on goods sold in the us, despite a last—minute deal that stopped them coming into effect on monday. the border agreement meant the us held off imposing tariffs on mexico. the us has given mexico 45 days to reduce the number of migrants crossing its territory on their way to the us. a helicopter has crashed into a 54—storey building in manhattan in poor visibility, killing one person, believed to have been the pilot. officials say the crash, which happened during poor visibility appears to have been an accident. and celebrities flexing their muscles has caught people's attention on our website. justin bieber has challenged tom cruise to a ufc—style cage fight. in a tweet, the 25—year—old singer said the hollywood actor would "never live it down" if he turned down the fight. that's all. stay with bbc world news. now on bbc news, a special edition of hardtalk recorded at the hay literary

festival. welcome to hardtalk with me, stephen sacker. and a wonderful audience here at the hay festival in wales. there is something very special about the human heart. its beat keeps us alive and we like to think it's where our strongest feelings and emotions come from. my guest today is the renowned heart surgeon samer nashef. his books give us an extraordinary insight into the highs and lows of a life spent mending broken hearts. applause. samer nashef, a very, very warm welcome to hardtalk. thank you. you have described the heart as a very simple mechanism. you say it is a bag made of muscle, the simplest of pumps.

is that really the way you see it? that is what it is. yes, but it's so much more to all of us as human beings. poets write about it, novelists invest it with so much. do you not, when you look at that heart in the operating theatre, think of it in slightly more mystical terms? well, the mystical think about it is that when it stops you're dead. so that's quite important. laughter. but it doesn't like anything like valentines cards and there is no point in making jewellery that looks like it. nobody makes jewellery that looks like livers or kidneys, as far as i know. laughter. it is simply a pump. there is probably a reason why people thought it was the seat of emotions because when you have emotions and release adrenaline and more adrenaline, they stimulate the heart and it beats a little bit faster and more strongly. so they assume it's the heart that's generating their emotions,

the heart is just simply responding to them, but it is a clever pump. a clever pump, you have, again, in your matter—of—fact way, described it, being a heart surgeon, as being dealing with the plumbing of the human body. so i'm wondering what drew you to something which in a sense makes you the human body's plumber? it was a series of strange decisions and mistaken ones, often, and not very intelligent ones. but i sort of liked the heart when i was a medical student because it was clean and neat and glamorous, and i wanted to become a cardiologist. but i got exasperated by physicians. cardiologists are physicians. and they drove me up the wall when i was a heart surgeon and i was asking them to come in and give advice

about surgical patients and they wasted an awful lot of my time and argued about silly things and kept on quoting the last paper from this and the last paper from that, and one day i swore that if they did that one more time, i will stop wanting to become a physician and become a surgeon, and that's how i switched. it wasn't an intelligent decision. so, in terms of the hospital process, the treatment process, the cardiologist will assess the problem in a broken orfailing heart and you will then be given the task of fixing it. yes, that is true to some extent, although nowadays the cardiologist can do quite a lot of stuff that's just short of an open heart operation, so they can put catheters in the groin and puts stents and stretch holes and try to close them so they do quite a fair bit of intervention stuff but it's the surgeon who opens the chest and does the final repair, if you see what i mean.

i do see what you mean, and you write about it very graphically, very frankly. but what you also lead us to understand is that open—heart surgery, which is now such a familiar part, such an important part of the medical kit bag, it really is, in medical terms, quite a new practice because the technology simply didn't exist before the 19505 to open up the chest and operate upon the heart. well, until about 100 years ago, maybe more, it was not possible to open the chest, let alone operate on the heart, because something that many people don't realise is that your lungs don't breathe by themselves. they need an intact chest wall around them. they are passive. the chest wall muscles stretch and the lungs just follow because they're inside it, and the minute you open the chest, you break that a seal and air gets in and then moving the chest muscles will do nothing and whenever surgeons in the past tried to operate on the heart,

they of course opened the chest and the lungs would disappear and crumple into a corner and the surgeons would think, oh, this is great, lots of space to get access to the heart and then two minutes later the patient‘s dead and they didn't understand why. so we had to wait for two things before we could operate on the heart. the first one was the invention of the endotracheal tube which allows you to blow air and oxygen actively into the lungs so you don't rely on the chest wall to ventilate, to breathe. and the second thing we had to wait for was to do with the heart itself because most organs you can do without for a few minutes or half—an—hour or an hour but you can't really do without the heart for half—an—hour because the brain dies. and it was a question of trying to find a way of keeping the patient alive while working

on the heart and this invention happened in the mid—19505 when a surgeon called gibbon, working in the united states, made this contraption which contained a pump and an oxygenator through which you could put the blood through and the pump would do the work of the heart, the oxygenator would do the work of the lungs and then you can bypass the heart completely and then when you fiddle with the heart, the patient stays alive and that, that invention in the mid—19505 was the starter pistol for heart surgery and itjust took off. you say, when you reflect on what you do, that in a sense, the technical side of it is actually quite straightforward. more straightforward, for example, than brain surgery. but it's the decision—making that is the essence of a good surgeon and good surgery. so what do you mean by the decision—making?

