First 100 days of Donald Trump's presidency

The first 100 days of Donald Trump's presidency began on January 20, 2017, the day Donald Trump was inaugurated as the 45th President of the United States. The first 100 days of a presidential term took on symbolic significance during Franklin D. Roosevelt's first term in office, and the period is considered a benchmark to measure the early success of a president. The 100th day of his presidency was April 29, 2017. Institutionally, President Trump had the advantage of a Republican Party majority in the U.S. House of Representatives and the Senate, but was unable to fulfill his major pledges in his first 100 days, with some approval rating polls reporting around 40%. He reversed his position on a number of issues including labeling China as a currency manipulator, NATO, launching the 2017 Shayrat missile strike, the North American Free Trade Agreement (NAFTA), renomination of Janet Yellen as Chair of the Federal Reserve, and the nomination of Export-Import Bank directors. Trump's approval among his base was high, with 96% of those who voted for him saying in an April 2017 poll that they would vote for him again. Near the end of the 100 days, the Trump administration introduced a broad outline of a sweeping tax reform focusing on deep tax cuts. Although Trump had to concede to delay funding for the U.S.–Mexico border wall he had promised, narrowly avoiding a government shutdown a few days before the end of the first 100 days. Trump signed 24 executive orders in his first 100 days. He signed 22 presidential memoranda, 20 presidential proclamations, and 28 bills. About a dozen of those bills roll-back regulations finalized during the last months of his immediate predecessor Barack Obama's presidency using the Congressional Review Act. Most of the other bills are "small-scale measures that appoint personnel, name federal facilities or modify existing programs." None of Trump's bills are considered to be "major bills"—based on a "longstanding political-science standard for 'major bills'". Presidential historian Michael Beschloss said that "based on a legislative standard"—which is what the first 100 days has been judged on since the tenure of President Franklin D. Roosevelt, who enacted 76 laws in 100 days including nine that were "major". Pledges: Trump pledged to do the following in his first 100 days: -Appoint judges "who will uphold the Constitution" and "defend the Second Amendment" -Construct a wall on the southern U.S. border and limit illegal immigration "to give unemployed Americans an opportunity to fill good-paying jobs" -Re-assess trade agreements with other nations and "crack down" on companies that send jobs overseas Repeal and replace the Patient Protection and Affordable Care Act (commonly called the Affordable Care Act or Obamacare) -Remove federal restrictions on energy production -Push for an amendment to the United States Constitution imposing term limits on Congress -Eliminate gun-free zones -Formulate a rule on regulations "that for every one new regulation, two old regulations must be eliminated" -Instruct the chairman of the Joint Chiefs of Staff to "develop a comprehensive plan to protect America's vital infrastructure from cyberattacks, and all other form of attacks." -Label China a "currency manipulator" -Enforce rules and regulations for China's unfair subsidy behavior. Instruct the U.S. trade representative to bring trade cases against China, both in U.S. and at the WTO. -Use every lawful presidential power to remedy trade disputes, including the application of 45% tariffs consistent with Section 201 and 301 of the Trade Act of 1974, and Section 232 of the Trade Expansion Act of 1962 to stop China's illegal activities, including its theft of American trade secrets. Inauguration: The first 100 days of the Presidency of Donald Trump began during the inauguration of Donald Trump with the conversion of Whitehouse.gov from the Obama Administration version to the Trump Administration version at 12:00 pm on January 20, 2017. This was the third presidential online portal transition and the first to transition social media accounts such as Twitter. As Trump took the oath of office, the official @POTUS Twitter account switched to President Trump with previous tweets archived under @POTUS44. Administration and Cabinet: On February 8, when Trump formally announced his 24-member-cabinet—the largest cabinet of any President so far—fewer cabinet nominees had been confirmed than any other president except George Washington by the same length of time into his presidency. Trump's reorganization of the cabinet removed the Chair of the Council of Economic Advisers that President Obama had added in 2009. The Director of National Intelligence and Director of the CIA were elevated to cabinet-level. During the transition period, Trump had named a full slate of Cabinet and Cabinet-level nominees, all of which require Senate confirmation except for White House Chief of Staff and the vice presidency. By April 29, almost all of his nominated cabinet members had been confirmed, including Secretaries of State Rex Tillerson, Treasury Steven Mnuchin, Defense James Mattis, Justice Jeff Sessions, the Interior Ryan Zinke, Secretary of Agriculture Sonny Perdue, Commerce Wilbur Ross, Secretary of Labor Alex Acosta, Health and Human Services HHS Tom Price, Housing and Urban Development HUD Ben Carson, Transportation Elaine Chao, Energy Rick Perry, Education Betsy DeVos, Veterans Affairs David Shulkin, Homeland Security John Kelly, Director of the Central Intelligence Agency (CIA) Mike Pompeo, UN Ambassador Nikki R. Haley, Environmental Protection Agency (EPA) Scott Pruitt, Small Business Administration Linda McMahon, Management and Budget OMB Mick Mulvaney, and Director of National Intelligence Dan Coats. Only two were awaiting confirmation—Trade Representative Robert Lighthizer and Council of Economic Advisers CEA Kevin Hassett. James Mattis was confirmed on January 20 as Secretary of Defense by a vote of 98–1. Mattis had previously received a waiver of the National Security Act of 1947, which requires a seven-year waiting period before retired military personnel can assume the role of Secretary of Defense. John Kelly was confirmed as United States Secretary of Homeland Security on the first day by a vote of 88–11. Former ExxonMobil CEO Rex Tillerson was sworn in as Secretary of State by Vice-President Mike Pence on February 1. Trump nominated Tillerson for the position as top U.S. diplomat (the equivalent of a foreign minister) on December 13, 2016. He was approved by the Senate Foreign Relations Committee on January 23, 2017, and by the full Senate in a 56–43 vote. Nikki Haley was confirmed as UN Ambassador with a Senate vote of 96 to 4. On January 26, 2017, when Tillerson visited the United States State Department, Undersecretaries Joyce Anne Barr, Patrick F. Kennedy, Michele Bond, and Gentry O. Smith all simultaneously resigned from the department. Former State Department chief of staff David Wade called the resignations "the single biggest simultaneous departure of institutional memory that anyone can remember." The Trump administration told CNN the officials had been fired and the Chicago Tribune reported that several senior state department career diplomats left the State Department, claiming they "had been willing to remain at their posts but had no expectation of staying." On February 10, Tom Price was confirmed as Secretary of Health and Human Services (HHS), a "$1 trillion government department". HHS includes National Institutes of Health (NIH), the Centers for Disease Control and Prevention, and the Food and Drug Administration (FDA). Price, who is a vocal opponent of the Affordable Care Act, will oversee its repeal and replacement. He has published articles in the "small, conservative medical association", the Association of American Physicians and Surgeons, to which he belongs, that opposes mandatory vaccination and continue to argue that the vaccines causes autism, a "discredited conspiracy theory that Trump has long espoused". In response to questions from Senators at the hearing as to whether he believes autism is caused by vaccines, he responded, "I think the science in that instance is that it does not". Steve Mnuchin, who was nominated by Trump in November 2016, was finally confirmed on February 13, 2017, as Secretary of the Treasury department after lengthy confirmation hearings. On February 16, the Senate voted 54 to 46 to advance Scott Pruitt's nomination as Administrator of the Environmental Protection Agency. On February 16, a District Court Judge in Oklahoma, Aletia Timmons, ordered Pruitt to "turn over thousands of emails related to his communication with the oil, gas and coal industry" in a case brought to court by the Center for Media and Democracy. Lawmakers had criticized Pruitt who sued the EPA 14 times on behalf of the State of Oklahoma. Trump nominated Alexander Acosta as Secretary of Labor on February 16, when his first nominee Andrew Puzder stepped down under a wave of criticism for having employed an illegal immigrant as a former housekeeper, for his "remarks on women and employees at his restaurants" and for his "rancorous 1980s divorce". Notable non-Cabinet positions: According to a database compiled by the Washington Post in collaboration with the Partnership for Public Service, as of April 27, 473 of the 554 key executive branch nominations that require Presidential nomination and Senate confirmation, had not yet been appointed, including "Cabinet secretaries, deputy and assistant secretaries, chief financial officers, general counsel, heads of agencies, ambassadors and other critical leadership positions." Only three of the 119 Department of State executive branch positions have been filled and only one position in the Department of Defense—the Secretary of Defense, James Mattis—has been filled out of 53 key positions. Trump has not yet nominated anyone for 49 of these positions. On February 28, in an exclusive interview Tuesday with Fox & Friends, said, "a lot of those jobs, I don't want to appoint, because they're unnecessary to have. ... You know, we have so many people in government, even me. I look at some of the jobs and it's people over people over people. I say, 'What do all these people do?' You don't need all those jobs ... Many of those jobs I don't want to fill. I say, isn't that a good thing? That's not a bad thing. That's a good thing. We're running a very good, efficient government." Prior to taking office, Trump named several important White House advisers to positions that do not require Senate confirmation, including Stephen K. Bannon as his "senior counselor and chief West Wing strategist" and Reince Priebus as Chief of Staff, with a mission "as equal partners to transform the federal government." Other important advisers outside of the Cabinet include (Counselor to the President) Kellyanne Conway, Senior Advisor (National Security Advisor) Michael Flynn (replaced by H. R. McMaster) and (National Trade Council) Director Peter Navarro. (Homeland Security Adviser) Thomas P. Bossert, (Regulatory Czar) Carl Icahn, (White House Counsel) Donald F. "Don" McGahn II, and (Press Secretary) Sean Spicer. Michael T. Flynn served as Trump's National Security Advisor from January 20 until his resignation on February 13, 2017. He set a record for the shortest tenure as National Security Advisor in American history. The Justice Department warned the Trump administration that Flynn, who had a "well-established history with Russia", may have been "vulnerable to blackmail by Moscow". Flynn had "mischaracterized his communications" with Russian Ambassador Sergey Kislyak to Vice President Mike Pence regarding U.S. sanctions on Russia. Flynn's phone calls had been "recorded by a government wiretap" and several days after Flynn was named as Trump's Advisor, Sally Yates, who was then acting attorney general, warned the White House that "Flynn was susceptible to blackmail by the Russians because he had misled Mr. Pence and other officials". According to a February 14 article by The New York Times, it was unclear why the White House did not react to Yates' warning in early January. There were also questions about how much was known in early January by Bannon, Pence, Spicer, and Trump. Yates was fired on January 30, in an unrelated incident. On February 20, 2017, Trump named "warrior-scholar deemed an expert in counter insurgency", Lieutenant General H. R. McMaster, to replace Flynn as National Security Advisor. Trump overruled McMaster's attempt to replace 30-year-old NSC aide Ezra Cohen-Watnick, a Mike Flynn appointee, with Linda Weissgold, when Bannon and Kushner intervened on Cohen-Watnick's behalf on March 11–12. Cohen-Watnick gathered classified files on intelligence information on U.S. persons. On January 28, 2017, Trump signed a Memorandum, the Organization of the National Security Council and the Homeland Security Council which restructured the Principals Committee—the senior policy committee—of the National Security Council, assigning a permanent invitation to Steve Bannon, White House Chief Strategist, while at the same time withdrawing the permanent invitations of the Chairman of the Joint Chiefs of Staff and Director of National Intelligence. On April 5, the 75th day of Trump's presidency, under guidance from Army Lieutenant General H. R. McMaster, the National Security Advisor (NSC advisor) who replaced Mike Flynn, Trump removed Bannon, who has no security experience, from the National Security Council's principals committee. Trump's 36-year-old son-in-law, Jared Kushner is Trump's Senior Advisor alongside Stephen Miller. "In his January interview with the Times of London, Trump said that Kushner would be in charge of brokering peace in the Israeli–Palestinian conflict. He is also a "top adviser on relations with Canada, China and Mexico". On April 3, Kushner accompanied the head of the Joint Chiefs of Staff, General Joseph F. Dunford Jr. and Homeland Security Advisor Thomas P. Bossert to meet with Iraqi Prime Minister Haider al-Abadi "to discuss the fight against the Islamic State and whether the United States would leave troops in Iraq afterward. Trump named Kushner as head of the White House Office of American Innovation, (OAI), established on March 29 and mandated to use ideas from the private-sector to overhaul all federal agencies and departments in order to "spur job creation". One of the OAI's first priorities is to modernize the technology of departments such as Veterans Affairs. In his new position, Kushner will work with Chris Christie, who will chair the newly established "President's Commission on Combating Drug Addiction and the Opioid Crisis" in response to Trump's pledge to combat opioid abuse. On January 28, in his eleventh Presidential Memoranda, "Organization of the National Security Council and the Homeland Security Council", White House Chief Strategist, Steve Bannon, was designated as a regular attendee to the National Security Council (NSC)′s Principals Committee, a Cabinet-level senior interagency forum for considering national security issues, in a departure from the previous format in which this role is usually held for generals. While at first there was some confusion over meeting attendees, Priebus clarified on January 30, that defense officials could attend the meetings. On April 5, the 75th day of Trump's presidency, under guidance from Army Lieutenant General H. R. McMaster, the National Security Advisor (NSC advisor) who replaced Mike Flynn, Trump removed Bannon, who has no security experience, from the National Security Council's principals committee. On February 2, Time published an article about Bannon as potentially, the second most powerful man in the world, illustrated with a cover labeling him as the "Great Manipulator". After only a fortnight into Trump's presidency, NPR described Bannon as "the power behind the throne" and the "gray eminence behind much of what Trump was prioritizing", rivalling Kushner's and Priebus' roles. Mike Pence affirmed in a PBS NewsHour report that only Trump was "in charge". Bannon and Steve Miller have been called the "architects" of the inaugural address, executive orders, including the controversial travel and refugees EO, and presidential memoranda. In an often-cited October 8, 2015, lengthy profile entitled "This Man Is the Most Dangerous Political Operative in America" by Joshua Green, a senior national correspondent for Bloomberg News, Green described how Breitbart News with Bannon at its helm, had "championed Trump's presidential candidacy" and helped "coalesce a splinter faction of conservatives" who were irate over the way in which Fox News had treated Trump. Green quoted then-Senator Jeff Sessions as an admirer of Breitbart, which was "extraordinarily influential", with many radio hosts "reading Breitbart every day". Trump cited Breitbart News to vindicate his claims. Stephen Miller, Trump's Senior Advisor, was Jeff Sessions' communications director when he served as Senator for Alabama. Thirty-one-year old Miller, Bannon, and Andrew Bremberg sent over 200 executive orders to federal agencies for review before January 20. Miller has been an architect behind the inaugural address and the most "contentious executive orders" including Executive Order 13769. In a February 12 interview with ABC News anchor George Stephanopoulos, when asked to provide evidence "for Trump's "unfounded allegations" where former Senator Kelly Ayotte lost her bid for election, and Trump narrowly lost to Clinton in 2016, Miller suggested Stephanopoulos interview Kansas Senator, Kris Kobach, who relied upon a 2012 Pew Research Center study in his voter fraud claims. The day before the interview a Federal Election Commission Commissioner called on Trump to provide evidence of what would "constitute thousands of felony criminal offenses under New Hampshire law." Gary Cohn, the former Goldman Sachs investment banker and executive, took office on January 20, as Trump's Director of the National Economic Council, (NEC), a position which did not require Congressional confirmation, By February 11, 2017, The Wall Street Journal described Cohn as an "economic-policy powerhouse" in Trump's administration and The New York Times called him Trump's "go-to figure on matters related to jobs, business and growth." While the confirmation of Trump's December 12, 2016, nominee for Secretary of Treasury, Steven Mnuchin, was delayed until February 13 by Congressional hearings, Cohn filled in the "personnel vacuum" and pushed "ahead on taxes, infrastructure, financial regulation and replacing health-care law." In November, Trump considered offering Cohn the position as Secretary of Treasury. If Cohn had stayed at Goldman Sachs, some believed he would have become CEO when Lloyd Blankfein vacated that office and his $285 million severance package "raised eyebrows" according to CNN. Bannon and Cohn disagree on the border-adjustment tax, the centerpiece of Paul Ryan's controversial tax reforms presented on February 17, which includes a 20% import tax, export subsidies and a 15% reduction in corporate tax rates that would, among other things, pay for the Mexican wall, which according to a The Washington Post study, would cost $25 billion and which Trump stated would cost $12 billion. Domestic policy- United States Domestic Policy Council: The Domestic Policy Council (DPC) consists of Trump and Andrew Bremberg as Directors with Paul Winfree as Deputy Assistant. Council attendees include Mike Pence, Jeff Sessions, Tom Price, John F. Kelly, David Shulkin, Ryan Zinke, Betsy DeVos, Ben Carson, Elaine Chao, Wilbur Ross, Rick Perry, Steven Mnuchin, and—when appointed—the Secretary of Labor and the Secretary of Agriculture. Additional attendees include Scott Pruitt, Mick Mulvaney (Director of the Office of Management and Budget), Gary Cohn, and—when appointed—the Chair of the Council of Economic Advisers and the Director of the Office of National Drug Control Policy. The Congressional Research Service describes DPC's role as analyses of domestic policies and social programs including "education, labor and worker safety; health-care insurance and financing; health services and research; aging policy studies; Social Security, pensions and disability insurance; immigration, homeland security, domestic intelligence and criminal justice; and welfare, nutrition and housing programs." Withdrawal of the Affordable Care Act: Within the first hours of Trump's presidency, he signed his first executive order, Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal (EO 13765) to fulfill part of his pledge to repeal the Patient Protection and Affordable Care Act (ACA), which was part of a series of steps taken prior to 2017 to repeal and defund the ACA, including most recently, the FY2017 budget resolution, S.Con.Res. 3, that contained language allowing the repeal of ACA through the budget reconciliation process. A CBO report estimated 18 million people would lose their insurance and premiums would rise by 20% to 25% in the first year after repealing Obamacare. Uninsured could reach 32 million by 2026, while premiums could double. The order states what Mr. Trump made clear during his campaign: that it is his administration's policy to seek the "prompt repeal" of Obamacare. During his Fox News interview with Bill O'Reilly airing before the Super Bowl, Trump announced that the timeline for replacing Obamacare had to be extended and that a replacement would probably not be ready until 2018. Republicans are limited as to how much of ACA they can undo as they do not have a 60-vote majority in the Senate. They also "must balance the interests of insurers and medical providers". According to the March 13, 2017 report by the nonpartisan Congressional Budget Office and staff of the Joint Committee on Taxation (JCT) on the budgetary impact of the Republican bill to repeal and replace ACA over the coming decade, there would be a $337 billion reduction in the federal deficit and an estimated loss of coverage to 24 million more Americans. The Republican health-care plan was unveiled on March 6 and faced opposition from both moderate and conservative Republicans, such as the House Freedom Caucus. The American Health Care Act of 2017 (AHCA), a bill to repeal and replace the ACA, was withdrawn in Congress on March 24, 2017 due to lack of support from within the Republican caucus. Immigration policy: In his first 100 days, President Trump set the tone for immigration policies, by signing executive orders to set in motion travel bans and restrictions on refugees and immigrants from Muslim-majority countries, increased immigration enforcement including deportations, and expanded efforts to prevent illegal entry into the United States by building a wall along the Mexico–United States border. While the numbers of people deported were very similar to those in 2016, the categories of people targeted for deportations was broadened during this period, which meant that many more people are at a heightened risk of deportation. Secretary Kelly clarified that Immigration and Customs Enforcement (ICE) "will no longer exempt classes or categories of removable aliens from potential enforcement." By April 3, according to ICE, there had been 35,604 removals in January and February 2017 compared to 35,255 in the same period in 2016. But the "tough rhetoric" and some "high-profile Ice operations" widely cited in the media resulted in widespread fear and panic within immigrant communities. In an AP April 20 interview, Trump said that, "The dreamers should rest easy". There are 800,000 young people protected by Obama's "Deferred Action for Childhood Arrivals" (DREAMERS) who came to the U.S. as children and are living there illegally. Some of these "dreamers" in interviews with The Associated Press on April 21, said they "were not comforted by Trump's pledge" particularly since the April 18 deportation of 23-year-old "dreamer", Juan Manuel Montes. Trump supporters who are "immigration hard-liners", such as NumbersUSA and Mark Krikorian of the Center for Immigration Studies, feel deceived by Trump's softening stance on DREAMERs arguing that "his promise on DACA was pretty clear and unequivocal". Travel ban and refugee suspension: