charging cardio workout three times a week, but your heart rate is suddenly spiking on your walk to work in the morning. What gives? Jonathan Newman MD, MPH, cardiologist at NYU Langone Medical Center in New York City, says higher temps have both direct and indirect effects on your heart.

For starters, if you live in an urban area, you may notice smog or haze fogging up summer skies. Air quality tends to get worse at higher temperatures, and that air pollution itself can take a toll on the heart and vascular system, Dr. Newman says.

Plus, at the most basic physical level, “your heart is working overtime” in the summer, says Kim Knowlton, MD, an assistant clinical professor at Columbia University’s Mailman School of Public Health. “Your heart beats faster in order to pump overly warm blood from your body’s core out to the skin’s surface,” says Dr. Knowlton, which helps cool you down.

Since your faster heartbeat is all part of your body’s way of keeping you cool, there’s not much you can do to prevent it. Taking normal precautions in the heat—drinking lots of water, not exerting yourself too much—are always good ideas. And of course, ”eating a heart-healthy diet, controlling your blood pressure, controlling your cholesterol, and increasing physical activity,” Dr. Newman says, will keep your ticker in good shape so it can handle 90-degree days.

RELATED: Everything You Must Know About Mosquitoes This Summer

You’re racking up lots of mosquito bites

When the weather is warm, you want to spend as much time in the great outdoors as possible. But while you’re embracing nature, dining al fresco, or just enjoying a backyard barbecue, mosquitoes are making you their buffet.

Unfortunately, summer is prime time for mosquitoes. Their prey (in other words, us) are outside more, and the little vampires also mature faster when the sun is out strong. That means skeeters live fast and die young, so the time between the day one hatches and the day it becomes a disease-transmitting adult is shorter. With mosquitoes taking less time to reach this stage, diseases (such as Zika and the West Nile Virus) can spread more quickly, says Aileen Marty, MD, an infectious disease specialist in Washington, D.C. 

What can you do to protect yourself? When you’re hanging outside, skip your signature scent in favor of bug spray, says Debra Jaliman, MD, New York City-based dermatologist and author of Skin Rules. She recommends Ultrathon Insect Repellent. ”It’s creamy and it says on your skin longer,” says Dr. Jaliman. It also has DEET, one of the few ingredients that have been shown to be truly effective in warding off mosquitoes.

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And what you heard as a kid is right—don’t scratch! As itchy as these bites are, scratching them can create an open wound, making you susceptible to infections, especially since there’s plenty of bacteria hiding under your nails, says Dr. Jaliman. 

If you just can’t keep your hands off your bites, Dr. Jaliman has a few suggestions. ”Use ice cubes to stop the itching; over-the-counter hydrocortisone cream or aloe vera gel will also diminish the itch and reduce swelling,” she adds.