the technical aspects are, they're not that easy but they are doable. somebody who's not totally cack—handed can learn to do heart surgery, yeah? laughter. i'm not particularly skilled with my hands. i'm not cack—handed, but i can do things... um, maybe some of your patients don't want to know that you're. .. laughter. i'm just being honest. some aspects of heart surgery, especially intricate coronary surgery, can be difficult and you have to be very careful because tiniest mistakes can actually lead to death but most heart surgery, valves, aortas, transplants, are actually stitching big things to big things. it's within the reach of most well—trained surgeons. but i think something that does differentiate good heart surgeons from ones who are not so good is knowing when to do, what to do and how to do it and that is largely decision—making. and it's important. and what you do in the way you write

about your work is you bring to life some extraordinary difficult cases where you have had to make, in real time and very quickly, you've had to make the most difficult decisions. i'm thinking for one in your most recent book the angina monologues, where you talk about a woman who is heavily pregnant with twins, i think she's in the 37th week, and she has the most terrible aorta problem with her heart. the aorta is wrecked, really. and you have to decide what to do — whether to immediately work on her because she's dying, or whether to get her twin babies out of the womb before working on her. yes, it was a very difficult decision, because one of the problems is that putting somebody on a heart—lung machine when they're pregnant is very likely to make them lose the pregnancy. on the other hand, that particular condition,

the acute aortic dissection, is fatal. it's got a 1% death rate per hour, so within a couple of days, half the patients have died, so you can't really wait that long. and we had to make the decision as to whose life we put first. we decided that we should probably deliver the babies first and allow her to take an extra, perhaps, 2—3% risk while this was done. i am interested in the personality of people such as yourself who take on such immense responsibility and it's the cliche about life and death work but that is indeed what yours is and some people think that surgeons at this level have a particular set of personality traits and some of them aren't always regarded as particularly nice. you know, i'm looking now at research done by simon patterson brown who's a former chairman of the patient safety board at the royal college of surgeons in scotland and he talks

about arrogance, narcissism, different character traits which sometimes make surgeons very difficult to work with. i think you're absolutely right there. that is very true of the early days of heart surgery. before the heart—lung machine worked properly and before any of the safety features were introduced, heart surgery was a sort of desperate last ditch attempt for people who were in dire straits and the sort of stuff that people did was horrible and dangerous and many patients died as a result. but if you survived, it began to look like it would be a feasible option. but to be one of the pioneering heart surgeons, you had to be a serious risk taker. you had to be a cowboy. you had to be prepared to throw caution to the wind in order to get anywhere. nowadays, i think we're a lot more boring.

laughter. but probably a lot safer as a result of 50 years of development. and interestingly, you say, even in the course of your career, you've noticed a change in yourself, that the waves of euphoria that you get when an operation goes well are perhaps not quite as high and dramatic as they were when you were younger and yet you say the degree of regret and self questioning and recrimination that you have when things go wrong, that's just as intense today as it was when you were a young man. that is true. why do you think that is? i'm not sure. perhaps the euphoria reduces because of expectation, or because we've been there a long time or perhaps the standards have gone up. we now operate on people who are much older and much sicker and much more challenging than anything we used to do at the beginning of my training. but don't get such a high

when things are going well and i wonder whether it's a combination of these reasons or maybe i'm just getting used to it. but the problem is when something does not go well, it still feels just as awful, if not even more so than it did before. and as i've said in the book, there will come a time when that balance is not so nice and not so positive, and then i'll retire. do think we, as patients, really want the warts and all descriptions of what it's truly like to be a top surgeon that you have given us, that people i had on the programme not so long ago, henry marsh, one of britten‘s leading brain surgeons. the thing you have in common with henry marsh is that you've both written books in where you're frank about the degree to which luck plays a part, the degree to which sometime you and others make mistakes,

sometimes you feel that you let patients down. do we really want to know all this? well, perhaps i should ask you that. laughter. well, good hardtalk question. my guess is that sometimes we'd rather not know, for example, the degree to which chance is relevant in any serious intervention that you make. i think that is true but i think that in heart surgery, at least, we are extremely honest about the downside. we give patients risks, calculated properly, scientifically, as percentages, we tell them likelihood of death, likelihood of stroke, likelihood of not getting a good outcome, and we tell them the benefits and we ask them to weigh these things, so at least we are being honest. and i think, nowadays, patients no longer accept the patriarchal approach of, "well, you know, there you are, my good man. i know what's best for you." and that's not good enough. i certainly wouldn't want to be