On January 27, at 4:42 p.m EST, Trump signed Executive Order 13769, entitled "Protecting the Nation From Terrorist Attacks by Foreign Nationals" which temporarily suspends the U. S. Refugee Admissions Program (USRAP) for 120 days and denies entry to citizens of Iraq, Iran, Libya, Somalia, Sudan, Syria and Yemen for 90 days. The suspension for Syrian refugees is for an indefinite period of time. The Economist described the order as "drafted in secret, enacted in haste and unlikely to fulfill its declared aim of sparing America from terrorism" with "Republican allies" lamenting that a "fine, popular policy was marred by its execution." Notably Saudi Arabia was not on the list though most of the 9/11 hijackers were from there. See Provisions of Order 13769. On February 4, the U.S. Department of Homeland Security and the State Department suspended all actions to implement the week-old EO in response to the February 3 ruling by federal judge James Robart which blocked the EO. According to CNN and the Los Angeles Times, the architects behind the order, were Stephen Miller and Steve Bannon. White House officials deny that it was written without input from the U.S. Department of Justice's Office of Legal Counsel (OLC). It was argued that these seven countries ranked among the lowest 15 of the 104 countries evaluated by the Henley & Partners Visa Restrictions Index in 2016 based on the "number of countries that their citizens can travel to visa-free". For example, Germany ranks the highest at 177 points, Afghanistan the lowest of all 104 at 25. The order also calls for an expedited completion and implementation of the Biometric Entry-Exit Tracking System for all travelers coming into the United States. The first legal challenge against the EO was filed on January 28, and within two days there were dozens of ongoing lawsuits in the United States federal courts. By February 3, federal judge, James Robart temporarily blocked the week-old EO which opened American airports to visa holders from the seven targeted countries. At the international level legal concerns have been raised by the UN, Zeid Ra'ad al Hussein, who claimed that "discrimination on nationality alone is forbidden under human rights law." On January 30, in a telephone call to Trump, German Chancellor Angela Merkel explained that his EO "ran counter to the duties of all signatory states" to the Geneva Refugee Convention "to take in war refugees on humanitarian grounds". Thousands protested at airports and other locations throughout the United States. Critics of the ban include most Democrats and several top Republican Congressmen, former President Obama, the Council on American–Islamic Relations, over a dozen state attorneys general, thousands of academics, Nobel laureates, technology companies, Iran, France, Germany, and 800,000 petitioners in Britain. Supporters of the ban include 82% of GOP voters, Paul Ryan, Bob Goodlatte, Czech President Miloš Zeman, and members of the European far right. According to an IPSOS online poll conducted on January 31, in response to the question, "Do you agree or disagree with the Executive Order that President Trump signed blocking refugees and banning people from seven Muslim majority countries from entering the U.S.?", 48% of the 1,201 Americans polled agreed with the statement (23% of the 453 Democrats, 82% of the 478 Republicans, and 44% of the Independents polled). On the evening of January 30, Trump replaced acting Attorney General Sally Yates with Dana Boente. Spicer's statement described Yates as an "Obama administration appointee" who had "betrayed the Department of Justice" by "refusing to enforce a legal order". In the Senate, Chuck Schumer, called her firing a Monday Night Massacre in reference to Nixon's firing of his attorney general, referred to as the Saturday Night Massacre during Watergate. Trump also replaced DHS's ICE Chief Daniel Ragsdale with Thomas Homan as Acting Director in the evening of January 30. In a live interview with Chris Wallace on January 29, Fox News Sunday, Kellyanne Conway, justified the list of seven countries by claiming that the countries were originally identified as a threat in the Terrorist Prevention Act passed by Congress in 2015. HUD's Visa Waiver Program Improvement and Terrorist Travel Prevention Act of 2015, was extended amid some controversy in February 2016, when it revoked the privilege of traveling to the States without a visa to people who "had recently traveled to Iraq, Syria, Iran or Sudan", as they were considered high-risk. A spokesman for former president Obama issued a statement stating, "The president Obama fundamentally disagrees with the notion of discriminating against individuals because of their faith or religion." In his final press statement as president, Obama said, "There's a difference between the normal functioning of politics and certain issues or certain moments where I think our core values may be at stake," and stated his intention to speak out if a situation is serious enough. Obama encouraged Americans to protest the issue. In response to a temporary restraining order (TRO) issued in the case of State of Washington v. Trump, the Department of Homeland Security said on February 4 that it had stopped enforcing the portions of the executive order affected by the judgment, while the State Department activated visas that had been previously suspended. The restraining order was upheld by the United States Court of Appeals for the Ninth Circuit on February 9, 2017. On March 15, a United States Federal Judge, Derrick Watson of the District Court of Hawaii, issued a 43-page ruling which blocked Trump's revised March 6 executive order 13780 on the grounds that it violated the First Amendment's Establishment Clause by disfavoring a particular religion. The temporary restraining order was converted to a preliminary injunction by Judge Watson on March 29. On an April 18 airing of the Mark Levin Show Jeff Sessions commented, "We are confident that the President will prevail on appeal and particularly in the Supreme Court, if not the Ninth Circuit. So this is a huge matter. I really am amazed that a judge sitting on an island in the Pacific can issue an order that stops the President of the United States from what appears to be clearly his statutory and Constitutional power." High-profile ICE operations: On February 8, 2017, Immigration and Customs Enforcement (ICE) agents arrested 35-year-old Guadalupe García de Rayos, when she attended her required annual review at the ICE office in Phoenix, and deported her to Mexico on the next day based on a removal order issued in 2013 by the Executive Office for Immigration Review. Immigrant advocates believe that she is the first to be deported after the EO was signed and that her deportation "reflects the severity" of the "crackdown" on illegal immigration. ICE officials said that her case went through multiple reviews in the immigration court system and that the "judges held she did not have a legal basis to remain in the US". In 2008, she was working at an amusement park in Mesa, Arizona when then-Sheriff Joe Arpaio ordered a raid that resulted in her arrest and felony identity theft conviction for possessing a false Social Security number. Arpaio was a subject of several controversies during his tenure as sheriff. In 2015, the U.S. Department of Justice partially settled a lawsuit filed against Arpaio for unlawful discriminatory police conduct, alleging that Arpaio had overseen the worst pattern of racial profiling in U.S. history. ICE officials in Los Angeles released a report on February 10, 2017, that about 160 foreign nationals were arrested in a five-day operation. Of those, 150 had criminal histories, and of the remaining arrests, five had final orders of removal or were previously deported. Ninety-five percent were male. Under Trump's EO, the definition of criminal is much more "sweeping" than Obama's, which "prioritized expulsion of undocumented immigrants who threatened public safety or national security, had ties to criminal gang activity, committed serious felony offenses or were habitual misdemeanor criminal offenders" and a single immigration officer decides. On the morning of February 14, ICE officials entered the Des Moines, Washington family home of 23-year-old Daniel Ramirez Medina on an arrest warrant for Ramirez' father, who was taken into custody. Ramirez, who has no criminal record, entered the United States illegally as a child, and was later able to get a legal work permit through the 2012 Deferred Action for Childhood Arrivals (DACA) policy, was placed in detention in the Northwest Detention Center, Tacoma, Washington. According to ICE, Ramirez was detained based on "his admitted gang affiliation and risk to public safety". According to Ramirez's lawyer, Ramirez "unequivocally denies" these allegations and claimed ICE agents "repeatedly pressured" Ramirez to "falsely admit" gang affiliation. "The case raises questions about what it could mean for Dreamers, undocumented immigrants who were brought to the United States as children." U.S.–Mexico border wall proposal: While visiting the Department of Homeland Security (DHS) on January 25, President Trump signed his third executive order Border Security and Immigration Enforcement Improvements (EO 13767) under the (INA), the Secure Fence Act, and the (IIRIRA) for the construction of a Mexican border wall to deter illegal migration and smuggling of illegal products. The existing Mexico–United States barrier is not one continuous structure, but a series of physical walls and physical and "virtual" fences monitored by the United States Border Patrol. The proposed wall which would be "a contiguous, physical wall or other similarly secure, contiguous, and impassable physical barrier" along the entire length of the border, which Trump estimated in 2016 would cost $10 billion to $12 billion, and by January 27 was estimated to be $20 billion, to be initially paid by Congress. Trump plans on eventually negotiating a reimbursement from the Mexican government. While the Executive Order entitled "Border Security and Immigration Enforcement Improvements", contains no information of payment, it requests federal agency reports by late March 2017 which "identify and quantify all sources of direct and indirect Federal aid or assistance to the Government of Mexico on an annual basis over the past five years, including all bilateral and multilateral development aid, economic assistance, humanitarian aid, and military aid." On January 27, Forbes cautioned that the 20% Mexican Import Tariff on all imported goods announced by Spicer to pay for the 1,933-mile (3,111 km) frontier wall would be "paid by Americans". GOP donors, Brothers Charles and David Koch, and their advocacy group, Americans For Prosperity, oppose Paul Ryan's 'Buy American' Tax Plan, which they claim would add a "whopping tax hike of more than $1 trillion on American families and small businesses over 10 years." The import tariff would raise prices at Wal-Mart, for example, directly impacting lower income families. The Washington Post reported on April 25, that Trump had agreed to delaying funding for the construction of the wall until September to avoid a government shutdown. Sanctuary cities: On January 25, Trump signed an executive order, "Enhancing Public Safety in the Interior of the United States", to the Secretary of Homeland Security and the Attorney General and their departments and agencies to increase the enforcement of immigration laws which included the hiring of 10,000 "additional immigration officers". His order requires the cooperation of state and local authorities. The order states "sanctuary jurisdictions" including "sanctuary cities" who refuse to comply will not be "eligible to receive Federal grants, except as deemed necessary for law enforcement purposes by the Attorney General or the Secretary". Some officials claim that the "U.S. Constitution bars the federal government from commandeering state officials or using federal funds to 'coerce' states into doing the bidding of Washington." Mayors of New York, Boston, Denver, Los Angeles, San Francisco, and Seattle have expressed concerns about the Order and do not want to "change the way their cities treat immigrants". Jeff Sessions is considered to be an "inspiration" for Trump's anti-immigration policies. On August 31, 2016, Trump laid out a 10-step plan as part of his immigration policy where he reiterated that all illegal immigrants are "subject to deportation" with priority given to illegal immigrants who have committed significant crimes and those who have overstayed visas. He noted that all those seeking legalization would have to go home and re-enter the country legally. In a meeting with concerned mayors, Sessions explained that the Executive Order merely directs cities to enforce the preexisting thirty-year-old law, 8 U.S.C. 1373 which means that "there is no sanctuary city debate." On April 25, U.S. District Judge William Orrick III sided with San Francisco and Santa Clara in their lawsuit against the Trump administration, issuing a temporary injunction effectively blocking the order targeting so-called sanctuary cities. Justice Orrick said that the president "has no authority to attach new conditions to federal spending". Judge Orrick issued a nationwide permanent injunction on November 20, 2017, declaring that section 9(a) of Executive Order 13768 was "unconstitutional on its face" and violates "the separation of powers doctrine and deprives the plaintiffs of their Tenth and Fifth Amendment rights." Social policy: Trump's appointment of a conservative justice, Neil Gorsuch, his reinstatement of the Mexico City Policy, and his signing H.J. Res. 43—HHS Title X Funding for Planned Parenthood Rule are in keeping with his pro-life policy. On January 23, Trump signed a Presidential Memorandum on the Mexico City Policy regarding federal funding to foreign NGOs. This is a key point in the abortion debate as foreign NGOs that receive US federal funding will no longer be able to offer, promote or perform abortion services as part of family planning in their own countries using non-U.S. government funds. Forbes claimed this could "potentially affect $9.5 billion" in programs that reach "225 million women globally". On April 13, Trump quietly signed H.J. Res. 43—HHS Title X Funding for Planned Parenthood Rule— reversing Obama's December 2016 regulation which had mandated that Title X recipients—like states local and state governments—distribute federal funds for services related to contraception, sexually transmitted infections, fertility, pregnancy care, and breast and cervical cancer screening to qualified health providers, regardless of whether they also perform abortions". Bloomberg noted that although this was "one of the few opportunities" Trump has had in his first 100 days to enact legislation, he signed this bill in private. The Obama rule never came into effect as it was blocked by a federal judge. Republicans want to cut off federal funding from health-care organizations such as Planned Parenthood that perform abortions. Proponents of the bill claim it supports states' rights over federalist rights. The bill was passed under the procedures of the Congressional Review Act. In the Senate Vice-President Pence cast a tie-breaking vote. This will be an issue at the end of the first 100 days as Congress tries to avoid a government shutdown. In Fiscal Year 2014, Planned Parenthood clinics received $20.5 million of the $252.6 million distributed under the Title X Family Planning grant program. The proposed American Health Care Act, announced by Congressional Republicans in March 2017, would have made Planned Parenthood "ineligible for Medicaid reimbursements or federal family planning grants". Suspended reduction of Federal Housing Mortgage Insurance Premium rates: Within the first hours of Trump's presidency, he "suspended indefinitely" the reduced "Mortgage Insurance Premiums for loans with Closing/Disbursement date on or after January 27, 2017", known as the Federal Housing Administration's (FHA) Annual Mortgage Insurance Premium (MIP) Rates managed under the United States Department of Housing and Urban Development (HUD). It is "effective immediately". Obama's rate cut would have lowered borrowing costs for first time and low income house buyers. Gun control: In February 2017, the Trump administration signed into law a bill that rolled back a regulation implemented by the Obama administration, which would have prohibited approximately 75,000 individuals who were receiving Social Security disability and had representative payees, from owning guns. The bill was supported by the ACLU, the National Association for Mental Health, The American Association of People with Disabilities, and the National Council on Disability, the Consortium for Citizens with Disabilities, as well as other disability rights advocates. The initial regulation was supported by the Brady Campaign to Stop Gun Violence, Moms Demand Action Against Gun Violence, Democratic gun control advocates, and some mental health experts. High-priority infrastructure: On January 24, Trump signed his second Executive Order entitled Expediting Environmental Reviews and Approvals for High Priority Infrastructure Projects (EO 13766) which is part of a series of five executive orders to date. This Order was part of a series "designed to speed environmental permitting and reviews" as " major infrastructure projects trigger an array of overlapping environmental and natural resource laws and requirements". On April 19, Trump signed a bill that extended the VA's Choice beyond August. The 2014 Veterans' Access to Care through Choice, Accountability, and Transparency Act was enacted in by the Obama administration in response to the Veterans Health Administration scandal of 2014. Foreign policy: The main group advising the President on foreign affairs and national security is the National Security Council (NSC) which coordinates national agencies such as the secretaries of defense and state; the secretaries of the army, navy, and air force.On April 10, The Wall Street Journal described Trump's foreign policy as moving away from the "America First", "isolationist" policies towards more "mainstream" and "conventional" tendencies under the more stabilizing influence of Tillerson, Mattis, McMaster, Ross, and Kushner. On the first day of Trump's presidency, the White House website had posted a 220-word description of its foreign policy. It was protectionist with a focus on "America First", as was his inaugural address. His three top priorities were to defeat ISIS, to rebuild the military, and to embrace diplomacy. Defense: At the time Trump took office, U.S. military spending had reached its highest peak ever. Trump requested $30 billion for FY 2017 which ends in September, and an increase of $54 billion to Defense Department for FY 2018. The $639 billion in FY2018 would result in deep cuts to many other departments including the State Department, the diplomatic arm of the administration. After Trump's April 12 first face-to-face meeting with NATO Secretary General Jens Stoltenberg, Trump announced that he had changed views about NATO. Trump had previously complained that NATO was "obsolete" as it did not fight terrorism. On March 18, Trump called on NATO's member nations to contribute more to NATO. After the White House meeting, Trump realized that NATO has been engaged in combating groups like ISIS. Trump will maintain the "US commitment to NATO while reiterating its member nations must step up their military financing". On January 29, Trump authorized the first military operation of his Presidency—a raid by US commandos on Al-Qaeda in Yakla, Baida in Yemen. At least 14 jihadists were killed in the raid, as well as 10 civilians, including children. The raid also resulted in the death of Chief Petty Officer William Owens a 36-year-old Virginia-based Navy SEAL, the first U.S. combat casualty in Trump's presidency. According to the New York Times, Owen's death "came after a chain of mishaps and misjudgments that plunged the elite commandos into a ferocious 50-minute firefight that also left three others wounded and a $75 million aircraft deliberately destroyed." On April 6, 2017, Trump ordered a missile strike on Shayrat Air Base near Homs, in Syria. 59 Tomahawk missiles were launched from the USS Ross (DDG-71) and USS Porter (DDG-78) from the Mediterranean Sea. On April 8, four days after North Korea had test-fired a ballistic missile, an announcement by the United States Pacific Command (PACOM) commander was posted via U.S. Third Fleet Public Affairs stating that PACOM had ordered the USS Carl Vinson supercarrier to "sail north and report on station in the Western Pacific Ocean". It was a premature announcement that led to a "glitch-ridden sequence of events"—a result of confusion created by a "miscommunication" between the Pentagon and the White House. On April 8 and April 9, media outlets such as Fox News, RT, CNN, USA Today, BBC and others had published the erroneous announcement that warships were heading to the Korean Peninsula within the context of escalating US-North Korean tensions. In an interview with FOX Business Network's Maria Bartiromo that aired on April 12, President Trump warned, "We are sending an armada. Very powerful. We have submarines. Very powerful. Far more powerful than the aircraft carrier. That I can tell you." By April 17, North Korea's deputy United Nations ambassador accused the United States of "turning the Korean peninsula into "the world's biggest hotspot" and the North Korean government stated "its readiness to declare war on the United States if North Korean forces were to be attacked." On April 17, the Defense News broke the story that the Carl Vinson and its escorts were 3,500 miles from Korea, engaged in scheduled joint Royal Australian Navy exercises in the Indian Ocean. According to Dana White, the Pentagon's chief spokeswoman, the Carl Vinson was heading north on April 18. The Wall Street Journal reported on April 19, that the incident sparked both "criticism and ridicule" as some felt "duped by Trump". In the article, Hong Joon-pyo, a candidate in the 2017 South Korean presidential election, was quoted as saying, "What President Donald Trump said was important for the national security of South Korea. If that was a lie, then during Trump's term, South Korea will not trust whatever Trump says." On April 13, the United States dropped a "mother of all bombs" (MOAB) in the Nangarhar Province Afghanistan— the first use of the bomb on the battlefield. On April 8, Staff Sgt. Mark De Alencar was killed during an operation against ISIS in Nangarhar Province. The most consequential shift in Trump's defense policy was the April 6 cruise-missile launch at a Syrian airbase. Trade policies: On January 23, Trump fulfilled a campaign pledge by signing an executive order withdrawing the United States from the Trans-Pacific Partnership (TPP) or Trans Pacific Partnership Agreement (TPPA). According to the BBC, Trump had pledged to withdraw from the Trans Pacific Partnership (TPP) and he signed an executive order on the TPP his first few days. However, the EO was largely symbolic since the deal has not been ratified by a divided US Congress." The Trans-Pacific Partnership (TPP) or Trans Pacific Partnership Agreement (TPPA), was a trade agreement between the United States and eleven Pacific Rim nations—Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, and Vietnam that would have created a "free-trade zone for about 40 percent of the world's economy. On April 18, 2017, President Trump signed an executive order that directed federal agencies to implement a "Buy American, Hire American" strategy. The executive order directs federal agencies to implement a new system that favors higher-skilled, higher-paid applicants. The order is the first initiative in response to a key pledge made by Trump during his presidential campaign to promote a 'Buy American, Hire American.' The EO is intended to order federal agencies to review and propose reforms to the H-1B visa system. Through the executive order, Trump states his broad policy of economic nationalism without having to go through Congress. Cabinet secretaries from Departments