treated like that as a patient. i want to make decisions. my health, my life, my say. in terms of heart health, we also have a different way of looking at the way we all live our lives and what is happening to our hearts, because we get constant public health messaging telling us that if we eat right, if we exercise right, if we do not drink and do not smoke and do not do all sorts of other things, our hearts should be healthy. i wonder whether you, as a heart surgeon, feel that we are getting the public health messaging right? no. because? because, for the majority of heart disease, unfortunately the risk factors are things that you cannot do anything about. for example, your genes, your family history. whether there is a lot

of heart history in your family, you can't do anything about that. you can't change your parents. the second thing is being male, you can't — well, perhaps you can change that nowadays — but that doesn't affect the heart disease symptoms. males do a little bit less well than females in the heart stakes and they have more — we are talking about coronary disease primarily which is the lifestyle association that most people think about. you can't do anything about getting old. that is going to happen to all of us and the older you get, the more likely you are to get coronary disease. for those things that affect the heart that you can't do anything about, there's nothing you can do about them and no amount of diet or whatever will make any difference. now, there are some things that we can do something about, and they are extremely important. for example, smoking is definitely very bad. we shouldn't do it, the evidence is there. you were a smoker weren't you? absolutely, yes. i used to love my french cigarettes. when did you stop? about 30 years ago.

0h, 0k. a long time ago. so you've given your heart a decent chance? hopefully, but hasn't worked that well, has it? well, we'll get to that, actually, because a heart doctor who's got a dodgy heart is a fascinating phenomenon. but we'll get to that in a moment. yeah, ok. but before we get there, i've noticed in your writing you are very critical of certain, for example, dietary instructions that have been given. you say that salt, for example has had a very bad rap. people have suggested that it's bad for the body but in particularfor the heart. you say, no real evidence. no, there is no real evidence. and there's one extraordinary story that you tell about how, and we'll get to you now, when you discovered you were suffering from angina, the first thing you did when you first felt it after you'd been to the gymnasium, was go to the pub, have a beer and a burger to think more about your condition. what else is there to do? some people might have taken the angina as a message that beer and burgers were part

of your problem. but there is no connection between beer and burgers, and angina. there is a connection between how many burgers, you know, so obesity, as well as smoking are bad for you. that is absolutely proven. type ii diabetes which often results from obesity is bad for you, hypertension, which also is an outcome, a consequence. all of these things are bad for you. you can control them, there's quite a few things you can do about cholesterol if you are in a high risk group. but nobody has ever proven that eating a burger causes heart disease by itself, or that putting salt on your chips causes heart disease. now, don't get me wrong, i'm not here to advertise the benefits of salt, chips and burgers. there are foods that i would rather eat far more than that, but i think what matters is that when we do give messages to patients and to the public, that we should concentrate on the messages that are backed by solid evidence.

let me ask you about a different aspect of the public health system in the united kingdom, that is the nhs itself, our free at the point of delivery healthcare system, that polls suggest the great majority of british people are immensely proud of. are you worried about the state of the nhs today? i'm worried about a lot of things in their nature, but if there's one thing that worries me most, it's funding. and we do not spend enough on health, i'm sorry, but that is true. if you look at most advanced, civilised countries, they're up to spending anything from 12 to 18, 19% of their gross domestic product on health. we, at the moment, are spending around 8, 8.5. and it's just not enough. here is the figure, ijust pulled it from a research document, the us spends more than twice as much per capita on healthcare as the uk. it amounts to $10,000

per person in the us, in the uk the equivalent is barely 4,000. you've worked in the us, but they don't have a public healthcare system as we do. and many would argue that access to healthcare in the us is much poorer, more defined by money. that's true. so, money isn't really the answer, is it? no, money is not the answer and the us, although it spends more than twice as much on healthcare, it does not get twice as good healthcare. the main reason the nhs care is so good is because it's relatively cheap and amazingly efficient. there are no people in the middle making money out of it. there is no insurance companies, no schemes, no profit—making organisations, the money comes from the government to the healthcare service. the healthcare service delivers the service. so we are very efficient,

however, patients are unpredictable and medicine is unpredictable and all it takes is for one thing to go wrong and your 100% occupancy of the intensive care unit leads to 20 operations being cancelled. and paying doctors and nurses and staff to sit there twiddling their thumbs is inefficient. so how close to breaking point do you feel your nhs, our nhs to be today? it already suffers from lack of funding to the extent that it actually affects patient care. heart surgery, for example, a lot of the heart operations we do, we do them because we want to make people feel better. you know, get through the pain, angina, breathlessness, all that sort of stuff. but a lot of the operations that we do also help people live longer. now, if you have to wait a year for an operation to help you live