of Labor, Justice, Homeland Security, and State will "fill in the details with reports and recommendations about what the administration can legally do." Trump argued that the EO would "end the 'theft of American prosperity'", which he said had been brought on by low-wage immigrant labor. On March 31, President Donald Trump signed two executive orders on trade. One examines forms of "trade abuse", taking a country-by-country as well as product and industry look over 90 days at cheating, law enforcement, and currency misalignment by foreign countries that causes U.S. trade deficits. President Trump said the order ensures "that we fully collect all duties imposed on foreign importers that cheat, the cheaters." Another to strengthen anti-dumping rules and countervailing duties. The order directs Homeland Security, Commerce, and Treasury departments to ensure enforcement and "those who break the rules will face severe consequences". Trump—who had been dismissive of the Export-Import Bank (ExIm)—made an about-face on April 15 by nominating Scott Garrett as head of the ExIm breaking a deadlock that had prevented the Bank from operating since 2014. Although Trump had privately made known that he would not side with "conservative Republicans, including those in his own administration", who wanted to "cripple" the ExIm in February, he did not announce it publicly until April 13, when he told The Wall Street Journal that he would fill two seats of ExIm's five-seat board which would allow the Bank to make loans greater than $10 million. Trump had been one of ExIm's harshest critics. Conservatives call it the 'Bank of Boeing' and an 'epicenter of crony capitalism'. Its supporters such as Boeing and General Electric Co, claim that it facilitates trade worth billions of dollars in exports helping hundreds of businesses. Prior to making the announcement, Trump held two significant meetings related to ExIm—an April 3 formal visit with Egyptian president Abdel Fattah el-Sisi who is negotiating for billions of dollars in ExIm financing and an April 11 meeting with Boeing Chief Executive Jim McNerney. Sisi also met with Lockheed Martin and General Electric CEOs during his visit to the U.S. in April. International relations- Australia: A February 2 report by The Washington Post claimed that US President Donald Trump berated the Australian, Prime Minister Turnbull during one of Trump's first phone calls made to foreign officials. Trump stated that the 2016 asylum deal was an attempt to export the next Boston bombers to the United States. The contentious deal involves a 2016 agreement between the Obama administration and Australia whereby the U.S. would resettle 1,250 refugees held in controversial offshore immigration detention facilities—Manus and Nauru islands. In return, Australia would 'resettle refugees from El Salvador, Guatemala and Honduras". The full transcript of that phone conversation was leaked in August 2017, and published by the Washington Post. Later that day, Trump explained that while he respected Australia, they, along with many other countries, were "terribly taking advantage" of the United States. The following day, Australian Ambassador to the United States Joe Hockey was sent to the White House and held meetings with White House Chief Strategist Steve Bannon and Chief of Staff Reince Priebus. Spicer described the phone call as "very cordial". The 25-minute phone call on January 28, was described as "acrimonious" by Reuters and Trump's "worst call by far" with a foreign leader by the Washington Post. During a joint news conference with Prime Minister Turnbull, Vice-President Pence—who was on a "10-day, four-country trip" in April to the Pacific Rim—announced that even if the United States did not "admire the agreement", Trump had made it clear the United States would honour the 2016 agreement to resettle refugees. Turnbull responded, "whatever the reservations of the president are", the decision "speaks volumes for the commitment, the integrity of President Trump, and your administration, sir, to honour that commitment." "The US is Australia's most important security partner, while China is its most important trading partner." Canada: Prime Minister Justin Trudeau met Trump in Washington, D.C. in February 2017. Trudeau said that "The last thing Canadians expect is for me to come down and lecture another country on how they choose to govern," referring to Trump's "refugee ban"—Executive Order 13769. The two leaders emphasized the importance of the two countries' ongoing relationship, with Trudeau adding that "there are times when we have differed in our approaches. And that's always been done firmly and respectfully." Commerce Secretary Wilbur Ross said that, "It has been a bad week for U.S.-Canada trade relations", as he announced stiff tariffs up stiff tariffs of up to 24% on Canadian lumber on April 24, as dairy product trade fell through. The Canada–United States softwood lumber dispute has been since ongoing since the 1980s making it one of the longest trade disputes between the two countries, as well as one of the largest. Trump is under pressure to begin renegotiating NAFTA, the trade deal between Canada, Mexico and the US. On April 25, Canada's International Trade Minister Francois-Philippe Champagne and soft lumber industry representatives promoted trade with China in Beijing in response to what is perceived as U.S. protectionist policies. China: The Mar-a-Lago summit meeting on April 6 and 7 between Trump and President Xi Jinping of China, during the first 100 days of the new US administration, was heralded by The Telegraph as the "most significant bilateral summit in decades". In spite of differences regarding Taiwan, the South China Sea and the most urgent issue—North Korea's nuclear programme—"the summit between the US and Chinese presidents had both symbolic and tangible successes," according to the South China Morning Post.[317] During the April 7–8 visit with Chinese President Xi Jinping, Trump acknowledged that international relations are much more complicated than he had imagined. In regards to North Korea, he had hoped to negotiate better trade deals with China in exchange for China dealing with the nuclear threat from North Korea. In an interview with Wall Street Journal's Gerald F. Seib Trump said, "After listening for 10 minutes, I realized it's not so easy. I felt pretty strongly that they had a tremendous power over North Korea. ... But it's not what you would think." Trump also affirmed that North Korea was the United States' "biggest international threat". The BBC reported on April 19 that China "was 'seriously concerned" about nuclear threats" as tensions between North Korea and the United States escalated with a "war of words" between North Korea's leader Kim Jong-un and the Trump administration. Recent threats included Vice President Mike Pence's statement that the period of "strategic patience" was over and his April 19 statement that the US "would meet any attack with an 'overwhelming response'". North Korea recently warned of "full-out nuclear war if Washington takes military action against it." Trump has called for China to rein in North Korea, but China Daily reported that "Washington must be aware of the limitations to Beijing's abilities, and refrain from assuming that the matter can be consigned entirely to Beijing alone." China Daily considered the U.N. Security Council statement adopted on April 20 condemning North Korea's recent attempted missile launch, as an indication that the Trump administration is considering a "diplomatic solution". In an April 12 interview with Wall Street Journal, Trump said he had changed his mind and he would not label China a currency manipulator, which had been one of his 100-day pledges. By April he believed that China had not been manipulating its currency for months. He did not want to "jeopardize" talks with the Chinese "on confronting the threat of North Korea". Early in Trump's presidency, the world's largest financial newspaper, Nikkei Asian Review, had reported on February 1, that Trump had labelled China and Japan as currency manipulators. The Trump administration confirmed its commitment to defend Japan against China's claims to the Senkaku Islands in the East China Sea through the Treaty of Mutual Cooperation and Security between the United States and Japan during a U.S. Defense Secretary James Mattis's visit to Japan on February 4. By February 9, US-Chinese relations—the most important bilateral relationship—had remained strained, President Xi Jinping and Trump had not spoken and this had "drawn increasing scrutiny". Xi was concerned by the December 2, 2016, phone call from Taiwan President Tsai Ing-wen to Trump and Trump's questioning of the One China policy. On February 10, Trump and Xi Jinpin spoke on the phone for the first time since Donald Trump took office, during which Donald Trump committed to honoring the One China policy at Xi's request. During the World Economic Forum annual meeting in Davos on January 17–20, China's President Xi Jinping, as keynote speaker, "vigorously" defended globalization in a speech that the Financial Times described as "one would have expected to come from a US president". Mr. Xi observed that "blaming economic globalisation for the world's problems is inconsistent with reality ... globalisation has powered global growth and facilitated movement of goods and capital, advances in science, technology and civilisation, and interactions among people In 2015, China became the United States' largest trade partner, placing Canada second. The Times 2017 article, citing an analysis by Peterson Institute for International Economics, noted that "China and Mexico together account for a quarter of US trade". Concerns have been raised about Trump's proposed imposition of a 45 percent tariff on imports from China. On January 23, The U.S. Commerce Department announced new countervailing duties (CVDs) ranging from 38.61 to 65.46 percent on Chinese vehicles in the antidumping case. In 2015, over 8.9 million Chinese truck and bus tires worth $1.07 billion were imported to the United States. At his Senate confirmation hearing as Secretary of State, in mid-January, Rex Tillerson's statements about the South China Sea, "set the stage for a possible crisis between the world's two biggest economies should his comments become official American policy" and "put further strains on one of the world's most important bilateral relationships." According to an article on January 28, in the South China Morning Post, an official from China's Central Military Commission's Defence Mobilisation Department, ranking Chinese military official considers war between China and the United States a real possibility during Trump's term as president. An article in The Guardian claims, "The bad news is that if in the coming months or years Trump faces an ignominious end to his presidency through scandal or mismanagement, a national crisis—involving China, or ISIS or another foreign actor—could allow him to cling to power." Egypt: On April 3, Trump hosted a formal visit with Egyptian president Abdel Fattah el-Sisi, in an effort to "reset" relations between the two countries, offering the U.S. government's "strong backing". Ties between the two countries were strained since Sisi deposed Egyptian president Mohamed Morsi during the July 2013 military coup. Trump publicly stated that Sisi's autocratic leadership was 'fantastic'. Sisi, who is seeking "billions of dollars in financing" from the Export-Import Bank for large investments in infrastructure investments, also met with the representatives from the IMF, the World Bank, Lockheed Martin and General Electric. Trump nominated a new head of ExIm which facilitates its operation—the ExIm had been hamstrung since 2014 because of opposition by Republicans.[299] During his talks with Sisi in April, Senate Foreign Relations Committee Chairman Bob Corker (R-Tenn.) had advocated for the release of six humanitarian workers, including a U.S. citizen—30-year-old Aya Hijazi and her husband, who had been imprisoned in Egypt since May 1, 2014. A court in Egypt dropped all charges against them on April 16. European Union: In a 60-minute interview at Trump Tower in mid-January, with Michael Gove of the Times of London and Kai Diekmann of Bild, Trump praised Brexit, criticized NATO as "obsolete", and the European Union as "basically a vehicle for Germany". He said it was a "very catastrophic mistake" on Angela Merkel's part to admit a million refugees—whom he refers to as "illegals". These "worrying declarations", among others, compelled the President of the European Council, Donald Tusk, to raise concerns in a letter to 27 European leaders, that the Trump administration seemed to "question the last 70 years of American foreign policy", placing the European Union in a "difficult situation". Iran: There are no formal diplomatic relations between Iran and the United States. Iranian citizens were temporary banned from entering the United States by the executive order "Protecting the Nation From Foreign Terrorist Entry Into the United States." Late on April 18, 2017, the Trump Administration certified that Iran had continued to comply with the 2015 nuclear framework agreement. During his campaign, Trump had denounced the agreement as 'the worst deal ever' but was frustrated in his plans to renegotiate the nuclear deal as "canceling the deal would likely cause significant problems." Israel: Israel's prime minister Benjamin Netanyahu and Trump held their first official visit at the White House on February 15. At the press conference, Trump urged Netanyahu to "'hold back' on building Jewish settlements on territories occupied by Israel in 1967 'for a little bit'". According to The Economist, Trump appeared to step back from the "long-standing, bipartisan American insistence that peace can be reached only through the establishment of a sovereign Palestinian state alongside the Jewish one", the two-state solution. Trump's priority of destroying the Muslim radicals of Islamic State (IS)" differs from Netanyahu's. Israel is more concerned about "containing Iran, the largest power in the Shia Muslim world. Given that Iran is itself fighting IS in Syria and Iraq, the two goals could even be in conflict." In a marked change from his visit to the White House under the Obama administration, Netanyahu blurred the distinction by "denouncing both IS and Iran in the same attack on 'militant Islam' and hailing Mr Trump's 'great courage' in tackling 'radical Islamic terror'". Mexico: Since early in Trump's presidency, Mexico and United States faced a diplomatic crisis. Mexican President Enrique Peña Nieto opposes Trump's approach to the renegotiation of NAFTA and the implications of Trump's Executive Order 13767. After decades of cooperation between the two nations relations between the US and Mexico are seriously weakened. North Korea: On February 12, North Korea tested a ballistic solid-fuel missile, the Pukkuksong-2, which is part of a series of missile tests that have largely defined the hostile North Korea–United States relations over recent years. According to The Economist, on February 13, while Trump promised "to deal with the 'big, big' problem of North Korea 'very strongly'", he has few options. Trump received the news of the launch during the first official visit of Japan's prime minister, Shinzo Abe. They were dining at Mar-a-Lago, Trump's Florida resort. Russia: According to a Reuters report on February 9, 2017, in his first 60-minute telephone call with Putin, Putin inquired about extending New START (Strategic Arms Reduction Treaty) a nuclear arms reduction treaty between the United States and the Russia signed in 2010, which was expected to last until 2021. and, after ratification, Trump denounced the treaty claiming that it favored Russia and was "one of several bad deals negotiated by the Obama administration". The New York Times reported that on February 14, Russia deployed a new type of fully operational ground-launched intermediate-range cruise missile that "violates a landmark arms control treaty". The Americans have changed its name from SSC-X-8 to SSC-8, reflecting its status as "operational" not "X" referring to "in development". On February 16, 2017, President Trump's Secretary of Defense, James Mattis, declared that the United States was not currently prepared to collaborate with Russia on military matters—including future anti-ISIL US operations. On February 24, Trump "risked triggering a new Cold War-style arms race between Washington and Moscow. In an interview with Reuters, Trump said that the "treaty limiting Russian and U.S. nuclear arsenals was a bad deal for Washington" and he "would put the U.S. nuclear arsenal "at the top of the pack". In response, Russia's Konstantin Kosachev wrote on his Facebook page, "arguably Trump's most alarming statement on the subject of relations with Russia". Trump's campaign slogan 'Make America great again', if that means nuclear supremacy, will return the world to the worst times of the arms race in the '50s and '60s. — Konstantin Kosachev, Chair of the Foreign Affairs Committee of the Russian Federation Council February 24, 2017 Trump had "promised one of the 'greatest military buildups in American history' in a feisty, campaign-style speech extolling robust nationalism" at the annual Conservative Political Action Conference on February 24 at National Harbor. Syria: On April 5, 2017, Trump responded to the April 4 chemical attack allegedly by Syrian Armed Forces on rebel-held Khan Shaykhun in Idlib Province, which enveloped men, women, and children in a suffocating fog of sarin gas, leaving more than eighty people dead and over three hundred more injured, saying that "... my attitude towards Syria and Assad has changed very much." Both Tillerson and Nikki Haley had previously stated that the Trump administration had no intention of interfering in President Bashar Assad's leadership in the Syrian Civil War, as the US focused on eliminating ISIS. United Kingdom: In January 2017, the Prime Minister Theresa May invited Trump to a state visit to the UK when she met Trump in Washington DC. The visit was planned to occur in June, although it may be delayed to July to coincide with the upcoming G20 summit in Hamburg. Some sources have suggested that the UK government may delay the visit until after the House of Commons is in recess for the summer to avoid criticism from MPs. The Speaker of the House of Commons, John Bercow, stated on February 6, 2017, that Trump would not be welcome to address parliament during any future state visit, drawing applause and cheering from some Members of Parliament. More than 1,860,000 people signed a petition to prevent Trump from making an official state visit, which states that such a visit "would cause embarrassment to Her Majesty the Queen". The FCO responded to this petition by stating that HM Government recognises the strong views expressed by the many signatories of this petition, but does not support this petition." Lord Ricketts, former Permanent Under-Secretary of State for Foreign Affairs, said that the unprecedented speed of May's invitation has put the Queen in a "very difficult situation". He questioned whether Trump was "specially deserving of this exceptional honour", given that US presidents are usually only invited to such visits after at least a year in office. Writing to May, opposition leader Jeremy Corbyn stated that the "invite should be withdrawn until the executive orders are gone". It was suggested that Trump's visit would have to take place outside London, after Sir Bernard Hogan-Howe, the chief of the Metropolitan Police, said that he had concerns about the visit given the number of protests expected. One suggestion considered was for Trump to address a rally at the National Exhibition Centre in Birmingham, a city where 50.4% of voters voted to leave the EU, rather than London, which saw 59.9% voting to remain. Local politicians and activists in Birmingham promised to stage protests if the visit is moved, with Shabana Mahmood, Labour MP for the Birmingham Ladywood constituency, saying that "President Trump with his hateful and divisive rhetoric, policies and Muslim ban is not welcome here." During a March 14 Fox & Friends interview, Andrew Napolitano said, "Three intelligence sources have informed Fox News that President Obama went outside the chain of command, using the British GCHQ to implement surveillance on Donald Trump to avoid leaving 'American fingerprints'." On March 16, Press Secretary Sean Spicer repeated Napolitano's claim at a White House press briefing. The following day, a GCHQ spokesperson called Napolitano's claim "utterly ridiculous". The White House denied reports that it had apologized to the British government for the accusation. Government and Finance (G&F): The G&F Division focuses on issues related to Congress, the executive and the judicial branches, the budget and appropriations, legislative process, homeland security, elections and certain financial issues such as public debt, inflation, savings, GDP, taxation and interest rates, banking, financial institutions, insurance and securities, public finance, fiscal and monetary policy, public debt, interest rates, gross domestic product, inflation and savings. Supreme Court nomination: On the evening of January 30, Trump announced his nomination of U.S. Appeals Court judge Neil Gorsuch for the Supreme Court fulfilling his campaign pledge that he would choose someone 'in the mold' of the late Justice Antonin Scalia. Following the February 3 ruling by federal judge James Robart, which temporarily blocked Trump's travel ban on people from seven Muslim countries, Trump has been openly critical of the Federal judiciary. According to CNN and Washington Post, on February 8, Gorsuch expressed concern that Trump's remarks on the judiciary were 'demoralizing' and 'disheartening' to the independence of the judiciary. Gorsuch was approved by the Senate Judiciary committee on April 3. Senate Republicans invoked the "nuclear option" after the April 6 filibuster that prevented cloture. After a year-long Republican block on nominations, the Senate confirmed Gorsuch's nomination with a 54–45 vote, mainly along party lines. Gorsuch took office in a private ceremony on April 10. Hours after Gorsuch and four other Supreme Court conservatives justices voted on April 20 to deny a stay of execution request from eight inmates on Arkansas death-row, Ledell Lee was put to death with a lethal injection, the first in Arkansas since 2005. Two inmates—Jack Jones and Marcel Williams—received lethal injections on April 24. Monetary policy: On April 19, in an interview with The Wall Street Journal—in a reversal of previous statements—Trump said he was considering keeping Janet Yellen as chair of the Federal Reserve System, which oversees the U.S. monetary policy. He explained that, "I do like a low-interest rate policy, I must be honest with you." In the same interview, Trump said he would not label China a currency manipulator, which had been one of his 100-day pledges. Trump expressed concerns in that interview that, "I think our dollar is getting too strong, and partially that's my fault because people have confidence in me. But that's hurting—that will hurt ultimately." He believes a low dollar favors the U.S. in international trade. From November 8, 2016—when Trump was elected—to December 30, 2016, the trade-weighted average of the foreign exchange value of the U.S. dollar (TWEXB) increased 4.4 percent. Towards the end of the first 100 days, the TWEXB had dropped two percent. This table shows some highs and lows of the Trade Weighted U.S. Dollar Index: Broad TWEXB from 2002 to April 2017. Small government: On January 23, President Trump signed an executive order that froze all federal hiring except for the military. The order specified that no new positions can be created and no currently vacant positions may be filled unless an agency head believes that the position is "necessary to meet national security or public safety responsibilities". The order is due to expire once the head of the Office of Management and Budget, Mick Mulvaney, creates a "long-term plan to reduce the size of the Federal Government's workforce through attrition". On January 24, the Associated Press reported on emails from the Administration to some government agencies sent shortly after the inauguration, which "detailed specific prohibitions" banning certain government agencies, such as the Agricultural Research Service Agriculture Department from issuing "press releases, blog updates or posts to the agency's social media accounts". In what the Associated Press described as a "broader communications clampdown within the executive branch", the Administration "instituted a media blackout". In his January 25 press briefing, White House press secretary Sean Spicer claimed that the emails did not come from the Administration: "They haven't been directed by us to do anything ... That directive did not come from here." On January 23, in a Presidential Memorandum, the president ordered a temporary government-wide hiring freeze of the civilian work force in the executive branch, which is managed by the Office of Personnel Management. This will prevent federal agencies, except for the offices of the new presidential appointees, national security, the military and public safety, from filling vacant positions. The Brookings Institution questioned whether this freeze would include financial regulators who exercise independence from the executive branch—such as the Federal Reserve Board of Governors (Fed), Office of the Comptroller of the Currency (OCC), the Securities and Exchange Commission (SEC) among others. In a Fox News report, based on statistics from the Office of Personnel Management, the number of executive branch employees "hasn't been this low since 1965" and has been "more or less steady" since 2001. Economic policy of Donald Trump: Trump's key economic policies included the dismantling of the Dodd–Frank Wall Street Reform and Consumer Protection Act, and the repeal of the Patient Protection and Affordable Care Act (ACA). According to the April 28, 2017 Commerce Department report, in the first quarter of 2017, there was a "sharp decline from the 2.1% in Q1 2016 to 0.7% in Q1 2017—representing the weakest quarterly economic growth in three years. The report presents a statistical analysis of the American economy in the 2017 Q1—the gross domestic product (GDP). In spite of the soft GDP, by the end of Q1 2017, the S&P 500 was near an all-time high, representing a 12% rise from the first quarter of 2016, as investor confidence remained elevated based on Trump's promise to cut taxes, deregulate and spend heavily on infrastructure such as roads and bridges. In March 2017, the unemployment rate fell to 4.5 percent and the Consumer Sentiment Index reached 125.6, a level of consumer confidence in the United States last seen in December 2000. It fell to 120.3 in April. Consumer confidence or soft data contrasted with real consumer spending or hard data, with a "big drop-off" in the amount Americans actually spent during Trump's first 100 days. Changes to Dodd–Frank Wall Street Reform and Consumer Protection Act: On February 3, after a meeting with his strategic and policy forum, which included Jamie Dimon, Chairman and CEO JPMorgan Chase, Trump issued an Executive Order, Core Principles for Regulating the United States Financial System, which directed the "Treasury secretary to submit a report on recommended changes to bank regulations in 120 days." Trump wants to get "banks to lend money more aggressively" and wants to make changes to the Dodd–Frank Wall Street Reform and Consumer Protection Act (2010) which was enacted in response to the Great Recession, bringing significant changes to U. S. financial regulation. We expect to be cutting a lot out of Dodd-Frank ... Frankly, I have so many people, friends of mine, that have nice businesses that can't borrow money. They just can't get any money because the banks won't let them borrow because of rules and regulations in Dodd-Frank. — Trump in meeting with his business advisory council, February 3; In an interview on February 3, with The Wall Street Journal, Trump's National Economic Council Director, Gary Cohn, announced the planned rollback of the fiduciary rule, which stated that brokers and advisers who work with tax-advantaged retirement savings "must work in the best interest of their clients" even at the expense of their own profits. Deregulation: One of the first acts by the Trump administration was an order signed by Chief of Staff Reince Priebus on January 20, under the subject "Regulatory Freeze Pending Review" to all Heads of Executive Departments and Agencies ordering agencies to immediately suspend all pending regulations and to "send no regulation" to the Office of Information and Regulatory Affairs (OFR) until the Trump administration can review them except for "emergency situations" or "urgent circumstances" allowed by the Director or Acting Director, Mark Sandy, of the Office of Management and Budget (OMB). This was comparable to prior moves by the Obama and Bush administrations shortly after their inaugurations to revert executive orders by outgoing presidents, signed in their final days in office. On January 30, Trump signed his seventh Executive Order "Reducing Regulation and Controlling Regulatory Costs". Deregulation and corporations: At a January 23 meeting with leaders of the United States' largest corporations, including Ford's Mark Fields, Dell Technologies' Michael Dell, Lockheed Martin's Marillyn Hewson, Under Armour's Kevin Plank, Arconic's Klaus Kleinfeld, Whirlpool's Jeff Fettig, Johnson & Johnson's Alex Gorsky, Dow Chemical's Andrew Liveris, U.S. Steel's Mario Longhi, SpaceX's Elon Musk, International Paper's Mark Sutton, and Corning's Wendell Weeks promised to reward the companies who stay in the United States with aggressive cuts on U.S. federal regulations governing their companies by "75 percent or more". Trump meets with CEOs of pharmaceutical companies: On January 31, Trump met with CEOs of pharmaceutical firms, including Novartis's Joseph Jimenez who also represented the Pharmaceutical Research and Manufacturers of America—the pharmaceutical industry's powerful lobbying group, Merck & Co.'s Kenneth Frazier, Johnson & Johnson, Celgene's Robert Hugin, Eli Lilly, Amgen's Robert Bradway. Trump called for lower prices, "We have no choice. For Medicare, for Medicaid. We have to get the prices way down." In return, he promised to boost the pharmaceutical companies competitiveness by curbing regulations "from 9,000 pages" to "100 pages", and by lowering pharmaceutical companies' tax rates. Trump noted that Food and Drug Administration (FDA) approvals "force pharmaceutical companies to spend years and billions of dollars developing drugs". He promised his nomination for FDA Commissioner would oversee an FDA overhaul. In the listening session with pharmaceutical industry leaders, Trump noted that, "it costs sometimes $2.5 billion on average, actually, to come up with a new product. ... 15 years, $2.5 billion to come up with a product where there's not even a safety problem. So it's crazy. I'm surprised you can't get them to move faster than that." Trump had promised in March 2016, to reform the pharmaceutical industry, including the removal of existing free market barriers to allow imported, dependable, safe, reliable, and cheaper drugs from overseas, bringing more options to American consumers. Following Trump's press conference on January 11, Fortune claimed that the largest pharmaceutical companies had lost over $20 billion in 20 minutes. The Medicare Prescription Drug, Improvement, and Modernization Act (2003) expressly prohibited Medicare from negotiating bulk prescription drug prices and Trump had pledged to revert this. Following the morning meeting with CEOs on January 31, Trump abandoned his pledge to allow "Medicare negotiate bulk discounts in the price it pays for prescription drugs." Limitations on executive agency members lobbying: On January 28, Trump signed an Executive Order to fulfilling his campaign pledge to limit lobbying of executive agency members. Department of Justice: On February 8, Alabama Senator Jeff Sessions, who was nominated by Trump in January, was confirmed as United States Attorney General (A.G.), the head of the Justice Department per 28 U.S.C. § 503. He is the United States government's chief law enforcement officer and lawyer with 113,000 employees working under his leadership. According to The Washington Post, Sessions' "conservative, populist views have shaped many" of Trump's "early policies, including on immigration". The nomination battle was described by The New York Times, as "a bitter and racially charged". The confirmation process for Trump's nominee Senator Jeff Sessions was described as " strikingly contentious" by The New York Times; with Fox News calling it a "wild night", and CNN calling the "rare rebuke" a "stunning moment" as Senator Mitch McConnell invoked Rule XIX to silence Senator Elizabeth Warren for the rest of the hearing. McConnell interrupted Warren as she read several pages by Coretta Scott King and Senator Ted Kennedy regarding Session's alleged racial bias from the 500-plus page transcript submitted in 1986, that contributed to the decision by the then-Republican-led Judiciary Committee to reject his nomination to a federal judgeship. Warren immediately live-streamed her reading of the letter, critical of Sessions, that the widow of Martin Luther King Jr. had written to Senator Strom Thurmond in 1986. and numerous media outlets made the full-text available. Trump appointed Dana J. Boente to serve as acting Attorney General until Session's Senate Confirmation. After firing Yates, Trumped signed his eleventh Executive Order 13775 on February 9, specifically reversing the DOJ's line of succession in Obama's EO 13762 in order to appoint the United States Attorney for the Eastern District of Virginia—Dana J. Boente—as Acting Attorney General. Trump revoked EO 13775 on March 31 with "Presidential Executive Order on Providing an Order of Succession Within the Department of Justice. Boente had replaced Acting Attorney General Sally Yates who was fired by Trump for ordering the Justice Department to not defend Trump's Executive Order 13769 which restricted entry to the United States. Yates claimed that, "At present, I am not convinced that the defense of the executive order is consistent with these responsibilities of the Department of Justice, nor am I convinced that the executive order is lawful". Voter fraud claims: Since November 2016, and during his presidency, Trump has repeated voter fraud allegations that between three and five million people voted illegally and cost him the popular vote to Hillary Clinton, and also that thousands of voters were illegally bused from Massachusetts into New Hampshire where former Senator Kelly Ayotte was defeated, and where Trump narrowly lost to Clinton in 2016. Trump had announced on January 25 that he was conducting an investigation into voter fraud. He repeated unsubstantiated claims about the number of fraudulent voters and referred to VoteStand founder Gregg Phillips, who could not produce any evidence of voter fraud. In January, US News reported that members of Trump's cabinet and family were registered to vote in multiple states. On February 10, Federal Election Commission (FEC) Commissioner Ellen L. Weintraub issued a statement calling on Trump to provide the evidence of what would "constitute thousands of felony criminal offenses under New Hampshire law." By February 12, Stephen Miller was still unable to provide concrete evidence to support claims of voter fraud in an interview with Stephanopoulos, but he seemed to direct Stephanopoulos to the often-cited 2012 Pew Research Center study. In fact, the 2012 Pew report entitled "Inaccurate, Costly, and Inefficient Evidence That America's Voter Registration System Needs an Upgrade," which was based on 2008 data, was about "outdated voter rolls, not fraudulent votes" and "makes no mention of noncitizens voting or registering to vote." The report showed that because of inefficiencies in the voter system, 24 percent of eligible citizens were not able to be registered, representing "51 million citizens." Problems related to voter registration often affected "military personnel—especially those deployed overseas and their families—who were almost twice as likely to report registration problems as was the general public in 2008." In November, "the former director of Pew's election program" explained, "We found millions of out of date registration records due to people moving or dying, but found no evidence that voter fraud resulted." On January 25, Spicer confirmed in a press briefing that Trump continued to believe that "millions voted illegally in the election" based on "studies and evidence that people have presented him." This included an often-cited and contested 2014 Old Dominion University study entitled "Do non-citizens vote in U.S. elections?" Using Cooperative Congressional Election Study data from 2008 and 2010, the researchers had argued that more than 14% of non-citizens "indicated that they were registered to vote." 2018 United States federal budget: Trump submitted his first budget request which recommends funding levels for the next fiscal year 2018—covering the period from October 1, 2017, to September 30, 2018—to the 115th Congress. Trump's request including a $639 billion defense budget and corresponding major cuts to other federal departments. To avert a possible government shutdown, the Trump administration face an April 28 deadline—the expiration of the December 10, 2016, continuing resolution (H.R. 2028) (Public Law 114-254). Discussion time on controversial issues such as funding for a border wall defunding Planned Parenthood, was limited by the two-week Easter recess that began on April 7. The government was shutdown during the Clinton and Obama administrations as a result of clashes between Republicans in Congress and Democrats in the White House. In late April 2017, Republicans have control of both Congress and the White House. A shutdown would result in "government agencies locking their doors, national parks refusing visitors and federal workers being told not to report to work". The appropriations process cannot be accomplished without consulting the Democrats—unlike rolling back federal regulations with Congressional Review Acts and attempts to repeal Obamacare. Tax reform: The White House memo entitled "2017 Tax Reform for Economic Growth and American Jobs" was presented on April 26 in what The Wall Street Journal described as his "finest moment" in the first 100 days and a policy and political success. Individual reform includes "reducing the 7 tax brackets to 3 tax brackets for 10%, 25% and 35%, doubling the standard deduction, providing tax relief for families with child and dependent care expenses." The taxation system will be simplified to "eliminate targeted tax breaks that mainly benefit the wealthiest taxpayers, protect the home ownership and charitable gift tax deductions, repeal the Alternative Minimum Tax, repeal the death tax and repeal the 3.8% Obamacare tax that hits small businesses and investment income." Business reform includes "15% business tax rate, territorial tax system to level the playing field for American companies, one-time tax on trillions of dollars held overseas and elimination of tax breaks for special interests." The memo did not provide legislative content but rather broad outlines that will be developed in Congress but may face some opposition from both sides. Energy, environmental, and science policy- Climate change: Trump rescinded many Obama-era regulations aimed at cutting the volume of greenhouse gas emissions, which faced strong opposition and legal challenges. The key focus of his deregulatory efforts was the Clean Power Plan created under the Obama administration, which restricted GHG emissions at coal-fired plants. Trump proposed defunding the Clean Power Plan in his FY2018 budget, and his March 28 executive order directed Environmental Protection Agency administrator Scott Pruitt to review the Clean Power Plan. He also lifted a 14-month-old halt on new coal leases on federal lands. Dakota Access and Keystone XL pipelines: On January 24, Trump signed three Presidential Memoranda regarding construction of pipelines; "Regarding Construction of American Pipelines" was his fifth memoranda, "Regarding Construction of the Dakota Access Pipeline" was his sixth and the seventh was "Regarding Construction of the Keystone XL Pipeline". These were intended to "clear the way to government approval" of the Dakota Access and the Keystone XL pipelines. In a meeting with small business leaders on January 30, Trump clarified that one of the reasons for approving the pipelines was to insist that pipeline makers implement a made-in-America approach. He revealed how the federal government could exercise eminent domain strategically in the appropriation of private land, to pressure pipeline makers to use American raw steel, for example. Deregulation on environmental policies and programs: Then White House Chief of Staff Reince Priebus signed an order on January 24, temporarily delaying the Environmental Protection Agency's (EPA) 30 final regulations that were pending in the Federal Register until March 21, 2017. Employees in the EPA's Office of Acquisition Management, received an email "within hours of President Trump's swearing in", from the new EPA administration, asking "that all contract and grant awards be temporarily suspended, effective immediately" which included "task orders and work assignments" until "further clarification". On February 1, the Trump administration published a Statement of Administration Policy to allow coal companies to dump mining waste in streams by nullifying the Department of the Interior regulation known as the "Stream Protection Rule", established in the Obama administration.[488] Under the Congressional Review Act Congress passed the resolution to repeal on February 1 and the Senate also approved it on February 2. The Statement nullified the Waste Prevention, Production Subject to Royalties, and Resource Conservation which limited venting, flaring, and leaks during oil and natural gas production. The Repeal of Stream Protection Rule (115-5) was signed into law by Trump on February 16. Additionally, the February 1 policy statement nullified the rule on Disclosure of Payments by Resource Extraction Issuers, a Securities and Exchange Commission regulation which required resource extraction issuers to report payments "to governments for the commercial development of oil, natural gas or minerals". The Repeal of the Disclosure of Payments by Resource Extraction Issuers Rule (115-4) was signed into law by Trump on February 14, 2017. On March 29, 2017, EPA Administrator Scott Pruitt overturned the 2015 EPA revocation and denied the 2007 administrative petition by the Natural Resources Defense Council and the Pesticide Action Network North America (PANNA) to ban the widely used Dow Chemical Company's chlorpyrifos.[491] The eight-year delay by the EPA to respond to PANNA, had resulted in a court case, PANNA v. EPA, in which EPA was ordered to respond by October 2015. EPA revoked "all tolerances for the insecticide chlorpyrifos" and Pruitt overturned the 2015 decision. On March 29, 2017, EPA Administrator Scott Pruitt overturned the 2015 EPA revocation and denied the administrative petition by the Natural Resources Defense Council and the Pesticide Action Network North America to ban chlorpyrifos. By reversing the previous administration's steps to ban one of the most widely used pesticides in the world, we are returning to using sound science in decision-making—rather than predetermined results. — Statement by Scott Pruitt, EPA, Administrator March 29, 2017; Accompanied by coal executives and coal miners, Trump signed a "sweeping executive order" on March 28, at the EPA. In his remarks he praised coal miners along with pipelines and U.S. manufacturing and addressed the coal miners directly, "Come on, fellas. Basically, you know what this is? You know what it says, right? You're going back to work." Trump instructed EPA "regulators to rewrite key rules curbing U.S. carbon emissions and other environmental regulations." Acts of the 115th United States Congress: By April 10, Trump had signed 21 Acts of Congress into law under the 115th United States Congress—laws 115-2 through 115–22. The GAO Access and Oversight Act of 2017 (Pub.L. 115–3 (text) (pdf),H.R. 72) was the second law Trump signed as president. The bill ensures that the Government Accountability Office (GAO) has full access to the database, National Directory of New Hires, to ensure that recipients of federal means-tested programs like Unemployment Insurance, Supplemental Nutrition Assistance Program (SNAP), Earned income tax credit (EITC), and Temporary Assistance for Needy Families (TANF) are eligible, thereby reducing government waste and increasing accountability. Congressional Review Act: Beginning in January, the Trump administration used the 1996 Congressional Review Act (CRA) to overturn regulations—some of them major—finalized during the final months of Obama's tenure. By April 6, Trump had signed into law 11 resolutions of disapproval under the CRA, after they were passed by the Republican majority in the House and Senate. Under the Congressional Review Act, Congress can circumvent the Senate's filibuster to overturn legislation issued in the last 60 days of the previous administration. On February 14, the Repeal of the Disclosure of Payments by Resource Extraction Issuers Rule (Pub.L. 115–4 (text) (pdf), H.J.Res. 41) was signed, nullifying the Securities and Exchange Commission regulation known as the "Disclosure of Payments by Resource Extraction Issuers" rule.