longer, well you might die during that year from the condition that you are trying to treat. that's not right. also, i'm just wondering whether you feel the british system is well—placed to exploit the very latest medical technology? artificial hearts, for example. replacing the transplant idea with creating artificial hearts. is that going to come and do we have the money to fund the research to make it happen? there is actually funding. research funding in the nhs is quite good now, because of the national institute for health research. there is money available for people with projects, that projects get properly funded, the research gets properly paid for, which is wonderful because before that happened, research was basically done on a shoestring by people in their spare time. so we have improved research quite lot. artificial hearts will happen, it's just a technology issue, to get them right, that is delaying us. but i think they will be available on the shelf properly within about 10—15 years. really? so that's going to happen. then, we would have an off—the—shelf treatment for heart failure

which is a massive killer, and that would change the face of the speciality quite a lot. because transplants will never meet the demand. yes, you mean because of the limited supply? yeah, limited supply of donors. it's also a treatment that requires a young, fit person to die. so an old, sick one lives, it's not great as a solution. no. i want to end with this thought that i planted earlier about what it is like to be one of the world's leading heart surgeons and to discover that you have your own, rather serious, heart problem. because you suffered from angina and you needed to go see a specialist. how difficult was it for you to accept that your own heart was beginning to let you down? slightly off—putting. how difficult was it for any of your colleagues to take you on as a patient? yes, that's perhaps a little bit more interesting. i was fortunate, you know, stephen, at the end of the day, it was a very minor single ruptured plug in a coronary artery which has healed and i don't have

angina anymore and i am very, very well. and for that i thank my lucky stars and i hope it carries on like this for a long time. but at the time, yes, i mean, everything was possible. it was quite likely that i would need an angioplasty, possibly stents, possibly rotablation, which is horrible, drilling holes in the coronary artery to make the stent fit, and if that didn't work, an open heart operation. i chose my surgeon for that, one of my colleagues, he's a welsh man. he is a very pale welsh man but he became a lot more pale when i asked him if he would. so, it was not a particularly fun time. but in the end i believe that that's all it was. and i daresay, just as a final thought, it gave you an even deeper understanding of what your patients are going through? absolutely, and i'm much more

sympathetic to them now. samer nashef it has been an extraordinary pleasure having you on hardtalk. thank you very much indeed. you're very welcome. thank you. tuesday is going to bring further heavy rain and they could be a lot of it, particularly across northern parts of england, the midlands, and wales. on monday, the heaviest of the rainfall was actually across eastern parts of the country in the south—east. if we look at europe, the big picture, we can see over the last two or three days, most of the clouds seem to be stuck across... from northern spain, france, germany, the uk. we have seen big thunderstorms

on the near continent, heavy rain here, of course. eastern parts of europe a different story, a few summertime showers and thunderstorms but on the whole a lot of sunshine and very hot, and the reason for this is that this vortex has formed across western europe. it has been dragging cold air all the way from the north across the uk, france and into spain, whereas this side of europe, warm air has been coming from the south, affecting central and eastern areas, so warsaw, for example, has been in excess of 30 degrees, when it was only 12 degrees in london. on tuesday, the early hours, rain across most of northern england, the midlands, wales, the south—west, just about starting to dry out in the extreme south—east, but no real rainfall across scotland and northern ireland except for a few showers. in fact, first thing in the morning there will probably be some sunshine in belfast, glasgow and edinburgh. the weather front is stuck. in fact, the whole weather pattern across europe is stuck, it is not moving or

moving very slowly. through tuesday, this band of weather, band of heavy rain, will very slowly drift, at a glacial pace it will move its way towards the north. it will continue to rain across yorkshire all through the day, the north—west of england, wales, the south—west, it sort of curls back into the centre of the low. the south—east will see sunshine and heavy showers. in the north of the country there will be some sunshine around. at times it will be cloudy, but dry at least. on wednesday, the weather system is still with us, a sense of things spiralling very slowly around, and again, more heavy showers being pushed into the uk, so again, it continues to remain very wet across many parts of the country into wednesday. wednesday and thursday, the low pressure is still with us, so this pattern is not in a hurry to change. it will be on the cool side, in fact, as far as the rest of the week is concerned very little change really, at times will be

quite windy as well.

hello, everyone. glad you could join us. hello, everyone. glad you could join us. you're watching newsday on the bbc. i'm rico hizon in singapore. the headlines: president trump defends his border agreement with mexico to curb migration, saying it is new and effective — and wasn't already in the works. a helicopter crashes onto a roof of a high—rise building in new york. one person is reported to have been killed. i'm kasia madera in london. also in the programme: dialling down a deadly disease — how mobile phone location data could stop the spread of malaria in bangladesh. and turning over a new leaf. air new zealand makes a u—turn on cabin crew