[497] The SEC regulation was mandated by the Dodd-Frank Wall Street Reform and Consumer Protection Act, which was similar to transparency initiatives adopted by the European Union and Canada. Advocates argued that "Disclosure of Payments" rule prevented companies from bribing foreign governments and engaging in other forms of corruption. Those who argued for its repeal claimed that rule had placed an excessive burden on American companies and created a competitive disadvantage. On February 16, Trump signed the Repeal of Stream Protection Rule (H.J.Res. 38 Pub.L. 115–5 (text) (pdf)), which nullified the DOI regulation known as the Stream Protection Rule. On February 28, the Repeal of the Implementation of the NICS Improvement Amendments Act of 2007 (H.J.Res. 40 Pub.L. 115–8 (text) (pdf)) was signed into law, which overturned the Social Security Administration related to the implementation of the NICS Improvement Amendments Act of 2007, which had amended the National Instant Criminal Background Check System to prohibit those with severe mental illness from possessing firearms. On March 27, Trump overturned the Bureau of Land Management's (BLM), which nullified the "Waste Prevention, Production Subject to Royalties, and Resource Conservation", also known as "Methane and Waste Prevention" or "methane venting and flaring rule" which "limited venting, flaring, and leaks during oil and natural gas production". with Bill (H.J.Res. 44 Pub.L. 115–11 (text) (pdf)) disapproved the DOI rule relating to Bureau of Land Management "regulations that established the procedures used to prepare, revise, or amend land use plans pursuant to the Federal Land Policy and Management Act of 1976". On the same day, he signed the "H.J.Res.37—Disapproving the rule submitted by the Department of Defense, the General Services Administration, and the National Aeronautics and Space Administration relating to the Federal Acquisition Regulation" (H.J.Res. 37 Pub.L. 115–11 (text) (pdf)), which overturned the Federal Acquisition Regulation (FAR) "Fair Pay and Safe Workplaces"—known by its opponents as the "Blacklisting" Rule. On March 27, he also signed the ED State and Local Education Accountability Rules (H.J.Res. 57 Pub.L. 115–13 (text) (pdf)), which overruled the Department of Education rule relating to accountability and State plans under the Elementary and Secondary Education Act of 1965 and the ED Teacher Preparation Rule (H.J.Res. 58 Pub.L. 115–14 (text) (pdf)), overturning the Department of Education relating to teacher preparation issues. On March 31, Trump signed the DOL Unemployment Insurance Drug Testing Rule (H.J.Res. 42 Pub.L. 115–17 (text) (pdf)) "disapproving the DOL rule relating to drug testing of unemployment compensation applicants." Trump also signed the DOL Employee Retirement Income Security Act ERISA Exemption for State-Run Retirement Plans Rule and the DOL ERISA Exemption for Municipality-Run Retirement Plans Rules. On April 3, Trump signed the Occupational Safety and Health Administration (OSHA) "Volks" Rule measure (115-21 Pub.L. 115–21 (text) (pdf)) which overturned the DOL "Clarification of Employer's Continuing Obligation to Make and Maintain an Accurate Record of Each Recordable Injury and Illness" enacted in December 2016. On the same day he signed Public Law 115-22 which overturned the December 2, 2016 FCC Privacy Rule relating to "Protecting the Privacy of Customers of Broadband and Other Telecommunications Services" and the Fish and Wildlife Service (FWS) Wildlife Management Rule (H.J.Res. 69 Pub.L. 115–20 (text) (pdf)) overturning DOI rule relating to "Non-Subsistence Take of Wildlife, and Public Participation and Closure Procedures, on National Wildlife Refuges in Alaska." Privacy advocates expressed concern that Internet service providers (ISPs)—including the largest ISPs, Comcast, Verizon, AT&T, Time Warner, Cox Communications, and CenturyLink Charter Communications and others— will create and monetize detailed customer data such as Internet search history and without consent. Supporters included Republicans who regarded the rule as executive overreach and trade groups that represent Internet service providers. On April 13, Trump signed the law which overturned the HHS Title X Funding for Planned Parenthood Rule. Speech to joint session of Congress: The 45th President of the United States, Donald Trump, gave his first public address before a joint session of the United States Congress on February 28, 2017. Trump announced the creation of the Office of Victims of Immigration Crime Engagement (VOICE). Protests: Protests against Donald Trump have occurred both in the United States and worldwide, following Donald Trump's 2016 presidential campaign, his electoral win, and through his inauguration.On January 21, there were large demonstrations protesting Trump worldwide in 673 cities, with estimates for the global total at approximately five million people. About half a million demonstrated in the Women's March on Washington (in Washington, D.C.). Day Without Immigrants 2017 and Not My Presidents Day were held on February 16 and 20, respectively. Later protests included the Tax Day March (April 15), March for Science (April 22), and People's Climate Mobilization (April 29). Rallies: March 4 Trump rallies, organized by Trump supporters, were held throughout the United States on March 4. Media coverage: On February 16, 2017, Trump held an hour-and-a-quarter-long press conference to "update the American people on the incredible progress that has been made in the last four weeks since my inauguration." CNN described it as an "animated and unorthodox" intervention in which Trump appeared to be "deeply frustrated" by the way he was being portrayed by the media. The media has often described the administration as chaotic, while Trump claimed it was "running like a fine-tuned machine". Trump said that "the stock market has hit record numbers ... there has been a tremendous surge of optimism in the business world, and ... a new Rasmussen Reports' poll which put his "approval rating at 55 percent and going up". Trump dismissed polls that gave lower numbers, such as those by Gallup and Pew Research Center, which reported 40% and 39%, respectively. When asked by an Associated Press journalist about Trump's performance at the press conference, Trump's supporters said he came across as the "champion of Middle America ... taking on the establishment and making good on his campaign promises to put the country first." NBC News, The Huffington Post/YouGov, Gallup, SurveyMonkey, Rasmussen Reports, the Associated Press/NORC, Pew Research Center, Quinnipiac University, The Economist/YouGov,The Wall Street Journal, Reuters/Ipsos, and ABC News/The Washington Post are among the organizations undertaking opinion polls on Trump's approval ratings. An April meeting of thirty White House staff members—including Communications Director, Mike Dubke, Jessica Ditto, and Kellyanne Conway—brainstormed on how to "repackage" the symbolic First 100 Days—which ends April 29—and to "rebrand Trump" by focusing on three main areas—prosperity, accountability and safety. The first includes "new manufacturing jobs, reduced regulations and pulling out of the Trans-Pacific Partnership trade deal", the second "swamp-draining campaign promises such as lobbying restrictions" and the third "the dramatic reduction in border crossings and the strike in Syria". Politico summarized this period as "marred by legislative stumbles, legal setbacks, senior staff kneecapping one another, the resignation of his national security adviser and near-daily headlines and headaches about links to Russia." CNN called it "largely win-less", The Atlantic described its as a "disaster" marked by "chaos, confusion, and infighting" comparing it to Bill Clinton's in 1993. The Washington Times claimed the numerous mainstream media descriptions of Trump's "worst 100 days" failed to mention the accomplishments: the TPP withdrawal, the Keystone XL and Dakota Access Pipelines approvals, the proposed "streamlined budget" with a "Reagan-era increase to national defense", immigration laws enforcement "which decreased illegal border crossing by 40 percent in his first month", and Gorsuch's "incredibly smooth" nomination to the Supreme Court, the Dow Jones 20,000-point threshold, and rebounding manufacturing and mining jobs". Sean Spicer: Sean Spicer was named as Trump's White House Press Secretary on December 22, 2016, and his Communications Director on December 24. after the resignation of Jason Miller. At his first official press conference, on January 21, Spicer criticized the media for underestimating the size of the crowds at the inauguration under Trump's direct orders. On February 1, Spicer held his sixth press briefing, which for the first time included a number of Skype Seats as Chuck Todd had suggested on January 23. Spicer fielded questions from Kim Kalunian (WPRI) in Rhode Island, Natalie Herbick (Fox 8) in Cleveland, Ohio, Lars Larson of the Lars Larson Show and Jeff Jobe of Jeff Jobe Publishing, South Central Kentucky. CBS NEWS reported that some journalists labelled their questions as "softball", others welcomed them. Spicer had also delivered a tense five-minute post-inauguration news conference on January 21. The Skype solution helped resolve a concern about moving to a larger press room. By February 13, Jim Hoft, from Gateway Pundit and the "freshly minted White House correspondent", 28-year-old artist Lucian Wintrich, were granted White House press credentials and attended the press conference with Trump and the Canadian prime minister, Justin Trudeau. On February 4, Melissa McCarthy lampooned Spicer on Saturday Night Live. On February 7, CNN reported that "President Donald Trump was disappointed with Spicer and with Priebus, who had recommended him. On February 24, journalists from The New York Times, The Los Angeles Times, CNN and Politico, The Los Angeles Times, and BuzzFeed were barred from Sean Spicer's small, off-camera press briefing or "gaggle", held in his office. Conservative-leaning Breitbart News, One America News Network, and The Washington Times were invited along with Fox News, Reuters, Bloomberg News, CBS and Hearst Communications. Reporters from the Associated Press and Time walked out of the briefing in protest. Media outlets allowed into the gaggle shared full details of the briefing, including their audio, with the entire press corps. Fox News "joined a complaint by the chair of the five-network television pool", although their journalist was not banned. The White House Communications Agency (WHCA) lodged a complaint. Spicer explained that the White House is fighting against "unfair coverage". I think we're going to aggressively push back. We're just not going to sit back and let false narratives, false stories, inaccurate facts get out there.— Sean Spicer on barring media from February 24 "gaggle"; On April 11, while defending President Trump's decision to bomb Syria, Spicer compared President Bashar al-Assad to Adolf Hitler and stated that even Hitler had not used chemical weapons on his own people during World War II, ignoring the Germany's use of gas chambers during the Holocaust. Spicer apologized on the next day, saying, "I got into a topic that I shouldn't have, and I screwed up." Kellyanne Conway: By February 3, televised interviews by Kellyanne Conway, Counselor to the President, were dominating the news cycle in the First 100 Days, according to the Washington Post claiming it was partly because of "misconstrued facts" and "falsehoods". Examples include the February 2 interview on Hardball with Chris Matthews, where she cited a fictitious incident involving two Iraqi refugees in Kentucky in 2011, whom she claimed were the masterminds behind the Bowling Green massacre, which she claimed was "brand new information" that had "very little media coverage". Conway promoted Ivanka Trump's business On February 9, on Fox & Friends in response to Nordstrom's decision to drop her products. Organizations filed formal ethics complaints against Conway for violating federal law prohibiting use of a federal position "for the endorsement of any product, service or enterprise". Public Citizen asked the Office of Governmental Ethics (OGE) to investigate and Citizens for Responsibility and Ethics in Washington filed a similar complaint. Investigations into Russian interference in the election: Three separate investigations on Russian interference in the 2016 United States elections include those undertaken by the FBI, the Senate Intelligence Committee and the House Intelligence Committee. On March 20, in a House Intelligence Committee public hearing FBI Director James Comey confirmed that the FBI has been conducting a broad counter-intelligence investigation of Russian interference in the elections starting in July 2016, which includes investigations into possible links between Trump associates and Russia. Comey stated that the FBI has no evidence that corroborates Trump's March 4 wiretapping claim. On March 22, Devin Nunes, Republican chairman of the committee, held a press conference to reveal that, based on classified reports he had seen, U.S. intelligence agencies had incidentally collected communications of Trump's transition team, and that Trump associates' names were unmasked in the reports. The next House Intelligence Committee hearings will be closed and will include NSA Director Mike Rogers and Comey. Nunes canceled the public hearing with "former Acting Attorney General Sally Yates, former CIA Director John Brennan, and former Director of National Intelligence James Clapper". On April 6, 2017, Nunes temporarily recused himself from the Russia investigation, as the House Ethics Committee began investigating claims that he improperly disclosed classified information. He called the allegations "entirely false". Mike Conaway (R-TX) replaced Nunes to lead the investigation. Re-election campaign: Trump filed a form with the FEC declaring his eligibility to run for re-election in 2020 within hours of his taking office. The first rally paid for by the campaign took place at the Orlando Melbourne International Airport near Orlando, Florida, on February 18, 2017. The campaign rally was the earliest such event by any incumbent U.S. president in history. During the event, Trump defended his actions as president and criticized the media.

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South Dakota's Mount Rushmore Fireworks Celebration 2020

South Dakota's Mount Rushmore Fireworks Celebration 2020 was a fireworks celebration at Mount Rushmore held on July 3, 2020, the day before Independence Day. It was notable for featuring the first use of fireworks at the site since 2008 and for being held amid the ongoing COVID-19 pandemic. The event had a large crowd in attendance who did not social distance and were not required to wear masks, despite recommendations to do so by the Center for Disease Control and Prevention and other science experts, due to the ongoing coronavirus pandemic. However, masks were handed out and attendees were given temperature screenings (despite COVID-19 being able to be spread by asymptomatic individuals). President Donald Trump spoke at the event, with other politicians and notable names including South Dakota Governor Kristi Noem, Host of Entertainment Tonight Mary Hart, First Lady Melania Trump and Trump's eldest son Donald Trump Jr. in attendance. Donald Trump Jr.'s girlfriend Kimberly Guilfoyle also attended, despite having tested positive for the coronavirus that same day. Speech: Trump's remarks at the event covered his deploying of law enforcement to protect monuments, repeatedly expressed his support for a "God", largely ignored the ongoing COVID-19 pandemic in the United States, and included a reiteration to build "the wall". The speech, as described by Matthew Rowley, is all about 'the power of positive history'—by focusing on what made America great, Americans will be moved to greatness; by focusing on failure, Americans will become harsh, judgmental and intolerant. Although the George Floyd protests form the backdrop to Trump's words, the President nowhere mentions police brutality. 'In other words', writes Rowley, Trump seems to argue that 'America is great because it removed the knee from the slave's neck, not wicked because it knelt over the slave for centuries'.

Author

I work as an author. My mom says you can't support yourself by doing that. Maybe as your royalties might not be enough but after a while maybe. It's a flexible enough job to work from home and can help cut costs of child care. I worked as a volunteer in a daycare before. I've seen a mom who worked a freelance job and so she had times where she'd have her kid and other times the kid was in the daycare.

Vaccine hesitancy

Vaccine hesitancy, also known as anti-vaccination or anti-vax, is a reluctance or refusal to be vaccinated or to have one's children vaccinated against contagious diseases. People who subscribe to this view are commonly known as "anti-vaxxers". The term encompasses outright refusal to vaccinate, delaying vaccines, accepting vaccines but remaining uncertain about their use, or using certain vaccines but not others. Arguments against vaccination are contradicted by overwhelming scientific consensus about the safety and efficacy of vaccines. The World Health Organization views vaccine hesitancy as one of the top ten global health threats. Hesitancy primarily results from public debates around the medical, ethical and legal issues related to vaccines. Vaccine hesitancy stems from multiple key factors including a person's lack of confidence (mistrust of the vaccine and/or healthcare provider), complacency (the person does not see a need for the vaccine or does not see the value of the vaccine), and convenience (access to vaccines). It has existed since the invention of vaccination, and pre-dates the coining of the terms "vaccine" and "vaccination" by nearly 80 years. The specific hypotheses raised by anti-vaccination advocates have been found to change over time. Vaccine hesitancy often results in disease outbreaks and deaths from vaccine-preventable diseases. Bills for mandatory vaccination have been considered for legislation, including California Senate Bill 277 and Australia's No Jab No Pay, all of which have been strenuously opposed by anti-vaccination activists. Opposition to mandatory vaccination may be based on anti-vaccine sentiment, concern that it violates civil liberties or reduces public trust in vaccination, or suspicion of profiteering by the pharmaceutical industry. Effectiveness: Scientific evidence for the effectiveness of large-scale vaccination campaigns is well established. Two to three million deaths are prevented each year worldwide due to vaccination and an additional 1.5 million deaths could be prevented each year if all recommended vaccines were used. Vaccination campaigns helped eradicate smallpox, which once killed as many as one in seven children in Europe, and have nearly eradicated polio. As a more modest example, infections caused by Haemophilus influenzae (Hib), a major cause of bacterial meningitis and other serious diseases in children, have decreased by over 99% in the US since the introduction of a vaccine in 1988. It is estimated that full vaccination, from birth to adolescence, of all US children born in a given year would save 33,000 lives and prevent 14 million infections. There exists anti-vaccine literature that argues that reductions in infectious disease are a result of improved sanitation and hygiene (rather than vaccination), or that these diseases were already in decline before the introduction of specific vaccines. These claims are not supported by scientific data; the incidence of vaccine-preventable diseases tended to fluctuate over time until the introduction of specific vaccines, at which point the incidence dropped to near zero. A Centers for Disease Control and Prevention website aimed at countering common misconceptions about vaccines argued, "Are we expected to believe that better sanitation caused incidence of each disease to drop, just at the time a vaccine for that disease was introduced?" Other critics argue that the immunity granted by vaccines is only temporary and requires boosters, whereas those who survive the disease become permanently immune. As discussed below, the philosophies of some alternative medicine practitioners are incompatible with the idea that vaccines are effective. Population health: Incomplete vaccine coverage increases the risk of disease for the entire population, including those who have been vaccinated, because it reduces herd immunity. For example, the measles vaccine is given to children between the ages of 9 and 12 months, and the short window between the disappearance of maternal antibody (before which the vaccine often fails to seroconvert) and natural infection means that vaccinated children are frequently still vulnerable. Herd immunity lessens this vulnerability if all the children are vaccinated. Increasing herd immunity during an outbreak or risk of an outbreak is perhaps the most widely accepted justification for mass vaccination. When a new vaccine is introduced mass vaccination helps increase coverage rapidly. If enough of a population is vaccinated, herd immunity takes effect, decreasing risk to people who cannot receive vaccines because they are too young or old, immunocompromised, or have severe allergies to the ingredients in the vaccine. The outcome for people with compromised immune systems who get infected is often worse than that of the general population. Cost-effectiveness: Commonly used vaccines are a cost-effective and preventive way of promoting health, compared to the treatment of acute or chronic disease. In the US during 2001, routine childhood immunizations against seven diseases were estimated to save over $40 billion per birth-year cohort in overall social costs, including $10 billion in direct health costs, and the societal benefit-cost ratio for these vaccinations was estimated to be 16.5. Necessity: When a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of disease as cultural memories of the effects of that disease fade. At this point, parents may feel they have nothing to lose by not vaccinating their children. If enough people hope to become free-riders, gaining the benefits of herd immunity without vaccination, vaccination levels may drop to a level where herd immunity is ineffective. According to Jennifer Reich, those parents who believe vaccination to be quite effective but might prefer their children to remain unvaccinated, are those who are the most likely to be convinced to change their mind, as long as they are approached properly. Common themes: While some anti-vaccinationists openly deny the improvements vaccination has made to public health, or succumb to conspiracy theories, it is much more common to cite concerns about safety. As with any medical treatment, there is a potential for vaccines to cause serious complications, such as severe allergic reactions, but unlike most other medical interventions, vaccines are given to healthy people and so a higher standard of safety is demanded. While serious complications from vaccinations are possible, they are extremely rare and much less common than similar risks from the diseases they prevent. As the success of immunization programs increases and the incidence of disease decreases, public attention shifts away from the risks of disease to the risk of vaccination, and it becomes challenging for health authorities to preserve public support for vaccination programs. The overwhelming success of certain vaccinations has made certain diseases rare and consequently this has led to incorrect heuristic thinking, in weighing risks against benefits, among people who are vaccine-hesitant. Once such diseases (e.g., Haemophilus influenzae B) decrease in prevalence, people may no longer appreciate how serious the illness is due to a lack of familiarity with it and become complacent. The lack of personal experience with these diseases reduces the perceived danger and thus reduces the perceived benefit of immunization. Conversely, certain illnesses (e.g., influenza) remain so common that vaccine-hesitant people mistakenly perceive the illness to be non-threatening despite clear evidence that the illness poses a significant threat to human health. Omission and disconfirmation biases also contribute to vaccine hesitancy. Various concerns about immunization have been raised. They have been addressed and the concerns are not supported by evidence. Concerns about immunization safety often follow a pattern. First, some investigators suggest that a medical condition of increasing prevalence or unknown cause is an adverse effect of vaccination. The initial study and subsequent studies by the same group have inadequate methodology—typically a poorly controlled or uncontrolled case series. A premature announcement is made about the alleged adverse effect, resonating with individuals suffering from the condition, and underestimating the potential harm of forgoing vaccination to those whom the vaccine could protect. Other groups attempt to replicate the initial study but fail to get the same results. Finally, it takes several years to regain public confidence in the vaccine. Adverse effects ascribed to vaccines typically have an unknown origin, an increasing incidence, some biological plausibility, occurrences close to the time of vaccination, and dreaded outcomes. In almost all cases, the public health effect is limited by cultural boundaries: English speakers worry about one vaccine causing autism, while French speakers worry about another vaccine causing multiple sclerosis, and Nigerians worry that a third vaccine causes infertility. Autism: The idea of a link between vaccines and autism has been extensively investigated and conclusively shown to be false. The scientific consensus is that there is no relationship, causal or otherwise, between vaccines and incidence of autism, and vaccine ingredients do not cause autism. Nevertheless, the anti-vaccination movement continues to promote myths, conspiracy theories, and misinformation linking the two. A developing tactic appears to be the "promotion of irrelevant research as an active aggregation of several questionable or peripherally related research studies in an attempt to justify the science underlying a questionable claim." Thiomersal: Thiomersal (called "thimerosal" in the US) is an antifungal preservative used in small amounts in some multi-dose vaccines (where the same vial is opened and used for multiple patients) to prevent contamination of the vaccine. Despite thiomersal's efficacy, the use of thiomersal is controversial because it can be metabolized or degraded in the body to ethylmercury (C2H5Hg+) and thiosalicylate. As a result, in 1999, the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP) asked vaccine makers to remove thiomersal from vaccines as quickly as possible on the precautionary principle. Thiomersal is now absent from all common US and European vaccines, except for some preparations of influenza vaccine. Trace amounts remain in some vaccines due to production processes, at an approximate maximum of 1 microgramme, around 15% of the average daily mercury intake in the US for adults and 2.5% of the daily level considered tolerable by the WHO. The action sparked concern that thiomersal could have been responsible for autism. The idea is now considered disproven, as incidence rates for autism increased steadily even after thiomersal was removed from childhood vaccines. Currently there is no accepted scientific evidence that exposure to thiomersal is a factor in causing autism. Since 2000, parents in the United States have pursued legal compensation from a federal fund arguing that thiomersal caused autism in their children. A 2004 Institute of Medicine (IOM) committee favored rejecting any causal relationship between thiomersal-containing vaccines and autism. The concentration of thiomersal used in vaccines as an antimicrobial agent ranges from 0.001% (1 part in 100,000) to 0.01% (1 part in 10,000). A vaccine containing 0.01% thiomersal has 25 micrograms of mercury per 0.5 mL dose, roughly the same amount of elemental mercury found in a three-ounce can of tuna. There is robust peer-reviewed scientific evidence supporting the safety of thiomersal-containing vaccines. MMR vaccine: In the UK, the MMR vaccine was the subject of controversy after the publication in The Lancet of a 1998 paper by Andrew Wakefield and others reporting case histories of 12 children mostly with autism spectrum disorders with onset soon after administration of the vaccine. At a 1998 press conference, Wakefield suggested that giving children the vaccines in three separate doses would be safer than a single vaccination. This suggestion was not supported by the paper, and several subsequent peer-reviewed studies have failed to show any association between the vaccine and autism. It later emerged that Wakefield had received funding from litigants against vaccine manufacturers and that he had not informed colleagues or medical authorities of his conflict of interest; had this been known, publication in The Lancet would not have taken place in the way that it did. Wakefield has been heavily criticized on scientific grounds and for triggering a decline in vaccination rates (vaccination rates in the UK dropped to 80% in the years following the study), as well as on ethical grounds for the way the research was conducted. In 2004, the MMR-and-autism interpretation of the paper was formally retracted by 10 of Wakefield's 12 coauthors, and in 2010 The Lancet's editors fully retracted the paper. Wakefield was struck off the UK medical register, with a statement identifying deliberate falsification in the research published in The Lancet, and is barred from practicing medicine in the UK. The CDC, the IOM of the National Academy of Sciences, Australia's Department of Health, and the UK National Health Service have all concluded that there is no evidence of a link between the MMR vaccine and autism. A Cochrane review concluded that there is no credible link between the MMR vaccine and autism, that MMR has prevented diseases that still carry a heavy burden of death and complications, that the lack of confidence in MMR has damaged public health, and that the design and reporting of safety outcomes in MMR vaccine studies are largely inadequate. Additional reviews agree, with studies finding that vaccines are not linked to autism even in high risk populations with autistic siblings. In 2009, The Sunday Times reported that Wakefield had manipulated patient data and misreported results in his 1998 paper, creating the appearance of a link with autism. A 2011 article in the British Medical Journal described how the data in the study had been falsified by Wakefield so that it would arrive at a predetermined conclusion. An accompanying editorial in the same journal described Wakefield's work as an "elaborate fraud" that led to lower vaccination rates, putting hundreds of thousands of children at risk and diverting energy and money away from research into the true cause of autism. A special court convened in the United States to review claims under the National Vaccine Injury Compensation Program ruled on February 12, 2009, that parents of autistic children are not entitled to compensation in their contention that certain vaccines caused autism in their children. Vaccine overload: Vaccine overload, a non-medical term, is the notion that giving many vaccines at once may overwhelm or weaken a child's immature immune system and lead to adverse effects. Despite scientific evidence that strongly contradicts this idea, there are still parents of autistic children that believe that vaccine overload causes autism. The resulting controversy has caused many parents to delay or avoid immunizing their children. Such parental misperceptions are major obstacles towards immunization of children. The concept of vaccine overload is flawed on several levels. Despite the increase in the number of vaccines over recent decades, improvements in vaccine design have reduced the immunologic load from vaccines; the total number of immunological components in the 14 vaccines administered to US children in 2009 is less than 10% of what it was in the 7 vaccines given in 1980. A study published in 2013 found no correlation between autism and the antigen number in the vaccines the children were administered up to the age of two. Of the 1,008 children in the study, one quarter of those diagnosed with autism were born between 1994 and 1999, when the routine vaccine schedule could contain more than 3,000 antigens (in a single shot of DTP vaccine). The vaccine schedule in 2012 contains several more vaccines, but the number of antigens the child is exposed to by the age of two is 315. Vaccines pose a very small immunologic load compared to the pathogens naturally encountered by a child in a typical year; common childhood conditions such as fevers and middle-ear infections pose a much greater challenge to the immune system than vaccines, and studies have shown that vaccinations, even multiple concurrent vaccinations, do not weaken the immune system or compromise overall immunity. The lack of evidence supporting the vaccine overload hypothesis, combined with these findings directly contradicting it, has led to the conclusion that currently recommended vaccine programs do not "overload" or weaken the immune system. Any experiment based on withholding vaccines from children is considered unethical, and observational studies would likely be confounded by differences in the healthcare-seeking behaviors of under-vaccinated children. Thus, no study directly comparing rates of autism in vaccinated and unvaccinated children has been done. However, the concept of vaccine overload is biologically implausible, as vaccinated and unvaccinated children have the same immune response to non-vaccine-related infections, and autism is not an immune-mediated disease, so claims that vaccines could cause it by overloading the immune system go against current knowledge of the pathogenesis of autism. As such, the idea that vaccines cause autism has been effectively dismissed by the weight of current evidence. Prenatal infection: There is evidence that schizophrenia is associated with prenatal exposure to rubella, influenza, and toxoplasmosis infection. For example, one study found a sevenfold increased risk of schizophrenia when mothers were exposed to influenza in the first trimester of gestation. This may have public health implications, as strategies for preventing infection include vaccination, simple hygiene, and, in the case of toxoplasmosis, antibiotics. Based on studies in animal models, theoretical concerns have been raised about a possible link between schizophrenia and maternal immune response activated by virus antigens; a 2009 review concluded that there was insufficient evidence to recommend routine use of trivalent influenza vaccine during the first trimester of pregnancy, but that the vaccine was still recommended outside the first trimester and in special circumstances such as pandemics or in women with certain other conditions. The CDC's Advisory Committee on Immunization Practices, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians all recommend routine flu shots for pregnant women, for several reasons: -their risk for serious influenza-related medical complications during the last two trimesters; -their greater rates for flu-related hospitalizations compared to non-pregnant women; -the possible transfer of maternal anti-influenza antibodies to children, protecting the children from the flu; and several studies that found no harm to pregnant women or their children from the vaccinations. -Despite this recommendation, only 16% of healthy pregnant US women surveyed in 2005 had been vaccinated against the flu. Ingredient concerns: Aluminum compounds are used as immunologic adjuvants to increase the effectiveness of many vaccines. The aluminum in vaccines simulates or causes small amounts of tissue damage, driving the body to respond more powerfully to what it sees as a serious infection and promoting the development of a lasting immune response. In some cases these compounds have been associated with redness, itching, and low-grade fever, but the use of aluminum in vaccines has not been associated with serious adverse events. In some cases, aluminum-containing vaccines are associated with macrophagic myofasciitis (MMF), localized microscopic lesions containing aluminum salts that persist for up to 8 years. However, recent case-controlled studies have found no specific clinical symptoms in individuals with biopsies showing MMF, and there is no evidence that aluminum-containing vaccines are a serious health risk or justify changes to immunization practice. Infants are exposed to greater quantities of aluminum in daily life in breastmilk and infant formula than in vaccines. In general, people are exposed to low levels of naturally occurring aluminum in nearly all foods and drinking water. The amount of aluminum present in vaccines is small, less than 1 milligram, and such low levels are not believed to be harmful to human health. Vaccine hesitant people have also voiced strong concerns about the presence of formaldehyde in vaccines. Formaldehyde is used in very small concentrations to inactivate viruses and bacterial toxins used in vaccines. Very small amounts of residual formaldehyde can be present in vaccines but are far below values harmful to human health. The levels present in vaccines are minuscule when compared to naturally-occurring levels of formaldehyde in the human body and pose no significant risk of toxicity. The human body continuously produces formaldehyde naturally and contains 50–70 times the greatest amount of formaldehyde present in any vaccine. Furthermore, the human body is capable of breaking down naturally occurring formaldehyde as well as the small amount of formaldehyde present in vaccines. There is no evidence linking the infrequent exposures to small quantities of formaldehyde present in vaccines with cancer. Sudden infant death syndrome: Sudden infant death syndrome (SIDS) is most common in infants around the time in life when they receive many vaccinations. Since the cause of SIDS has not been fully determined, this led to concerns about whether vaccines, in particular diphtheria-tetanus toxoid vaccines, were a possible causal factor. Several studies investigated this and found no evidence supporting a causal link between vaccination and SIDS. In 2003, the Institute of Medicine favored rejection of a causal link to DTwP vaccination and SIDS after reviewing the available evidence. Additional analyses of VAERS data also showed no relationship between vaccination and SIDS. In fact, evidence is mounting that vaccination may protect children against SIDS. Anthrax vaccines: In the mid-1990s media reports on vaccines discussed the Gulf War Syndrome, a multi-symptomatic disorder affecting returning US military veterans of the 1990–1991 Persian Gulf War. Among the first articles of the online magazine Slate was one by Atul Gawande in which the required immunizations received by soldiers, including an anthrax vaccination, were named as one the likely culprits for the symptoms associated with the Gulf War Syndrome. In the late 1990s Slate published an article on the "brewing rebellion" in the military against the anthrax immunization because of "the availability to soldiers of vaccine misinformation on the Internet". Slate continued to report on concerns about the required anthrax and smallpox immunization for US troops after the September 11 attacks and articles on the subject also appeared on the Salon website. The 2001 anthrax attacks heightened concerns about bioterrorism and the Federal government of the United States stepped up its efforts to store and create more vaccines for American citizens. In 2002, Mother Jones published an article that was highly skeptical of the anthrax and smallpox immunization required by the United States Armed Forces. With the 2003 invasion of Iraq a wider controversy ensued in the media about requiring US troops to be vaccinated against anthrax. From 2003 to 2008 a series of court cases were brought to oppose the compulsory anthrax vaccination of US troops. Swine flu vaccine: The US swine flu immunization campaign in response to the 1976 swine flu outbreak has become known as "the swine flu fiasco" because the outbreak did not lead to a pandemic as US President Gerald Ford had feared and the hastily rolled out vaccine was found to increase the number of Guillain-Barré Syndrome cases two weeks after immunization. Government officials stopped the mass immunization campaign due to great anxiety about the safety of the swine flue vaccine. The general public was left with greater fear of the vaccination campaign than the virus itself and vaccination policies in general were challenged. During the 2009 flu pandemic, significant controversy broke out regarding whether the 2009 H1N1 flu vaccine was safe in, among other countries, France. Numerous different French groups publicly criticized the vaccine as potentially dangerous. Because of similarities between the 2009 influenza A subtype H1N1 virus and the 1976 influenza A/NJ virus many countries established surveillance systems for vaccine-related adverse effects on human health. A possible link between the 2009 H1N1 flu vaccine and Guillain-Barré Syndrome cases was studied in Europe and the United States. Other safety concerns: Other safety concerns about vaccines have been promoted on the Internet, in informal meetings, in books, and at symposia. These include hypotheses that vaccination can cause epileptic seizures, allergies, multiple sclerosis, and autoimmune diseases such as type 1 diabetes, as well as hypotheses that vaccinations can transmit bovine spongiform encephalopathy, hepatitis C virus, and HIV. These hypotheses have been investigated, with the conclusion that currently used vaccines meet high safety standards and that criticism of vaccine safety in the popular press is not justified. Large well-controlled epidemiologic studies have been conducted and the results do not support the hypothesis that vaccines cause chronic diseases. Furthermore, some vaccines are probably more likely to prevent or modify than cause or exacerbate autoimmune diseases. Another common concern parents often have is about the pain associated with administering vaccines during a doctor's office visit. This may lead to parental requests to space out vaccinations; however, studies have shown a child's stress response is not different when receiving one vaccination or two. The act of spacing out vaccinations may actually lead to more stressful stimuli for the child. CIA fake vaccination clinic: In Pakistan, the CIA ran a fake vaccination clinic in an attempt to locate Osama bin Laden. As a direct consequence, there have been several attacks and deaths among vaccination workers. Several Islamist preachers and militant groups, including some factions of the Taliban, view vaccination as a plot to kill or sterilize Muslims. Efforts to eradicate polio have furthermore been disrupted by American drone strikes. This is part of the reason Pakistan and Afghanistan are the only countries where polio remained endemic as of 2015. Vaccine myths: There are several vaccination myths that contribute to parental concerns and vaccine hesitancy. These include the alleged superiority of natural infection when compared to vaccination, questioning whether the diseases vaccines prevent are dangerous, whether vaccines pose moral or religious dilemmas, suggesting that vaccines are not effective, proposing unproven or ineffective approaches as alternatives to vaccines, and conspiracy theories that center on mistrust of the government and medical institutions. Vaccination during illness: Many parents are concerned about the safety of vaccination when their child is sick. Moderate to severe acute illness with or without a fever is indeed a precaution when considering vaccination. Vaccines remain effective during childhood illness. The reason vaccines may be withheld if a child is moderately to severely ill is because certain expected side effects of vaccination (e.g. fever or rash) may be confused with progression of the illness. It is safe to administer vaccines to well-appearing children who are mildly ill with the common cold. Natural Infection: Another common anti-vaccine myth is that the immune system produces a better immune protection in response to natural infection when compared to vaccination. In some cases, actual infection with the illness may produce lifelong immunity. However, natural disease carries a higher risk of harming a person's health than vaccines. For example, natural varicella infection carries a higher risk of bacterial superinfection with Group A streptococci. HPV vaccine: The idea that the HPV vaccine is linked to increased sexual behavior is not supported by scientific evidence. A review of nearly 1,400 adolescent girls found no difference in teen pregnancy, incidence of sexually transmitted infection, or contraceptive counseling regardless of whether they received the HPV vaccine. Thousands of Americans die each year from cancers preventable by the vaccine. Vaccine schedule: Other concerns have been raised about the vaccine schedule recommended by the Advisory Committee on Immunization Practices (ACIP). The immunization schedule is designed to protect children against preventable diseases when they are most vulnerable. The practice of delaying or spacing out these vaccinations increases the amount of time the child is susceptible to these illnesses. Receiving vaccines on the schedule recommended by the ACIP is not linked to autism or developmental delay. Events following reductions in vaccination: In several countries, reductions in the use of some vaccines were followed by increases in the diseases' morbidity and mortality. According to the Centers for Disease Control and Prevention, continued high levels of vaccine coverage are necessary to prevent resurgence of diseases that have been nearly eliminated. Pertussis remains a major health problem in developing countries, where mass vaccination is not practiced; the World Health Organization estimates it caused 294,000 deaths in 2002. Vaccine hesitancy has contributed to the resurgence of preventable disease. For example, in 2019, the number of measles cases increased by 30% worldwide and many cases occurred in countries that had nearly eliminated measles. Stockholm, smallpox (1873–74): An anti-vaccination campaign motivated by religious objections, concerns about effectiveness, and concerns about individual rights led to the vaccination rate in Stockholm dropping to just over 40%, compared to about 90% elsewhere in Sweden. A major smallpox epidemic began there in 1873. It led to a rise in vaccine uptake and an end of the epidemic. UK, pertussis (1970s–80s): In a 1974 report ascribing 36 reactions to whooping cough (pertussis) vaccine, a prominent public-health academic claimed that the vaccine was only marginally effective and questioned whether its benefits outweigh its risks, and extended television and press coverage caused a scare. Vaccine uptake in the UK decreased from 81% to 31%, and pertussis epidemics followed, leading to the deaths of some children. Mainstream medical opinion continued to support the effectiveness and safety of the vaccine; public confidence was restored after the publication of a national reassessment of vaccine efficacy. Vaccine uptake then increased to levels above 90%, and disease incidence declined dramatically. Sweden, pertussis (1979–96): In the vaccination moratorium period that occurred when Sweden suspended vaccination against whooping cough (pertussis) from 1979 to 1996, 60% of the country's children contracted the disease before the age of 10; close medical monitoring kept the death rate from whooping cough at about one per year. Netherlands, measles (1999–2000): An outbreak at a religious community and school in the Netherlands resulted in three deaths and 68 hospitalizations among 2,961 cases. The population in the several provinces affected had a high level of immunization, with the exception of one of the religious denominations, which traditionally does not accept vaccination. Ninety-five percent of those who contracted measles were unvaccinated. UK and Ireland, measles (2000): As a result of the MMR vaccine controversy, vaccination rates dropped sharply in the United Kingdom after 1996. From late 1999 until the summer of 2000, there was a measles outbreak in North Dublin, Ireland. At the time, the national immunization level had fallen below 80%, and in parts of North Dublin the level was around 60%. There were more than 100 hospital admissions from over 300 cases. Three children died and several more were gravely ill, some requiring mechanical ventilation to recover. Nigeria, polio, measles, diphtheria (2001–): In the early first decade of the 21st century, conservative religious leaders in northern Nigeria, suspicious of Western medicine, advised their followers not to have their children vaccinated with oral polio vaccine. The boycott was endorsed by the governor of Kano State, and immunization was suspended for several months. Subsequently, polio reappeared in a dozen formerly polio-free neighbors of Nigeria, and genetic tests showed the virus was the same one that originated in northern Nigeria. Nigeria had become a net exporter of the polio virus to its African neighbors. People in the northern states were also reported to be wary of other vaccinations, and Nigeria reported over 20,000 measles cases and nearly 600 deaths from measles from January through March 2005. In Northern Nigeria, it is a common belief that vaccination is a strategy created by the westerners to reduce the Northerners' population. As a result of this belief, a large number of Northerners reject vaccination. In 2006, Nigeria accounted for over half of all new polio cases worldwide. Outbreaks continued thereafter; for example, at least 200 children died in a late-2007 measles outbreak in Borno State. United States, measles (2005–): In 2000, measles was declared eliminated from the United States because internal transmission had been interrupted for one year; remaining reported cases were due to importation. A 2005 measles outbreak in the US state of Indiana was attributed to parents who had refused to have their children vaccinated. The Centers for Disease Control and Prevention (CDC) reported that the three biggest outbreaks of measles in 2013 were attributed to clusters of people who were unvaccinated due to their philosophical or religious beliefs. As of August 2013, three pockets of outbreak—New York City, North Carolina, and Texas—contributed to 64% of the 159 cases of measles reported in 16 states. The number of cases in 2014 quadrupled to 644, including transmission by unvaccinated visitors to Disneyland in California. Some 97% of cases in the first half of the year were confirmed to be due directly or indirectly to importation (the remainder were unknown), and 49% from the Philippines. More than half of the victims (165 out of 288, or 57%) during that time were confirmed to be unvaccinated by choice; 30 (10%) were confirmed to have been vaccinated. The final count of measles in 2014 was 668 cases in 27 states. From January 1 to June 26, 2015, 178 people from 24 states and the District of Columbia were reported to have measles. Most of these cases (117 cases 66%) were part of a large multi-state outbreak linked to Disneyland in California, continued from 2014. Analysis by the CDC scientists showed that the measles virus type in this outbreak (B3) was identical to the virus type that caused the large measles outbreak in the Philippines in 2014. On July 2, 2015, the first confirmed death from measles in 12 years was recorded. An immunocompromised woman in Washington State was infected and later died of pneumonia due to measles. By July 2016, a three-month measles outbreak affecting at least 22 people was spread by unvaccinated employees of the Eloy, Arizona detention center, an Immigration and Customs Enforcement (ICE) facility owned by for-profit prison operator CoreCivic. Pinal County's health director presumed the outbreak likely originated with a migrant, but detainees had since received vaccinations. However convincing CoreCivic's employees to become vaccinated or demonstrate proof of immunity was much more difficult, he said. In spring 2017, a measles outbreak occurred in Minnesota. As of June 16, 78 cases of measles had been confirmed in the state, 71 were unvaccinated and 65 were Somali-Americans. The outbreak has been attributed to low vaccination rates among Somali-American children, which can be traced back to 2008, when Somali parents began to express concern about disproportionately high numbers of Somali preschoolers in special education classes who were receiving services for autism spectrum disorder. Around the same time, disgraced former doctor Andrew Wakefield visited Minneapolis, teaming up with anti-vaccine groups to raise concerns that vaccines were the cause of autism, despite the fact that multiple studies have shown no connection between the MMR vaccine and autism. From fall 2018 to early 2019, New York State experienced an outbreak of over 200 confirmed measles cases. Many of these cases were attributed to ultra-Orthodox Jewish communities with low vaccination rates in areas within Brooklyn and Rockland County. State Health Commissioner Howard Zucker stated that this was the worst outbreak of measles in his recent memory. In January 2019, Washington state reported an outbreak of at least 73 confirmed cases of measles, most within Clark County, which has a higher rate of vaccination exemptions compared to the rest of the state. This led state governor Jay Inslee to declare a state of emergency, and the state's congress to introduce legislation to disallow vaccination exemption for personal or philosophical reasons. Wales, measles (2013–): In 2013, an outbreak of measles occurred in the Welsh city of Swansea. One death was reported. Some estimates indicate that while MMR uptake for two-year-olds was at 94% in Wales in 1995, it had fallen to as low as 67.5% in Swansea by 2003, meaning the region had a "vulnerable" age group. This has been linked to the MMR vaccine controversy, which caused a significant number of parents to fear allowing their children to receive the MMR vaccine. June 5, 2017, saw a new measles outbreak in Wales, at Lliswerry High School in the town of Newport. United States, tetanus: Most cases of pediatric tetanus in the U.S. occur in unvaccinated children. In Oregon, in 2017, an unvaccinated boy had a scalp wound that his parents sutured themselves. Later the boy arrived at a hospital with tetanus. He spent 47 days in the Intensive Care Unit (ICU), and 57 total days in the hospital, at a cost of $811,929, not including the cost of airlifting him to the Oregon Health and Science University, Doernbecher Children's Hospital, or the subsequent two-and-a-half weeks of inpatient rehabilitation he required. Despite this, his parents declined the administration of subsequent tetanus boosters or other vaccinations. Due to privacy regulations, publicly identifying the payer of the costs was prohibited. Romania (2016–present): As of September 2017, a measles epidemic was ongoing across Europe, especially Eastern Europe. In Romania, there were about 9300 cases of measles, and 34 people—all of whom were unvaccinated—had died of measles. This was preceded by a 2008 controversy regarding the HPV vaccine. In 2012, doctor Christa Todea-Gross published a free downloadable book online, this book contained misinformation about vaccination from abroad translated into Romanian, which significantly stimulated the growth of the anti-vaccine movement. The government of Romania officially declared a measles epidemic in September 2016, and started an information campaign to encourage parents to have their children vaccinated. By February 2017, however, the stockpile of MMR vaccines was depleted, and doctors were overburdened. Around April, the vaccine stockpile had been restored. By March 2019, the death toll had risen to 62, with 15,981 cases reported. Samoa, measles (2019): The 2019 Samoa measles outbreak began in October 2019 and as of December 12, there were 4,995 confirmed cases of measles and 72 deaths, out of a Samoan population of 201,316. A state of emergency was declared on November 17, ordering all schools to be closed, barring children under 17 from public events, and making vaccination mandatory. UNICEF has sent 110,500 vaccines to Samoa. Tonga and Fiji have also declared states of emergency. The outbreak has been attributed to a sharp drop in measles vaccination from the previous year, following an incident in 2018 when two infants died shortly after receiving measles vaccinations, which led the country to suspend its measles vaccination program. The reason for the two infants' deaths was incorrect preparation of the vaccine by two nurses who mixed vaccine powder with expired anesthetic. As of November 30, more than 50,000 people were vaccinated by the government of Samoa. Approach: Vaccine hesitancy is challenging and optimal strategies for approaching it remain uncertain. Many interventions designed to address vaccine hesitancy have been based on the information deficit model. This model assumes that vaccine hesitancy is due to a person lacking the necessary information and attempts to provide them with that information to solve the problem. Despite many educational interventions attempting this approach, ample evidence indicates providing more information is often ineffective in changing a vaccine-hesitant person's views and may, in fact, have the opposite of the intended effect and reinforce their misconceptions. Several communication strategies are recommended for use when interacting with vaccine-hesitant parents. These include establishing honest and respectful dialogue; acknowledging the risks of a vaccine but balancing them against the risk of disease; referring parents to reputable sources of vaccine information; and maintaining ongoing conversations with vaccine-hesitant families. The American Academy of Pediatrics recommends healthcare providers directly address parental concerns about vaccines when questioned about their efficacy and safety. Additional recommendations include asking permission to share information; maintaining a conversational tone (as opposed to lecturing); not spending excessive amounts of time debunking specific myths (this may have the opposite effect of strengthening the myth in the person's mind); focusing on the facts and simply identifying the myth as false; and keeping information as simple as possible (if the myth seems simpler than the truth, it may be easier for people to accept the simple myth). Storytelling and anecdote (e.g., about the decision to vaccinate one's own children) can be powerful communication tools for conversations about the value of vaccination. A New Zealand General Practitioner has used a comic, Jenny and the Eddies, both to educate children about vaccines and address his patients’ concerns through open, trusting and non-threatening conversations, concluding that "I always listen to what people have to say on any matter. That includes vaccine hesitancy. That’s a very important opening stage to improving the therapeutic relationship. If I’m going to change anyone’s attitude, first I need to listen to them and be open-minded." The perceived strength of the recommendation, when provided by a healthcare provider, also seems to influence uptake, with recommendations that are perceived to be stronger resulting in higher vaccination rates than perceived weaker recommendations. Limited evidence suggests that a more paternalistic or presumptive approach ("Your son needs three shots today.") is more likely to result in patient acceptance of vaccines during a clinic visit than a participatory approach ("What do you want to do about shots?") but decreases patient satisfaction with the visit. A presumptive approach helps to establish that this is the normative choice. Similarly, one study found that the way in which physicians respond to parental vaccine resistance is important. Nearly half of initially vaccine-resistant parents accepted vaccinations if physicians persisted in their initial recommendation. The Centers for Disease Control and Prevention has released resources to aid healthcare providers in having more effective conversations with parents about vaccinations. Parents may be hesitant to have their child vaccinated due to concerns about the pain of vaccination. There are several strategies that can be used to reduce the child's pain. Such strategies include distraction techniques (pinwheels); deep breathing techniques; breastfeeding the child; giving the child sweet-tasting solutions; quickly administering the vaccine without aspirating; keeping the child upright; providing tactile stimulation; applying numbing agents to the skin; and saving the most painful vaccine for last. As above, the number of vaccines offered in a particular encounter is related to the likelihood of parent vaccine refusal (the more vaccines offered, the higher the likelihood of vaccine deferral). The use of combination vaccines to provide protection against more diseases but with fewer injections may provide reassurance to parents. Similarly, reframing the conversation with less emphasis on the number of diseases the healthcare provider is immunizing against (e.g., "we will do two injections (combined vaccinations) and an oral vaccine") may be more acceptable to parents than "we're going to vaccinate against 7 diseases". It is unclear whether interventions intended to educate parents about vaccines improve the rate of vaccination. It is also unclear whether citing the reasons of benefit to others and herd immunity improves parents' willingness to vaccinate their children. In one trial, an educational intervention designed to dispel common misconceptions about the influenza vaccine decreased parents' false beliefs about the vaccines but did not improve uptake of the influenza vaccine. In fact, parents with significant concerns about adverse effects from the vaccine were less likely to vaccinate their children with the influenza vaccine after receiving this education. Multicomponent initiatives which include targeting undervaccinated populations, improving the convenience of and access to vaccines, educational initiatives, and mandates may improve vaccination uptake. It is recommended that healthcare providers advise parents against performing their own web search queries since many websites on the Internet contain significant misinformation. Many parents perform their own research online and are often confused, frustrated, and unsure of which sources of information are trustworthy. Additional recommendations include introducing parents to the importance of vaccination as far in advance of the initial well-child visit as possible; presenting parents with vaccine safety information while in their pediatrician's waiting room; and using prenatal open houses and postpartum maternity ward visits as opportunities to vaccinate. Internet advertising, on Facebook and elsewhere, is purchased by both public health authorities and anti-vaccination groups. In the United States, the majority of anti-vaccine Facebook advertising in December 2018 and February 2019 had been paid for one of two groups: Robert F. Kennedy Jr.'s Children's Health Defense and Stop Mandatory Vaccination. The ads targeted women and young couples and generally highlighted the alleged risks of vaccines, while asking for donations. Several anti-vaccination advertising campaigns also targeted areas where measles outbreaks were underway during this period. The impact of Facebook's subsequent advertising policy changes has not been studied. The World Health Organization (WHO) published a paper in 2016 with the goal of aiding experts on how to respond to vaccine deniers in public. The WHO recommends for experts to view the general public as their target audience rather than the vaccine denier when debating in a public forum. The WHO also suggests for experts to make unmasking the techniques that the vaccine denier uses to spread misinformation as the goal of the conversation. The WHO asserts that this will make the public audience more resilient against anti-vaccine tactics. History- Variolation: Early attempts to prevent smallpox involved deliberate inoculation with the milder form of the disease—Variola Minor—in the expectation that a mild case would confer immunity and avoid Variola Major. Originally called inoculation, this technique was later called variolation to avoid confusion with cowpox inoculation (vaccination) when that was introduced by Edward Jenner. Although variolation had a long history in China and India, it was first used in North America and England in 1721. Reverend Cotton Mather introduced variolation to Boston, Massachusetts, during the 1721 smallpox epidemic.[189] Despite strong opposition in the community, Mather convinced Zabdiel Boylston to try it. Boylston first experimented on his 6-year-old son, his slave, and his slave's son; each subject contracted the disease and was sick for several days, until the sickness vanished and they were "no longer gravely ill". Boylston went on to variolate thousands of Massachusetts residents, and many places were named for him in gratitude as a result. Lady Mary Wortley Montagu introduced variolation to England. She had seen it used in Turkey and, in 1718, had her son successfully variolated in Constantinople under the supervision of Charles Maitland. When she returned to England in 1721, she had her daughter variolated by Maitland. This aroused considerable interest, and Sir Hans Sloane organized the variolation of some inmates in Newgate Prison. These were successful, and after a further short trial in 1722, two daughters of Caroline of Ansbach Princess of Wales were variolated without mishap. With this royal approval, the procedure became common when smallpox epidemics threatened. Religious arguments against inoculation were soon advanced. For example, in a 1722 sermon entitled "The Dangerous and Sinful Practice of Inoculation", the English theologian Reverend Edmund Massey argued that diseases are sent by God to punish sin and that any attempt to prevent smallpox via inoculation is a "diabolical operation". It was customary at the time for popular preachers to publish sermons, which reached a wide audience. This was the case with Massey, whose sermon reached North America, where there was early religious opposition, particularly by John Williams. A greater source of opposition there was William Douglass, a medical graduate of Edinburgh University and a Fellow of the Royal Society, who had settled in Boston. Smallpox vaccination: After Edward Jenner introduced the smallpox vaccine in 1798, variolation declined and was banned in some countries. As with variolation, there was some religious opposition to vaccination, although this was balanced to some extent by support from clergymen, such as Reverend Robert Ferryman, a friend of Jenner's, and Rowland Hill, who not only preached in its favour but also performed vaccination themselves. There was also opposition from some variolators who saw the loss of a lucrative monopoly. William Rowley published illustrations of deformities allegedly produced by vaccination, lampooned in James Gillray's famous caricature depicted on this page, and Benjamin Moseley likened cowpox to syphilis, starting a controversy that would last into the 20th century. There was legitimate concern from supporters of vaccination about its safety and efficacy, but this was overshadowed by general condemnation, particularly when legislation started to introduce compulsory vaccination. The reason for this was that vaccination was introduced before laboratory methods were developed to control its production and account for its failures. Vaccine was maintained initially through arm-to-arm transfer and later through production on the skin of animals, and bacteriological sterility was impossible. Further, identification methods for potential pathogens were not available until the late 19th to early 20th century. Diseases later shown to be caused by contaminated vaccine included erysipelas, tuberculosis, tetanus, and syphilis. This last, though rare—estimated at 750 cases in 100 million vaccinations—attracted particular attention. Much later, Charles Creighton, a leading medical opponent of vaccination, claimed that the vaccine itself was a cause of syphilis and devoted a book to the subject. As cases of smallpox started to occur in those who had been vaccinated earlier, supporters of vaccination pointed out that these were usually very mild and occurred years after the vaccination. In turn, opponents of vaccination pointed out that this contradicted Jenner's belief that vaccination conferred complete protection. The views of opponents of vaccination that it was both dangerous and ineffective led to the development of determined anti-vaccination movements in England when legislation was introduced to make vaccination compulsory. England: Because of its greater risks, variolation was banned in England by the 1840 Vaccination Act, which also introduced free voluntary vaccination for infants. Thereafter Parliament passed successive acts to enact and enforce compulsory vaccination. The 1853 act introduced compulsory vaccination, with fines for non-compliance and imprisonment for non-payment. The 1867 act extended the age requirement to 14 years and introduced repeated fines for repeated refusal for the same child. Initially, vaccination regulations were organised by the local Poor Law Guardians, and in towns where there was strong opposition to vaccination, sympathetic Guardians were elected who did not pursue prosecutions. This was changed by the 1871 act, which required Guardians to act. This significantly changed the relationship between the government and the public, and organized protests increased. In Keighley, Yorkshire, in 1876 the Guardians were arrested and briefly imprisoned in York Castle, prompting large demonstrations in support of the "Keighley Seven". The protest movements crossed social boundaries. The financial burden of fines fell hardest on the working class, who would provide the largest numbers at public demonstrations. Societies and publications were organized by the middle classes, and support came from celebrities such as George Bernard Shaw and Alfred Russel Wallace, doctors such as Charles Creighton and Edgar Crookshank, and parliamentarians such as Jacob Bright and James Allanson Picton. By 1885, with over 3,000 prosecutions pending in Leicester, a mass rally there was attended by over 20,000 protesters. Under increasing pressure, the government appointed a Royal Commission on Vaccination in 1889, which issued six reports between 1892 and 1896, with a detailed summary in 1898. Its recommendations were incorporated into the 1898 Vaccination Act, which still required compulsory vaccination but allowed exemption on the grounds of conscientious objection on presentation of a certificate signed by two magistrates. These were not easy to obtain in towns where magistrates supported compulsory vaccination, and after continued protests, a further act in 1907 allowed exemption on a simple signed declaration. Although this solved the immediate problem, the compulsory vaccination acts remained legally enforceable, and determined opponents lobbied for their repeal. No Compulsory Vaccination was one of the demands of the 1900 Labour Party General Election Manifesto. This was done as a matter of routine when the National Health Service was introduced in 1948, with "almost negligible" opposition from supporters of compulsory vaccination. Vaccination in Wales was covered by English legislation, but the Scottish legal system was separate. Vaccination was not made compulsory there until 1863, and conscientious objection was allowed after vigorous protest only in 1907. In the late 19th century, the city of Leicester in the UK received much attention because of the way smallpox was managed there. There was particularly strong opposition to compulsory vaccination, and medical authorities had to work within this framework. They developed a system that did not use vaccination but was based on the notification of cases, the strict isolation of patients and contacts, and the provision of isolation hospitals. This proved successful but required acceptance of compulsory isolation rather than vaccination. C. Killick Millard, initially a supporter of compulsory vaccination, was appointed Medical Officer of Health in 1901. He moderated his views on compulsion but encouraged contacts and his staff to accept vaccination. This approach, developed initially due to overwhelming opposition to government policy, became known as the Leicester Method. In time it became generally accepted as the most appropriate way to deal with smallpox outbreaks and was listed as one of the "important events in the history of smallpox control" by those most involved in the World Health Organization's successful Smallpox Eradication Campaign. The final stages of the campaign, generally referred to as "surveillance containment", owed much to the Leicester method. United States: In the US, President Thomas Jefferson took a close interest in vaccination, alongside Benjamin Waterhouse, chief physician at Boston. Jefferson encouraged the development of ways to transport vaccine material through the Southern states, which included measures to avoid damage by heat, a leading cause of ineffective batches. Smallpox outbreaks were contained by the latter half of the 19th century, a development widely attributed to the vaccination of a large portion of the population. Vaccination rates fell after this decline in smallpox cases, and the disease again became epidemic in the late 19th century. After an 1879 visit to New York by prominent British anti-vaccinationist William Tebb, The Anti-Vaccination Society of America was founded. The New England Anti-Compulsory Vaccination League formed in 1882, and the Anti-Vaccination League of New York City in 1885. Tactics in the US largely followed those used in England. Vaccination in the US was regulated by individual states, in which there followed a progression of compulsion, opposition, and repeal similar to that in England. Although generally organized on a state-by-state basis, the vaccination controversy reached the US Supreme Court in 1905. There, in the case of Jacobson v. Massachusetts, the court ruled that states have the authority to require vaccination against smallpox during a smallpox epidemic. John Pitcairn, the wealthy founder of the Pittsburgh Plate Glass Company (now PPG Industries), emerged as a major financier and leader of the American anti-vaccination movement. On March 5, 1907, in Harrisburg, Pennsylvania, he delivered an address to the Committee on Public Health and Sanitation of the Pennsylvania General Assembly criticizing vaccination. He later sponsored the National Anti-Vaccination Conference, which, held in Philadelphia in October 1908, led to the creation of The Anti-Vaccination League of America. When the league organized later that month, members chose Pitcairn as their first president. On December 1, 1911, Pitcairn was appointed by Pennsylvania Governor John K. Tener to the Pennsylvania State Vaccination Commission, and subsequently authored a detailed report strongly opposing the commission's conclusions. He remained a staunch opponent of vaccination until his death in 1916. Brazil: In November 1904, in response to years of inadequate sanitation and disease, followed by a poorly explained public health campaign led by the renowned Brazilian public health official Oswaldo Cruz, citizens and military cadets in Rio de Janeiro arose in a Revolta da Vacina, or Vaccine Revolt. Riots broke out on the day a vaccination law took effect; vaccination symbolized the most feared and most tangible aspect of a public health plan that included other features, such as urban renewal, that many had opposed for years. Later vaccines and antitoxins: Opposition to smallpox vaccination continued into the 20th century and was joined by controversy over new vaccines and the introduction of antitoxin treatment for diphtheria. Injection of horse serum into humans as used in antitoxin can cause hypersensitivity, commonly referred to as serum sickness. Moreover, the continued production of smallpox vaccine in animals and the production of antitoxins in horses prompted anti-vivisectionists to oppose vaccination. Diphtheria antitoxin was serum from horses that had been immunized against diphtheria, and was used to treat human cases by providing passive immunity. In 1901, antitoxin from a horse named Jim was contaminated with tetanus and killed 13 children in St. Louis, Missouri. This incident, together with nine deaths from tetanus from contaminated smallpox vaccine in Camden, New Jersey, led directly and quickly to the passing of the Biologics Control Act in 1902. Robert Koch developed tuberculin in 1890. Inoculated into individuals who have had tuberculosis, it produces a hypersensitivity reaction, and is still used to detect those who have been infected. However, Koch used tuberculin as a vaccine. This caused serious reactions and deaths in individuals whose latent tuberculosis was reactivated by the tuberculin. This was a major setback for supporters of new vaccines. Such incidents and others ensured that any untoward results concerning vaccination and related procedures received continued publicity, which grew as the number of new procedures increased. In 1955, in a tragedy known as the Cutter incident, Cutter Laboratories produced 120,000 doses of the Salk polio vaccine that inadvertently contained some live polio virus along with inactivated virus. This vaccine caused 40,000 cases of polio, 53 cases of paralysis, and five deaths. The disease spread through the recipients' families, creating a polio epidemic that led to a further 113 cases of paralytic polio and another five deaths. It was one of the worst pharmaceutical disasters in US history. Later 20th-century events included the 1982 broadcast of DPT: Vaccine Roulette, which sparked debate over the DPT vaccine, and the 1998 publication of a fraudulent academic article by Andrew Wakefield which sparked the MMR vaccine controversy. Also recently, the HPV vaccine has become controversial due to concerns that it may encourage promiscuity when given to 11- and 12-year-old girls. Arguments against vaccines in the 21st century are often similar to those of 19th-century anti-vaccinationists. Covid-19: Surveys have gathered information on whether people would be willing to take a potential COVID-19 vaccine. Researchers have estimated that 67% or 80% of people in the US would accept a new vaccination against COVID-19. In the United Kingdom, a 16 November 2020 YouGov poll showed that 42% said they were very likely to take the vaccine and 25% were fairly likely (67% likely overall); 11% would be very unlikely and 10% fairly unlikely (21% unlikely overall) and 12% are unsure. However, there are a number of reasons why people do not wish to take the current COVID-19 vaccines, with concerns such as safety, self-perception of being 'low risk', or questioning the Pfizer-BioNTech vaccine in particular. 8% of those reluctant to take it the say it is because they oppose vaccinations overall; this amounts to just 2% of the British public. A December Ipsos/World Economic Forum 15-country poll asked online respondents whether they agreed with the statement: "If a vaccine for COVID-19 were available, I would get it". Rates of agreement were smallest in France (40%), Russia (43%) and South Africa (53%). In the United States, 69% of those polled agreed with the statement; rates were even higher in Britain (77%) and China (80%). Epidemiology: Vaccine hesitancy is becoming an increasing concern, particularly in industrialized nations. For example, one study surveying parents in Europe found that 12–28% of surveyed parents expressed doubts about vaccinating their children. Several studies have assessed socioeconomic and cultural factors associated with vaccine hesitancy. Both high and low socioeconomic status as well as high and low education levels have all been associated with vaccine hesitancy in different populations. Other studies examining various populations around the world in different countries found that both high and low socioeconomic status are associated with vaccine hesitancy. An Australian study that examined the factors associated with vaccine attitudes and uptake separately found that under-vaccination correlated with lower socioeconomic status but not with negative attitudes towards vaccines. The researchers suggested that practical barriers are more likely to explain under-vaccination among individuals with lower socioeconomic status. Studies have demonstrated that children of parents who refused the pertussis vaccine, varicella vaccine, and pneumococcal vaccine are 23 times more likely to contract pertussis (whooping cough), nine times more likely to catch varicella (chickenpox), and six times more likely to be hospitalized with severe pneumonia from Streptococcus pneumoniae (pneumococcus). Policy implications: Multiple major medical societies including the Infectious Diseases Society of America, the American Medical Association, and the American Academy of Pediatrics support the elimination of all nonmedical exemptions for childhood vaccines. Individual liberty: Compulsory vaccination policies have been controversial as long as they have existed, with opponents of mandatory vaccinations arguing that governments should not infringe on an individual's freedom to make medical decisions for themselves or their children, while proponents of compulsory vaccination cite the well-documented public health benefits of vaccination. Others argue that, for compulsory vaccination to effectively prevent disease, there must be not only available vaccines and a population willing to immunize, but also sufficient ability to decline vaccination on grounds of personal belief. Vaccination policy involves complicated ethical issues, as unvaccinated individuals are more likely to contract and spread disease to people with weaker immune systems, such as young children and the elderly, and to other individuals in whom the vaccine has not been effective. However, mandatory vaccination policies raise ethical issues regarding parental rights and informed consent. In the United States, vaccinations are not truly compulsory, but they are typically required in order for children to attend public schools. As of January 2021, five states--Mississippi, West Virginia, California, Maine, and New York--have eliminated religious and philosophical exemptions to required school immunizations. Children's rights: Medical ethicist Arthur Caplan argues that children have a right to the best available medical care, including vaccines, regardless of parental feelings toward vaccines, saying "Arguments about medical freedom and choice are at odds with the human and constitutional rights of children. When parents won’t protect them, governments must." A review of court cases from 1905 to 2016 found that, of the nine courts that have heard cases regarding whether not vaccinating a child constitutes neglect, seven have held vaccine refusal to be a form of child neglect. To prevent the spread of disease by unvaccinated individuals, some schools and doctors' surgeries have prohibited unvaccinated children from being enrolled, even where not required by law. Refusal of doctors to treat unvaccinated children may cause harm to both the child and public health, and may be considered unethical, if the parents are unable to find another healthcare provider for the child. Opinion on this is divided, with the largest professional association, the American Academy of Pediatrics, saying that exclusion of unvaccinated children may be an option under narrowly defined circumstances. Religion: Since most religions were started far before vaccinations were invented, scriptures do not specifically address the topic of vaccination. However, vaccination has been opposed on religious grounds ever since it was first introduced. Some Christian opponents argued, when vaccination was first becoming widespread, that if God had decreed that someone should die of smallpox, it would be a sin to thwart God's will via vaccination. Religious opposition continues to the present day, on various grounds, raising ethical difficulties when the number of unvaccinated children threatens harm to the entire population. Many governments allow parents to opt out of their children's otherwise mandatory vaccinations for religious reasons; some parents falsely claim religious beliefs to get vaccination exemptions. Many Jewish community leaders support vaccination. Among early Hasidic leaders, Rabbi Nachman of Breslov (1772–1810) was known for his criticism of the doctors and medical treatments of his day. However, when the first vaccines were successfully introduced, he stated: "Every parent should have his children vaccinated within the first three months of life. Failure to do so is tantamount to murder. Even if they live far from the city and have to travel during the great winter cold, they should have the child vaccinated before three months." Although gelatin can be derived from many animals, Jewish and Islamic scholars have determined that since the gelatin is cooked and not consumed as food, vaccinations containing gelatin are acceptable. However, in 2015 and again in 2020, the possible use of porcine-based gelatin in vaccines raised religious concerns among Muslims and Orthodox Jews about the halal or kosher status of several vaccinations against COVID-19. The Muslim Council of Britain argued against the use of intranasal influenza vaccine in 2019 due to the presence of gelatin in the vaccine and consider such vaccines to be non-halal (unclean). In India, in 2018, a 3-minute doctored clip circulated among Muslims claiming that the MR-VAC vaccine against measles and rubella was a "Modi government-RSS conspiracy" to stop the population growth of Muslims. The clip was taken from a TV show that exposed the baseless rumors. Hundreds of madrassas in the state of Uttar Pradesh refused permission to health department teams to administer vaccines because of rumors spread using WhatsApp. Some Christians have objected to the use of cell cultures of some viral vaccines, and the virus of the rubella vaccine, on the grounds that they are derived from tissues taken from therapeutic abortions performed in the 1960s. The principle of double effect, originated by Thomas Aquinas, holds that actions with both good and bad consequences are morally acceptable in specific circumstances. The Vatican Curia has said that for vaccines originating from embryonic cells, Catholics have "a grave responsibility to use alternative vaccines and to make a conscientious objection", but concluded that it is acceptable for Catholics to use the existing vaccines until an alternative becomes available. In the United States, some parents falsely claim religious exemptions when their real motivation for avoiding vaccines is supposed safety concerns. For a number of years, only Mississippi, West Virginia, and California did not provide religious exemptions. Following the 2019 measles outbreaks, Maine and New York repealed their religious exemptions, and the state of Washington did so for the measles vaccination. Alternative medicine: Many forms of alternative medicine are based on philosophies that oppose vaccination (including germ theory denialism) and have practitioners who voice their opposition. As a consequence, the increase in popularity of alternative medicine in the 1970s planted the seed on the modern anti-vaccination movement. More specifically, some elements of the chiropractic community, some homeopaths, and naturopaths developed anti-vaccine rhetoric. The reasons for this negative vaccination view are complicated and rest at least in part on the early philosophies that shaped the foundation of these groups. Chiropractic: Historically, chiropractic strongly opposed vaccination based on its belief that all diseases were traceable to causes in the spine and therefore could not be affected by vaccines. Daniel D. Palmer (1845–1913), the founder of chiropractic, wrote: "It is the very height of absurdity to strive to 'protect' any person from smallpox or any other malady by inoculating them with a filthy animal poison." Vaccination remains controversial within the profession. Most chiropractic writings on vaccination focus on its negative aspects. A 1995 survey of US chiropractors found that about one third believed there was no scientific proof that immunization prevents disease. While the Canadian Chiropractic Association supports vaccination, a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% advised against, vaccinations for patients or for their children. Although most chiropractic colleges try to teach about vaccination in a manner consistent with scientific evidence, several have faculty who seem to stress negative views. A survey of a 1999–2000 cross-section of students of Canadian Memorial Chiropractic College (CMCC), which does not formally teach anti-vaccination views, reported that fourth-year students opposed vaccination more strongly than did first-year students, with 29.4% of fourth-year students opposing vaccination. A follow-up study on 2011–12 CMCC students found that pro-vaccination attitudes heavily predominated. Students reported support rates ranging from 84% to 90%. One of the study's authors proposed the change in attitude to be due to the lack of the previous influence of a "subgroup of some charismatic students who were enrolled at CMCC at the time, students who championed the Palmer postulates that advocated against the use of vaccination". Policy positions: The American Chiropractic Association and the International Chiropractic Association support individual exemptions to compulsory vaccination laws. In March 2015, the Oregon Chiropractic Association invited Andrew Wakefield, chief author of a fraudulent research paper, to testify against Senate Bill 442, "a bill that would eliminate nonmedical exemptions from Oregon's school immunization law". The California Chiropractic Association lobbied against a 2015 bill ending belief exemptions for vaccines. They had also opposed a 2012 bill related to vaccination exemptions. Homeopathy: Several surveys have shown that some practitioners of homeopathy, particularly homeopaths without any medical training, advise patients against vaccination. For example, a survey of registered homeopaths in Austria found that only 28% considered immunization an important preventive measure, and 83% of homeopaths surveyed in Sydney, Australia, did not recommend vaccination. Many practitioners of naturopathy also oppose vaccination. Homeopathic "vaccines" (nosodes) are ineffective because they do not contain any active ingredients and thus do not stimulate the immune system. They can be dangerous if they take the place of effective treatments. Some medical organizations have taken action against nosodes. In Canada, the labeling of homeopathic nosodes require the statement: "This product is neither a vaccine nor an alternative to vaccination." Financial motives: Alternative medicine proponents gain from promoting vaccine conspiracy theories through the sale of ineffective and expensive medications, supplements, and procedures such as chelation therapy and hyperbaric oxygen therapy, sold as able to cure the 'damage' caused by vaccines. Homeopaths in particular gain through the promotion of water injections or 'nosodes' that they allege have a 'natural' vaccine-like effect. Additional bodies with a vested interest in promoting the "unsafeness" of vaccines may include lawyers and legal groups organizing court cases and class action lawsuits against vaccine providers. Conversely, alternative medicine providers have accused the vaccine industry of misrepresenting the safety and effectiveness of vaccines, covering up and suppressing information, and influencing health policy decisions for financial gain. In the late 20th century, vaccines were a product with low profit margins, and the number of companies involved in vaccine manufacture declined. In addition to low profits and liability risks, manufacturers complained about low prices paid for vaccines by the CDC and other US government agencies. In the early 21st century, the vaccine market greatly improved with the approval of the vaccine Prevnar, along with a small number of other high-priced blockbuster vaccines, such as Gardasil and Pediarix, which each had sales revenues of over $1 billion in 2008. Despite high growth rates, vaccines represent a relatively small portion of overall pharmaceutical profits. As recently as 2010, the World Health Organization estimated vaccines to represent 2–3% of total sales for the pharmaceutical industry. War: The United States has a very complex history with compulsory vaccination, particularly in enforcing compulsory vaccinations both domestically and abroad to protect American soldiers during times of war. There are hundreds of thousands of examples of soldier deaths that were not the result of combat wounds, but were instead from disease. Among wars with high death tolls from disease is the Civil War where an estimated 620,000 soldiers died from disease. American soldiers in other countries have spread diseases that ultimately disrupted entire societies and healthcare systems with famine and poverty. Spanish–American War: The Spanish–American War began in April 1898 and ended in August 1898. During this time the United States gained control of Cuba, Puerto Rico, and the Philippines from Spain. As a military police power and as colonizers the United States took a very hands-on approach in administering healthcare particularly vaccinations to natives during the invasion and conquest of these countries. Although the Spanish–American War occurred during the era of "bacteriological revolution" where knowledge of disease was bolstered by germ theory, more than half of the soldier casualties in this war were from disease. Unknowingly, American soldiers acted as agents of disease transmission, fostering bacteria in their haphazardly made camps. These soldiers invaded Cuba, Puerto Rico, and the Philippines and connected parts of these countries that had never before been connected due to low population density, thereby beginning epidemics. The mobility of American soldiers around these countries encouraged a newfound mobility of disease that quickly infected natives. Military personnel used Rudyard's Kipling's poem "The White Man's Burden" to explain their imperialistic actions in Cuba, the Philippines, and Puerto Rico and the need for the United States to help the "dark-skinned Barbarians" reach modern sanitary standards. American actions abroad before, during, and after the war emphasized a need for proper sanitation habits especially on behalf of the natives. Natives who refuse to oblige with American health standards and procedures risked fines or imprisonment. One penalty in Puerto Rico included a $10 fine for a failure to vaccinate and an additional $5 fine for any day a person continued to be unvaccinated; refusal to pay resulted in ten or more days of imprisonment. If entire villages refused the army's current sanitation policy at any given time they risked being burnt to the ground in order to preserve the health and safety of soldiers from endemic smallpox and yellow fever. Vaccines were forcibly administered to the Puerto Ricans, Cubans, and Filipinos. Military personnel in Puerto Rico provided Public Health services that culminated in military orders that mandated vaccinations for children before they were six months old, as well as a general vaccination order. By the end of 1899 in Puerto Rico alone the U.S. military and other hired native vaccinators called practicantes, vaccinated an estimated 860,000 natives in a five-month period. This period began the United States' movement toward an expansion of medical practices that included "tropical medicine" in an attempt to protect the lives of soldiers abroad. Vietnam War: During the Vietnam War, vaccination was necessary for soldiers to fight overseas. Because disease follows soldiers, they had to receive vaccines preventing cholera, influenza, measles, meningococcemia, Bubonic plague, poliovirus, smallpox, tetanus, diphtheria, typhoid, typhus, and yellow fever. However, the diseases mainly prevalent in Vietnam at this time were measles and polio. After arriving in Vietnam, the United States Military conducted the "Military Public Health Assistance Project". This public health program was a joint United States Military and Government of Vietnam concept to create or expand public medical facilities throughout South Vietnam. Local villages in Vietnam were inoculated. The United States military screened patients, dispensed medication, distributed clothing and food, and even passed out propaganda such as comic books. Information warfare: An analysis of tweets from July 2014 through September 2017 revealed an active campaign on Twitter by the Internet Research Agency (IRA), a Russian troll farm accused of interference in the 2016 U.S. elections, to sow discord about the safety of vaccines. The campaign used sophisticated Twitter bots to amplify highly polarizing pro-vaccine and anti-vaccine messages, containing the hashtag #VaccinateUS, posted by IRA trolls. Confidence in vaccines varies over place and time and among different vaccines. The London School of Hygiene & Tropical Medicine's Vaccine Confidence Project in 2016 found that confidence was lower in Europe than in the rest of the world. Refusal of the MMR vaccine has increased in 12 European states since 2010. The project published a report in 2018 assessing vaccine hesitancy among the public in all the 28 EU member states and among general practitioners in ten of them. Younger adults in the survey had less confidence than older people. Confidence had risen in France, Greece, Italy, and Slovenia since 2015 but had fallen in the Czech Republic, Finland, Poland, and Sweden. 36% of the GPs surveyed in the Czech Republic and 25% of those in Slovakia did not agree that the MMR vaccine was safe. Most of the GPs did not recommend the seasonal influenza vaccine. Confidence in the population correlated with confidence among GPs. One study in the United States found that after vaccine-hesitant college students interviewed survivors of vaccine-preventable diseases, they were more likely to become pro-vaccine than a control group. Parties opposed to the use of vaccines frequently refer to data obtained from the US Vaccine Adverse Event Reporting System (VAERS). This is a database of reports of issues associated with vaccines. When used appropriately VAERS is a useful tool for investigation, but since anyone can make a claim and have it entered into the VAERS, by itself it is not a reliable source of information. Dubious claims about vaccines against hepatitis B, HPV and other diseases have been propagated based on misuse of data from VAERS.